# Not sure where to begin..need help with component separation, hernia



## bda23054 (Jan 8, 2013)

PREOPERATIVE DIAGNOSIS
Incarcerated incisional hernia.

POSTOPERATIVE DIAGNOSIS
Incarcerated incisional hernia.

NAME OF OPERATION
Exploratory laparotomy, lysis of adhesions and primary closure with Biologic mesh placement. 

INDICATIONS 
This is a 90-year-old female who has had an extensive surgical history, who presents with acute onset of abdominal pain.  CAT scan was done, which showed the small bowel obstruction starting at the level of incisional hernia that was found infraumbilical, so the patient was brought in for hernia repair.

DESCRIPTION OF OPERATION
The patient was brought to the operating table and placed in the supine position.  General  anesthesia was induced.   The abdomen was prepped and draped in the usual sterile fashion.

A vertical skin incision was made through a previous scar the started infraumbilical and continued just above the pubic bone.  There was noted to be thin skin and subcutaneous tissue and there was noted to be a large hernia sac.  This was retracted and opened and there was small bowel contents contained within it that were easily reducible.  It was noted to be viable without strangulation or necrosis.  Once this was done the hernia sac was resected from the subcutaneous layers in its entirety and sent off the table as specimen.  Kochers were then grasped on the fascia and using a component separation technique, or myofascial release, the subcutaneous tissues were divided laterally on both sides until the external oblique aponeurosis was encountered.  An incision was made vertically through it and bilaterally and noted to have more than a 3 cm release on both sides.  This then easily closed the defect and so to reinforce this technique a Stratus Biologic mesh 10x10 cm was then prepared by soaking in saline for approximately four minutes in duration and then using 2-0 Prolene sutures on the corners, the sutures were brought through the fascia, through the mesh and back through the fascia again.  They were then tied and the hernia defect was closed primarily using an 0 PDS suture.  There was noted to be good lay without any tension whatsoever.

The subcutaneous tissues were then approximated using 3-0 Vicryl.  To closed suction drainage were brought through left stab wound incisions and lay on top of the fascia and secured with a 3-0 nylon suture.  The skin was approximated using skin staples and a Provena Wound V.A.C. system was placed.


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## MCook (Jan 9, 2013)

The AAPC has a good article on this surgery.  See:
http://news.aapc.com/index.php/2010/06/expose-the-layers-of-abdominal-wall-reconstruction/


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