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June 2012 Hernia Newsletter >>
Clinical Scenario: Progressive Pneumoperitoneum Before Open Repair of Large Ventral Hernia
A patient presented with a very large ventral hernia and significant loss of abdominal wall domain. He will undergo several procedures, including progressive preoperative pneumoperitoneum, before component separation and open repair.
A 50-year-old man presented with a very large (at least 20 cm wide) ventral hernia and abdominal pain that rated 7 on a scale of 1 to 10.
Two years earlier, as a result of a gunshot wound, the patient had undergone a laparotomy with resection of the small and large bowels. A subsequent wound infection and dehiscence caused the hernia to progressively enlarge, causing significant loss of abdominal wall domain, and affecting the patient’s breathing and posture.
The patient had also undergone previous umbilical hernia repair. He is obese and has asthma, COPD, hypertension, diabetes, hyperlipidemia, and obstructive sleep apnea that requires CPAP therapy. He was a tobacco user at the time of the initial evaluation, though upon orders, had stopped smoking and was nicotine-free at his next preoperative clinic visit.
Because of the size of the hernia and extensive loss of domain, and to reduce the risk of postoperative abdominal compartment syndrome, we recommended that this patient undergo several procedures before hernia repair.
In the first procedure, will we insert a peritoneal dialysis catheter and an inferior vena cava filter. Then, while the patient remained in the intensive care unit, we will begin progressive pneumoperitoneum, continuously inflating his abdomen with medical-grade air. This will stretch his abdominal wall muscles and fascia so that we can achieve complete abdominal closure during the repair.
Finally, we will perform open component separation and ventral hernia repair using mesh.
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