bda23054
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PREOPERATIVE DIAGNOSIS
Incisional hernia.
POSTOPERATIVE DIAGNOSIS
Incisional hernia.
NAME OF OPERATION
Exploratory laparotomy, component separation, myofascial release bilaterally, biologic mesh placement, and repair of incisional ventral hernia.
INDICATIONS
This was a 90-year-old female who was known to me from initially having an intracutaneous fistula through an infected mesh that had to be removed approximately 2 years ago. At that time she had a large ventral hernia and that was the reason the mesh was placed initially, but she developed a fistula in which we had to remove the mesh. She subsequently the re-developed the incisional ventral hernia and was brought in this time for closure with component separation.
DESCRIPTION OF OPERATION
The patient was brought to the Operating Room table and placed in the supine position. General endotracheal anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion. A vertical skin incision was made through the easily palpable defect, very saucily because you could see peristalsis just beneath the skin surface. This was carefully dissected through the subcutaneous tissues until the hernia sac was identified and opened using Metzenbaum scissors. Again, there was noted to be large amounts of small bowel contained within the large ventral hernia which measured approximately 17 cm vertically, greatest diameter. All contents were reduced. The hernia sac was then excised and there was obvious tension when primary closure was attempted. So, it was decided to proceed only with a component separation, myofascial release. Flaps were developed between subcutaneous tissues and the anterior rectus sheath all the way out to the external oblique aponeurosis, where a superficial incision was made through the aponeurosis of the external oblique. This was done bilaterally affording now at this point easy primary closure, and despite this easy approximation of the fascial edges, a Stratus biologic mesh 25 x 10 was then prepared by soaking in saline for 4 minutes and then fixating using transfascial sutures laterally as far as they would go through the myofascial release through the mesh and back through the fascia. These were secured first in all 4 quadrants and then dissecting with more Prolene sutures, 2-0 Prolene used. This afforded a good underlay of the mesh and again primary closure was easily done. Once the mesh placement was completed, the fascia was then reapproximated using an 0-PDS looped suture. Again, this afforded easy primary closure without undue tension after myofascial release. Then, 2 close suction drains were brought through separate stab wound incisions laterally on both sides of the mesh, one was laid starting laterally and swinging superiorly and the other one was laid laterally and running inferiorly. The subcutaneous tissues were then approximated using 3-0 Vicryl. It was noted at this point that there was a large amount of redundant skin, so this too was resected using a 10 blade scalpel to bring in the skin approximation tightly again without undue tension. The skin was approximated using skin staples. A Provena wound V.A.C. system was placed. The wound was then irrigated with approximately 500 mL of normal saline, and suctioned out. Bleeding was controlled with electrocautery and then the wound was approximated using skin staples and a Provena wound V.A.C. system was placed.
Incisional hernia.
POSTOPERATIVE DIAGNOSIS
Incisional hernia.
NAME OF OPERATION
Exploratory laparotomy, component separation, myofascial release bilaterally, biologic mesh placement, and repair of incisional ventral hernia.
INDICATIONS
This was a 90-year-old female who was known to me from initially having an intracutaneous fistula through an infected mesh that had to be removed approximately 2 years ago. At that time she had a large ventral hernia and that was the reason the mesh was placed initially, but she developed a fistula in which we had to remove the mesh. She subsequently the re-developed the incisional ventral hernia and was brought in this time for closure with component separation.
DESCRIPTION OF OPERATION
The patient was brought to the Operating Room table and placed in the supine position. General endotracheal anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion. A vertical skin incision was made through the easily palpable defect, very saucily because you could see peristalsis just beneath the skin surface. This was carefully dissected through the subcutaneous tissues until the hernia sac was identified and opened using Metzenbaum scissors. Again, there was noted to be large amounts of small bowel contained within the large ventral hernia which measured approximately 17 cm vertically, greatest diameter. All contents were reduced. The hernia sac was then excised and there was obvious tension when primary closure was attempted. So, it was decided to proceed only with a component separation, myofascial release. Flaps were developed between subcutaneous tissues and the anterior rectus sheath all the way out to the external oblique aponeurosis, where a superficial incision was made through the aponeurosis of the external oblique. This was done bilaterally affording now at this point easy primary closure, and despite this easy approximation of the fascial edges, a Stratus biologic mesh 25 x 10 was then prepared by soaking in saline for 4 minutes and then fixating using transfascial sutures laterally as far as they would go through the myofascial release through the mesh and back through the fascia. These were secured first in all 4 quadrants and then dissecting with more Prolene sutures, 2-0 Prolene used. This afforded a good underlay of the mesh and again primary closure was easily done. Once the mesh placement was completed, the fascia was then reapproximated using an 0-PDS looped suture. Again, this afforded easy primary closure without undue tension after myofascial release. Then, 2 close suction drains were brought through separate stab wound incisions laterally on both sides of the mesh, one was laid starting laterally and swinging superiorly and the other one was laid laterally and running inferiorly. The subcutaneous tissues were then approximated using 3-0 Vicryl. It was noted at this point that there was a large amount of redundant skin, so this too was resected using a 10 blade scalpel to bring in the skin approximation tightly again without undue tension. The skin was approximated using skin staples. A Provena wound V.A.C. system was placed. The wound was then irrigated with approximately 500 mL of normal saline, and suctioned out. Bleeding was controlled with electrocautery and then the wound was approximated using skin staples and a Provena wound V.A.C. system was placed.
