Mahadar (Mumbai) - Open Approach 15cm_photo5

Open Approach with IFT and BTA

Open Abdominal Wall Repair in Recurrent Ventral Hernia

Jeevanshree Hospital, Maharashtra, India – July 2024

Dr. Rahul Mahadar operated on a 59-year-old female patient (BMI 35) presenting with a large right paramedian ventral hernia measuring 19 x 22 cm, following an exploratory laparotomy performed in 2002 for bowel perforation with a delayed and complicated recovery.

Mahadar-(Mumbai)---Open-Approach-15cm-Pre-op-CT

Preoperative CT Scan

Cross-sectional imaging prior to repair, demonstrating extensive herniation of abdominal viscera beyond the abdominal cavity, illustrating the degree of loss of domain and the challenge for fascial closure.

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Functional Test

Clinical assessment before surgery. With coughing, the hernia sac shows marked outward bulging, highlighting both the size of the defect and the lack of functional abdominal wall support.

Preoperative Planning

Prehabilitative included:
-Botulinum toxin injections for muscle relaxation;
-Dietary modification for 5–6 kg weight reduction
-Dobutamine Stress Echo for cardiac clearance.
The hernia boundaries and surgical incision lines were marked on the abdominal wall.

Intra-operative Exposure

Upon entering the abdomen, dense adhesions and the old surgical scar were clearly visualized. Careful dissection was required to avoid injury.

Hernia Sac Mobilization

The hernia sac and surrounding tissue were dissected and mobilized to enable fascial edge visualization and tension-free manipulation.

Fascial Defect Measurement

After adhesiolysis, the fascial gap was measured to be approximately 15 cm wide, confirming the need for additional techniques to achieve fascial closure.

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Posterior Rectus Sheath Closure

The posterior rectus sheath was reconstructed using the hernia sac as bridging to create a retrorectus plane for mesh placement, where a 50x50cm synthetic mesh was placed in a sublay position.

Fascial Traction Evaluation

The (anterior) fascial edges were brought under tension and measured to assess whether midline approximation was possible, still showing a defect and requiring fascial traction.

Interoperative Fascial Traction

The fasciotens® hernia device was applied for anterior fascial traction, allowing low-tension closure of the anterior rectus sheath.

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Final Closure

The subcutaneous tissue was closed in layers and skin stapled. A successful anterior fascial closure was achieved. The patient was extubated on the table and had an uncomplicated recovery. She was mobilized on postop day 1 and discharged home on postop day 7.

Mahadar-(Mumbai)---Open-Approach-Post-op-CT

Postoperative CT Scan

Follow-up imaging after reconstruction. The abdominal contents are restored to their proper position with reestablished midline continuity, showing effective defect closure and restoration of domain.

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