Complicated incisional hernia repair for a giant parastomal hernia with open, retromuscular bioprosthetic mesh augmentation

Status post median laparotomy with sigmoid resection and creation of an end colostomy (Hartmann's situation). Now progressive scar hernia recurrence with skin ulceration and partially exposed mesh after multiple therapeutic attempts, most recently with the implantation of a non-resorbable mesh in onlay technique.

After conditioning of the abdominal wall through a preoperative progressive pneumoperitoneum (see Sublay Open Perioperative Management), a renewed hernia repair is performed using the technique described here. The AP reversal offered to the patient with reconnection of the colon was not desired.

In potentially infected sites, the use of a biological mesh is indicated for hernia repair.

First, marking of the incision line, then the skin incision begins laterally on the right. This is successively completed during the course of the procedure to a complete circumcision of the hernia sac and excision of the ulcerated and thinned skin areas.

Starting on the right side, exposure of the fascial edge and epifascial preparation from the upper wound pole down to the symphysis using bipolar scissors. Beginning of the complete removal of the insufficient scar tissue, which is completed in the fourth step, including the synthetic mesh up to the edge of the rectus abdominis muscle. This results in the opening of the abdominal cavity, revealing bowel loops as scar-adherent to the hernia sac or former onlay mesh. The adherent small bowel loops are carefully, step-by-step detached, and on the left side, the colon loop, which is led out as an end stoma, is exposed.

Tip:
Depending on the situation, a normal dissecting scissors, bipolar scissors, or a scalpel is used for the maneuver.

This is followed by an extensive adhesiolysis with consideration of the terminal colostomy.

Scar and old mesh as well as excess portions of the hernia sac are removed.

Detachment of the subcutaneous tissue from the anterior rectus sheath laterally to reach the myofascial transition of the external oblique muscle. Approximately 1 cm lateral to the rectus muscle, the external oblique aponeurosis is vertically split along its entire length from below the anterior superior iliac spine to cranially 2-3 cm above the chondrocostal margin. Further dissection is performed bluntly in the avascular and nerve-free layer between the external and internal oblique muscles at least to the mid-axillary line.

Note 1: It is important not to go under the internal oblique muscle, as this could compromise the segmental innervation and blood supply of the rectus muscle.

Note 2: A relief incision on the left side is only possible if the stoma is actually placed in the area of the rectus muscle.