Clinical examination

Clinically, there was a pronounced abdominal wall defect due to the previous patient history as described above.

CT Scan

The CT scan showed a 16 x 18 cm ventral hernia with no significant loss of domain. The small intestine was directly adjacent to the skin graft, suggesting that extensive adhesiolysis and preparation would be required.

Pre-treatment with Botox

Prior to surgery, the patient was pretreated with Botox to achieve maximum relaxation of the lateral abdominal wall.

Surgical removal of the skin graft

During surgery, the skin graft was carefully detached first. A cholecystectomy was performed before treatment of the hernia was started.

Rives-Stoppa Preparation + Flap

The rectus sheath is opened on the right side ventral to the flap and the posterior rectus sheath is dissected far back to the transverse muscle while preserving the perforating vessels and the epigastric vessels. Repeat the procedure on the left side, incising the rectus sheath on the dorsal side of the flap. The dissection is performed cranially up to the xiphoid process and costal arch, and caudally down to the symphysis.

Closure of the posterior fascia sheet

Thanks to the Botox, the two posterior layers can already be approximated. After appropriate mobilization, the omentum is completely placed over the bowel. The posterior layer is closed with a continuous 2-0 Maxon suture.

Sublay-Mesh

A Dynamesh CICAT was trimmed to dimensions of 13 cm × 30 cm with rounded corners. The mesh was positioned on the posterior layer without tension or folds and secured using 2-0 Surgipro sutures in a U-stitch configuration. A closure of the anterior fascia was impossible, so intraoperative fascial traction was performed.

Intraoperative fascial traction (IFT)

On each side of the defect, 6 USP 2 vicryl sutures were inserted using a U-stich technique. The crossed sutures were fixed into the suture retention frame of the fasciotens®Hernia device. IFT was performed for 30 minutes with a traction force of approx. 16-18 kg. During traction, the ventilation pressure remains stable at 14 mmHg, with no increase due to closure of the abdomen.

Clousure of the anterior fascia sheet

The anterior fascia sheet was successfully closed with the small-bites technique with a 2-0 Maxon suture.

Result before skin closure

Result after skin closure

Postoperative cosmetic result

Postoperative result on the 19th day after surgery.