General Surgery · Year 3 · from General Surgery

Case 3: Recurrent Ventral Hernia with Loss of Domain

Patient Demographics

  • Age: 55 years
  • Sex: Female
  • Occupation: Administrative assistant

Chief Complaint

"My hernia keeps getting bigger and is causing back pain."

History of Present Illness

The patient presents for surgical consultation regarding a large ventral hernia. She underwent open cholecystectomy 15 years ago, complicated by wound infection. She developed an incisional hernia 2 years later, which was repaired with mesh. The hernia recurred 5 years ago and has been progressively enlarging. She now has difficulty with activities of daily living, experiences chronic back pain from altered posture, and has skin breakdown over the hernia. She has had two episodes of partial incarceration requiring ED visits.

Past Medical History

  • Morbid obesity (BMI 42)
  • Type 2 diabetes (HbA1c 8.4%)
  • Hypertension
  • Obstructive sleep apnea on CPAP
  • Previous surgeries:
  • Open cholecystectomy (complicated by wound infection)
  • Ventral hernia repair with mesh (recurred)

Medications

  • Metformin 1000 mg twice daily
  • Glipizide 10 mg twice daily
  • Lisinopril 20 mg daily
  • HCTZ 25 mg daily

Physical Examination

  • Vitals: BP 142/88 mmHg, HR 78 bpm, BMI 42
  • General: Morbidly obese female in no acute distress
  • Abdomen:
  • Large midline ventral hernia, approximately 20 cm wide
  • Hernia contains significant bowel content
  • Reducible with patient supine and relaxation
  • Fascial defect estimated at 15 cm
  • Skin changes over hernia with areas of thinning
  • Previous surgical scar incorporated into hernia

Imaging

CT Abdomen/Pelvis:

  • Large midline ventral hernia with 18 cm fascial defect
  • Hernia sac contains transverse colon and multiple loops of small bowel
  • Loss of domain present (>50% of abdominal contents outside peritoneal cavity)
  • Previous mesh not visualized (likely degraded or displaced)
  • Liver and remaining intra-abdominal organs normal

Preoperative Optimization Plan

1. Weight Loss Program:

  • Referred to bariatric medicine
  • Goal: Lose 10% body weight before elective repair
  • Nutrition counseling and supervised diet
  • Consider bariatric surgery consultation

2. Diabetes Optimization:

  • Endocrinology referral
  • Goal: HbA1c <7.5%
  • Medication adjustment

3. Smoking Cessation:

  • Not applicable (non-smoker)

4. Preoperative Conditioning:

  • Progressive pneumoperitoneum considered for loss of domain
  • Pulmonary function testing
  • Cardiology clearance

5. Skin Care:

  • Wound care for skin breakdown
  • Hernia binder for support

Six-Month Follow-up

  • Weight loss: 18 kg (12% of initial weight)
  • HbA1c improved to 7.2%
  • Skin healed
  • Patient now candidate for repair

Surgical Planning

Given the complex hernia with loss of domain, the following approach was planned:

  • Component separation technique (anterior or posterior)
  • Sublay mesh placement
  • Possible progressive pneumoperitoneum preoperatively

Operative Procedure

  • Anterior component separation with bilateral external oblique release
  • Hernia sac dissected and contents reduced
  • Extensive adhesiolysis
  • Primary fascial closure achieved (tension-free)
  • Large sublay (retrorectus) mesh placement
  • Drain placement

Postoperative Course

  • ICU admission for 24 hours (respiratory monitoring)
  • CPAP continued postoperatively
  • Abdominal binder applied
  • Drains removed when output <30 mL/day
  • Discharged POD 7

Teaching Points

  1. Obesity and wound infection are major risk factors for incisional hernia
  2. Loss of domain requires special preoperative planning
  3. Component separation allows tension-free repair of large defects
  4. Preoperative optimization reduces complications
  5. Sublay mesh position has lowest recurrence rate

Clinical Image

Image Description: Surgical illustration demonstrating the component separation technique for abdominal wall reconstruction. The external oblique aponeurosis is released lateral to the rectus sheath, allowing medial advancement of the abdominal wall components to achieve tension-free midline closure.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Abdominal_hernias

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