Perioperative management - Ramirez component separation technique

Complex incisional hernia:

• Incisional hernia with abdominal wall defect:
- Giant hernia, extra-abdominal organ displacement (“loss of domain”)
  - Inevitable abdominal wall hernia (herniation after laparostomy)
  - Partial loss of the abdominal wall and/or skin cover
• Recurrent incisional hernia:
- Following previous direct suture repair
  - Following mesh augmentation (herniation at edge of mesh, rupture or torn out mesh)
  - Following flap transfer (denervation, donor defect)
  - Multiple recurrences

• Superficial and deep skin infection, pressure sores
• Severe cirrhosis of the liver with ascites
• Respiratory infection

• Medical history
• Asking the patient to elevate the upper trunk allows good assessment of the surrounding muscles and the size of the fascial defect.
• Ultrasonography
• CT or MRI
• Pulmonary function testing and echocardiography, depending on the patient’s morbidity

Preoperative pneumoperitoneum for abdominal wall conditioning:

At least 10 days before the planned surgery insert a single-lumen central venous catheter through a trocar into the intraperitoneal space. Over a period of 10 days, insufflate 1 liter of ambient air per day into the abdominal cavity, thereby expanding the abdominal wall.

General risks as in any other surgical procedure:

• Bleeding
• Secondary bleeding
• Hematoma
• Thrombosis
• Embolism
• Injury to adjacent structures such as nerves, vessels, bladder, and intestines
• Impaired intestinal passage (atony/ileus)
• Secondary healing
• Infection and abscess

Special risks:

• Limited movement
• Chronic pain
• Wound seroma
• Mesh migration
• Mesh infection
• Mesh rupture
• Recurrence