Carlos Javier García Sánchez (Seville / ES), Francisco Moreno Suero (Seville / ES), Fátima Aguilar del Castillo (Seville / ES), Isidro Martínez Casas (Seville / ES), Virginia Durán Muñoz-Cruzado (Seville / ES), Felipe Pareja Ciuró (Seville / ES)
Abstract text (incl. references and figure legends)
CASE HISTORY
72-year-old male presented to the emergency department with diffuse abdominal pain and intestinal obstruction. Past medical history of sigmoidectomy due to large bowel volvulus.
CLINICAL FINDINGS
Clinical exploration revealed a giant multi-sacular incisional hernia (EHS class M2-4bW3 with loss of domain and M1-2 W2 with signs of incarceration).
INVESTIGATION/RESULTS
Abdominal CT scan showed giant hernia with a 12cm diameter ring containing jejunum, ileum and sigmoid colon, and an epigastric hernia with a 7 cm ring containing transverse colon and causing a retrograde dilation with a 9cm caecum.
DIAGNOSIS
Bowel obstruction secondary to incarcerated ventral hernia resulting in large abdominal wall defect.
THERAPY AND PROGRESSIONS
Despite an initial conservative treatment with NG-tube considering the complex hernia repair and the patient stability, on day 3 patient worsened and we decided an exploratory laparotomy. 30cm ischemic small bowel was encountered. Due to patient instability, we opted to resect the necrotic small bowel deferring the anastomosis and placing an open abdomen system with a mesh for fascial traction. In the second surgical revision an anastomosis was performed and after a 4º surgical review (POD 7), due to the impossibility for primary closure, a vertical fascial traction system (Fasciotens®) was placed, with 16cm of fascial defect. After 3 days of Fasciotens® therapy, on POD 10 fascial closure was performed by means of an anterior component separation and an onlay mesh. An ileostomy was performed too because of an anastomotic leak.
COMMENTS
Surgical management of complicated giant incisional hernias with loss of domain is challenging and a clear strategy remains to be defined. In this setting, the use of an open abdomen system combined with vertical fascial traction could be a good approach to achieve fascial closure without tension.
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