COMPLEX ABDOMINAL WALL SURGERY

Good afternoon, There are situations in which, as surgeons, we face significant challenges, as in the case presented below. This is an elderly, multi-operated patient who presented with full-thickness evisceration along the entire length of a previous laparotomy performed for a sigmoid volvulus. The initial surgery had been complicated by suture dehiscence, requiring reoperation and resulting in a terminal colostomy. At the time of surgery, we found a completely open abdominal wall, with only a continuous suture partially holding the tissues, associated with tearing of the aponeurosis on one side. Despite performing a component separation, which was particularly challenging due to the presence of a colostomy, it was not possible to approximate the fascial edges. Therefore, we opted to place a viscera-contact mesh using an inlay technique, followed by skin and subcutaneous closure with a tubular drain. The patient had a favorable postoperative course and was discharged after 10 days. The inlay technique is known to have the worst long-term outcomes, with a high likelihood of developing an incisional hernia that may eventually require reoperation. However, in my view, the option chosen was appropriate in that context and was valuable in the acute setting, as it stabilized the abdominal wall and contributed to saving the patient. I would be interested to hear your thoughts on this approach.