--- title: "Case Report: Preoperative Conditioning" description: Do you want to see how fasciotens is applied in a surgery? Read the case report for a detailed step-by-step and hear the surgeon's opinion --- [Go Back Up](https://www.fasciotens.com/case-report-preoperative-conditioning#top) [Skip to Content](https://www.fasciotens.com/case-report-preoperative-conditioning#body) [![fasciotens home](https://www.fasciotens.com/hs-fs/hubfs/Logos/fasciotens_logo_aws_2020.png?width=200&height=52&name=fasciotens_logo_aws_2020.png "fasciotens home")](https://www.fasciotens.com?hsLang=en) Toggle Menu - [Open Abdomen](https://www.fasciotens.com/abdomen) Toggle children for Open Abdomen Main Menu (Press to Return) \> Open Abdomen - [Discover more](https://www.fasciotens.com/abdomen) - [Publications & Case Reports](https://www.fasciotens.com/case-reports-abdomen) - [E-learning courses](https://academy.fasciotens.com/pages/abdomen) - [How-tos & Instructions](https://www.fasciotens.com/how-tos-abdomen) - [Complex Hernias](https://www.fasciotens.com/hernia) Toggle children for Complex Hernias Main Menu (Press to Return) \> Complex Hernias - [Discover more](https://www.fasciotens.com/hernia) - [Publications & Case Reports](https://www.fasciotens.com/case-reports-hernia) - [E-learning courses](https://academy.fasciotens.com/collections/hernia) - [How-tos & Instructions](https://www.fasciotens.com/how-tos-hernia) - [Congenital Defects](https://www.fasciotens.com/pediatric) Toggle children for Congenital Defects Main Menu (Press to Return) \> Congenital Defects - [Discover more](https://www.fasciotens.com/pediatric) - [How-tos & Instructions](https://www.fasciotens.com/how-tos-pediatric) - [Congresses & Workshops](https://www.fasciotens.com/congresses-workshops) - Services Toggle children for Services Main Menu (Press to Return) \> Services - [E-Learning](https://academy.fasciotens.com) - [Case Discussion](https://www.fasciotens.com/case-discussion) - [Product Feedback & Complaints](https://www.fasciotens.com/product-feedback) - [Downloads](https://www.fasciotens.com/downloads) - [Newsletter](https://www.fasciotens.com/newsletter) - [About us](https://www.fasciotens.com/about-us) - [Local Distribution Partners](https://www.fasciotens.com/contact#distributor) - [Contact](https://www.fasciotens.com/contact) - - [English](https://www.fasciotens.com/case-report-preoperative-conditioning) - [Deutsch](https://www.fasciotens.com/de/case-report-preoperative-conditioning) ![Case York\_Header](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_Header.jpg?width=1024&height=1024&name=Case%20York_Header.jpg) Holistic approach in managing complex abdominal wall hernias # When the case demands the full skill set of AWR surgery *York Abdominal Wall Unit, UK - September 2024* Srinivas Chintapatla (Consultant Colorectal Surgeon) and Tom Macleod (Consultant Plastic Surgeon) at York Abdominal Wall Unit together performed an Abdominal Wall Reconstruction using various techniques, including fasciotens®. Asim Abbas (Abdominal Wall Research Fellow) kindly provided the following case description. ## Preoperative Remarks - The Patient - Surgical History - Quality of Life - Prehabilitation - BTA - PPP The Patient ### Case presentation This 62-year-old patient presented with a complex, massive recurrent, incisional hernia significantly impacting his quality of life. The hernia footprint was extensive including a large left-sided hernia (30x30 cm), and additional paraumbilical and midline hernia. The defects spanned M2, M3, M4, and L regions, and the case was VHWG Grade 2. ![Case York\_1\_Before](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_1_Before.jpg?width=1024&height=1024&name=Case%20York_1_Before.jpg) Surgical History ### Extensive hernia surgery history **2015** - primary right inguinal hernia repair with mesh. **2016** - epigastric and paraumbilical hernia repairs with sublay mesh **2019** - exploratory laparotomy and small bowel resection for an incarcerated recurrent right inguinal hernia. **2019** - redo Lichtenstein mesh repair for a recurrent inguinal hernia. ![Case York\_2\_History](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_2_History.jpg?width=1024&height=1024&name=Case%20York_2_History.jpg) Quality of Life ### Severe impact on quality of life York Abdominal Wall Unit looks into five domains: 1. *Body image* - he described feeling unsightly and uncomfortable, avoiding activities like swimming. 2. *Mental health* was affected, with him being on medication for depression and mentioning that his condition contributed to his divorce. 3. *Symptoms & Function* - he experienced discomfort and avoided physical work. 4. *Employment* - he reported a lack of confidence in seeking employment. 5. *Interpersonal relationships*, particularly his sexual relationship with his wife, were negatively impacted. ![Case York\_3\_Quality of Life](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_3_Quality%20of%20Life.jpg?width=1024&height=1024&name=Case%20York_3_Quality%20of%20Life.jpg) Prehabilitation ### Increasing Fitness level The patient weighed 124 kg, height was 1.75 m with BMI of 40.7, with CeDAR calculation of 66%. He was enrolled in a prehabilitation program to optimize fitness for surgery. York runs an 8-week 'prehab' programme to bring about behavioural changes like reduced portion sizes, daily walking, and strength exercises using 3kg dumbbells.  The [leaflet](https://www.yorkhospitals.nhs.uk/seecmsfile/?id=6244)on display was handed out to the patient.  ![Case York\_4\_Fitter](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_4_Fitter.jpg?width=1024&height=1024&name=Case%20York_4_Fitter.jpg) BTA ### Preconditioning with BTA During the prehabilitation phase, the patient had an episode of bowel obstruction. A CT scan at this stage showed significant protrusion and abdominal wall dysfunction. Botulinum toxin A (Dysport) injections were administered to the abdominal wall, and the obstruction subsequently resolved, although it remains unclear whether the resolution was directly related to the injections. ![Case York\_5\_CT](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_5_CT.jpg?width=1024&height=1024&name=Case%20York_5_CT.jpg) PPP ### Continued Preoperative Optimisation Preoperative optimisation continued with the placement of an IVC filter to manage thrombotic risk. York Abdominal Wall Unit's Progressive Pneumo Peritoneum (PPP) protocol was delivered to increase intra-abdominal volume and improve the feasibility of hernia closure. ![Case York\_6\_PPP](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_6_PPP.jpg?width=1024&height=1024&name=Case%20York_6_PPP.jpg) ## Intraoperative Course - Rives-Stoppa - Anatomical Reconstruction - Intraoperative Fascial Traction Rives-Stoppa ![Case York\_7\_In Surgery](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_7_In%20Surgery.jpg?width=1024&height=1024&name=Case%20York_7_In%20Surgery.jpg) ### Extended Rives-Stoppa Repair The surgical team performed an extended Rives-Stoppa repair. The retrorectus space was reinforced with Phasix mesh, chosen for long-term durability and resistance to infection. The mesh was carefully tailored to cover the extensive defect. Anatomical Reconstruction ![Case York\_8\_Defect Size](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_8_Defect%20Size.jpg?width=1024&height=1024&name=Case%20York_8_Defect%20Size.jpg) ### Considerations for IFT During closure, attention was given to achieving tension-free midline approximation. However, to minimize dissection and reduce the risk of complications, they opted to utilise the fasciotens® device. This allowed the anterior rectus sheath to be mobilised effectively without performing a Component Separation. Intraoperative Fascial Traction ![Case York\_9\_IFT](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_9_IFT.jpg?width=1024&height=1024&name=Case%20York_9_IFT.jpg) ### Controlled Traction during IFT The fasciotens® device was applied to exert controlled tension at 14-18 Kg, gradually bringing the anterior rectus sheath together over 30 minutes. ## Postoperative Outcomes - Postoperative Course - Quality of Life - Summary Postoperative Course ### Discharge on Day 5 Postoperatively, the patient had a good recovery and was discharged on day five. A clinical photo taken three weeks after surgery shows a well-healed abdomen with significant improvement in contour. ![Case York\_10\_After](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_10_After.jpg?width=1024&height=1024&name=Case%20York_10_After.jpg) Quality of Life ### Improved Daily Life The patient reported improvements in quality of life across all domains during follow-up. For: 1. *Body image* - stating, "Now I feel great; my body is in better shape than it has been for years." 2. *Mental health* improved significantly, with him expressing newfound confidence and a sense of rejuvenation. 3. *Symptoms* improved, being able to lift and carry light loads and engage in activities such as gardening, badminton, and swimming. 4. *Employment* - he also regained confidence in seeking employment. 5. *Interpersonal relationships* had greatly improved, particularly with his wife and children. His relationship with his wife had resumed intimacy, which he described as a major positive change. ![Case York\_11\_Increased QOL](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/Case%20York_11_Increased%20QOL.jpg?width=1024&height=1024&name=Case%20York_11_Increased%20QOL.jpg) Summary ### Satisfying Outcomes This case highlights the effectiveness of the fasciotens® device in facilitating midline closure in complex hernia repairs with significant loss of domain. The device allowed for tension-free closure, thus sparing component separation, leading to a successful surgical outcome and a marked improvement in the patient’s quality of life. The case also emphasizes the importance of a holistic approach, including prehabilitation and comprehensive quality-of-life assessment, in managing complex abdominal wall hernias. Read more about York's abdominal wall reconstruction service [here](https://www.yorkhospitals.nhs.uk/our-services/organdonation/a-z-of-services/abdominal-wall-reconstruction/). ![YAWU logo](https://www.fasciotens.com/hs-fs/hubfs/Case%20Reports/Hernia_2024_09_UK_York/YAWU%20logo.png?width=577&height=595&name=YAWU%20logo.png) ![Cover\_Hernia\_UK\_York\_Srinivas Chintapatla](https://www.fasciotens.com/hs-fs/hubfs/Website%20Images/Cover_Hernia_UK_York_Srinivas%20Chintapatla.jpg?width=3840&height=2160&name=Cover_Hernia_UK_York_Srinivas%20Chintapatla.jpg) × ### Srinivas Chintapatla summarises the impressive outcome The leading surgeon, Srinivas Chintapatla, is very satisfied with the results. The patient is back to a normal life despite the complex history before the abdominall wall reconstruction involving intraoperative fasciotens® application. ## The surgeons ![Srinivas Chintapatla](https://www.fasciotens.com/hs-fs/hubfs/Testimonials_Surgeons/Chintapatla.jpg?width=600&height=600&name=Chintapatla.jpg) ### Srinivas Chintapatla Consultant Surgeon – York and Scarborough Teaching Hospital ![Surgeon Placeholder Male](https://www.fasciotens.com/hs-fs/hubfs/Testimonials_Surgeons/Surgeon%20Placeholder%20Male.jpg?width=600&height=600&name=Surgeon%20Placeholder%20Male.jpg) ### Tom Macleod Consultant Plastic, Reconstructive and Cosmetic Surgeon – York and Scarborough Teaching Hospital Start with fasciotens yourself ### Do you want to use fasciotens®Hernia during your next complex hernia surgery? Fill out the form and we will get in touch asap. 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