Society for Surgery of the Alimentary Tract
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Goran T. Andersen*, Erik A. ELDEN, Dmitrij Vorontsov, Hallvard Græslie
Department of Surgery, Sykehuset Namsos, Namsos, Norway

Background: Complex ventral hernia are considered to be a surgical challenge due to high recurrence rate, previous major surgery and often comorbidity with obesity. This case report illustrates how a complex ventral hernia repair with obesity and multiple stomas can be managed by a staged minimal invasiv approach in local hospital in collaboration with the obesity team.

Case presentation: After robotic-assisted radical prostatectomy in 2016 the patient had a secondary operation with laparotomy due to small bowel obstruction. This led to a lower ventral hernia and the patient had minimal invasiv intraperitoneal onlay mesh repair (IPOM+) repair in 2018. Unfortunately, the patient developed shortly afterwards port site herniation with bowel obstruction. This resulted in bowel ischemia and new laparotomy with mesh removal, right sighted hemicolectomy, ileostomy and colostomy. In the spring 2021 the patient had a complex ventral hernia with a transverse defect on 17 cm and a longitudinal defect on 23 cm, colostomy in the upper part of the hernia and ileostomy with a separate parastomal hernia in the lower right quadrant. In addition obesity with BMI 35.8. Firstly, the patient was referred to a dietitian and started on weight loss medication with goal of achieving a BMI<30 at abdominal wall reconstruction. To manage the complexitiy of one large ventralhernie, separate colostomy and ileostomy with parastomal hernia we decided to plan for staged approach with two operations. In June 2021 laparoscopic closure of ileostomy and colonstomy with ileotransversal anastomosis was performed successfully. December 2021 the patient received 300 IE Botox bilaterally in the lateral abdominal muscles. January 2022 we performed abdominal wall reconstructive surgery with a combination of laparoscopic surgery and open surgery – hybrid operation. We conducted laparoscopic TAR bilaterally with laparoscopic suturing of the posterior retromuscular layer. Afterwards, we performed scar and hernia sac excision and we placed a 45x30 cm mesh in the retromusculuar space and fixated it with tisseal glue. The midline and the anterior rectus sheath was adapted with stratafix. Postoperatively, no surgical complications, but prolonged stay for 10 days due to pneumonia. Outpatient control with CT scan after surgery shows complete reconstruction of the abdominal wall and so fare the patient has had a satisfactory outcome.

Conclusion: This case report illustrates how a complex large ventral hernia with two separate stomas can be successfully repaired with minimal invasive technique. It also demonstrates the importance of long term planning and involvement of the obesity team for these complicated cases.

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