Introduction

Primary abdominal wall hernia is a worldwide common disease, with an estimated occurrence of 20% in adults [1]. A primary (non-incisional) hernia mostly occurs in the naturally weak points of the abdominal wall. In addition to the inguinal area, this mainly affects the umbilical and epigastric region. There is an indication for treatment in case of incarceration (emergency) or discomfort of the patient. High intra-abdominal pressure (e.g. obesity, chronic cough, chronic obstructive pulmonary disease, vomiting, ascites, pregnancy) can significantly increase the risk of development as well as the size of the hernia sac. Smoking and alcoholism are additional risk factors that should be addressed and minimized, if possible, before treatment is desired [2].

Case Presentation

A 58-year-old male patient presented to our clinic in October 2022 with a huge primary umbilical/ventral hernia (EHS classification M3W3). He reported having the hernia for at least 7-8 years, with rapid increase in size over the past 6 months. Despite the enormous size of the hernia, he had no symptoms until 2 months before presenting in our clinic. The patient also had type 2 diabetes mellitus on medication (metformin 1000mg 3/d; Ozempic 0.75mg 1/week), hypertension, moderate obstructive sleep apnea/ hypopnea syndrome, bronchial asthma, atrial fibrillation (on Eliquis 5mg 1-0-1) and grade III obesity with a BMI of 47.7kg/m². He had no prior abdominal surgery.

Clinically, we found a huge ventral abdominal wall hernia with the hernia sac starting above the umbilicus (Figure 1).

Figure 1: Pre-Operative clinical finding of the giant ventral abdominal wall hernia. Left in supine position, right standing patient.

The hernia sac overlapped the inguinal/genital region. Preoperative CT scan (24^th of October 2022) revealed an abdominal wall hernia with a defect of the abdominal wall measuring 5.5 x 6 cm. The hernial sac included the transverse colon and parts of the small intestine without signs of incarceration. We estimated a loss of domain of 30% bowel outside the abdominal cavity. In addition, there was a small inguinal hernia on the left side. No other relevant pathologic findings. Sections from the CT scan are shown in Figures 2 to 4 to illustrate the size of the hernia (Figure 2-4).

Figure 2: CT-Scan 24.10.22 axial scan left to right - cranial to caudal; red lines illustrating the hernia sac.

Figure 3: CT-Scan 24.10.22 coronary scan – dorsal to ventral; red lines illustrating the hernia sac.

Figure 4: CT-Scan 24.10.22 sagittal scan; red lines illustrating the hernia sac.

Because of the bizarre findings, we planned early surgical management of the hernia to avoid incarceration or strangulation of the overlapping bowel as well as vascular injury of the small bowel mesentery. For this purpose, we omitted preoperative Botox infiltration, which would have meant delaying the operation another 4-6 weeks. Therefore, we discussed the that in case of significant fascial tension and/or intraoperatively high estimated risk of postoperative abdominal compartment syndrome, a transversusabdominis-release (TAR) would be performed. The patient was informed in detail about the procedure, possible adjustments during surgery, peri- and postoperative complications, especially pulmonary complications, an abdominal compartment and the risk of infection or seroma in the setting of mesh implantation. The patient was also informed about postoperative wound treatment by vacuum dressing, as well as secondary wound closure with corresponding time expenditure.

The patient was in the supine position and under general anesthesia. Disinfection of the abdomen followed by standardized sterile draping. The patient received an i.v. antibiotic injection of Kefzol 3g (1^st generation Cephalosporine) preoperatively and repeated Kefzol 1g after 2 and 6 hours. After the routine “team time-out,” a median laparotomy was performed. Especially in the umbilical region there were severe adhesions, which made the separation of the hernia sac from the subcutaneous fat difficult and time-consuming. We entered on the fascia, which was well exposed beyond the hernia-rim. The space in the abdomen was clearly limited, therefore it was evident that a TAR would be necessary to avoid a compartment syndrome by having a tension free closure of the two rectus sheaths in the end. In addition, the decision was quickly made to perform a total omentectomy. The intestines were carefully reduced, the mesentery of the small bowel was totally dislocated. The entire ascending colon, transverse colon and about half of the small intestine were fused to the mesentery within the hernia. Debridement and complete adhesiolysis was performed. Provisional closure of the peritoneum was done to continue with the next step in the sublay-layer. Incision of the left posterior rectus sheath relatively cranially and entering retro-muscular space. This plane was dissected free, bone-to-bone (xiphoid to pubic tuberosity) under precise hemostasis. The same procedure was done on the right side. At this moment it was totally impossible to close the two rectus sheaths. Therefore, the TAR was performed: We started cranially and on the left side. Incision of the posterior rectus sheath about 1 cm away from the margo lateralis under preservation of the small perforating vessels. Visualization of the transverse muscles, which were gradually loaded on a Rommel and cut with electrocautery, from the costal arches downward to beneath the anterior superior iliac spin (ASIS). A decision must be made whether the inguinal hernia treatment on the left side should be performed at the same time: We refrained from doing so because even the largest available Phasix mesh (50 x 50 cm) would have been too short to cover both hernias properly. Since the patient was asymptomatic in this respect, we decided against the additional procedure. Same procedure was done on the right side. Now the intestines were reduced without problems and the rectus sheaths was sutured together without tension. The skin surrounding the hernia sac was removed due to its poor condition (Figure 5) and a radical panniculectomy up to the fascia was performed.

Figure 5: intraoperatively removed skin-flap of poor conditioned skin once covering the hernia-sac.

The closure of the posterior rectus sheath was performed with PDS Loop 2-0 running suture. We trimmed and adjusted the Phasix mesh (43 x 40cm). The fixation of the mesh is done with Prolene 2-0 caudally (ASIS and Lig. Coopery) and laterally. Additional fixation with Vicryl 2-0 in single knot technique and Histoacryl-glue. We inserted in total 4 redon drains on the mesh. After flushing the situs with Ringer-Solution the ventral rectus sheath was closed tension-free by a PDS 1-0 Loop followed by a partial skin closure and installation if a vacuum dressing (-120mmHg).

Postoperatively, the patient was transferred to our intensive care unit for the first night. Thromboprophylaxis was started 6 hours after completion of surgery. A final antibiotic treatment with Kefzol 1g was given 4 hours postoperatively. Two drains were removed on day 3 and the last two on day 4 after surgery. The patient was pain-controlled with a peridural catheter. The preoperatively paused oral anticoagulation was reestablished on day 6. He was discharged home in good condition on day 8. Frequent follow-up was performed in our wound outpatient clinic. The vacuum dressing was successfully removed on 6^th of December 2022. Further treatment was with betadine and moist compress. Secondary wound healing was continued with successful results until the end of January 2023 (compare Figure 6).

Figure 6: Demonstration of the wound-healing process after surgery.