الفهرس 
Anatomy of the anterior abdominal wallOnly 14 pages are availabe for public view
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Abstract
Summary
This study was conducted on 30 patients with large ventral hernias underwent elective open repair by components separation technique with giant onlay mesh.
There were 29 females and one male, with a mean age of 50.2 ± 8.7 years and a mean BMI of 33.1 ± 3.8 kg/m².
The most common clinical presentations were discomfort from huge abdominal swelling (100% of patients) and persistent pain in 46.6%.
The predisposing risk factors for hernia occurrence were: obesity in 70%, multiparity in 93%, DM in 26 %, drugs hindering the healing in 16.7%, chest disease in 16.7% and chronic liver disease in 13.3%.
This study included 19 incisional hernias and 11 PUHs (7 de novo and 4 recurrent).
All incisional hernia patients had previous midline incisions (midline above and below the umbilicus in 47.3%, lower midline in 36.8, upper midline in 15.7%) resulting after elective surgery in 11 patients (57.8%) and emergency surgery in 8 patients (42.2%). Twelve patients presented with incisional hernia for first time, 5 patients with one recurrence and two patients with 2 recurrences.
The period of presence of hernia was <2 years in 36.6% of the cases, 2-<4 years in 26.6%, 4-<6 years in 20% and ≥6 years in 16.6%.
Regarding preoperative laboratory investigations, the mean of hemoglobin was 12.2 ± 1.1 gm/dl, the mean of albumin was 3.9 ± 0.3 gm/dl and the mean of creatinine was 0.5 ± 0.1 mg/dl. Urine culture and sensitivity was done for one patient with colo-ureteric fistula. CA19.9 and CEA were done for a patient with previous resection of colonic carcinoma.
Routine US was performed for all patients revealing 6 patients with gall bladder stones. CT examination was performed in 2 patients. Upper endoscopy was performed for 6 patients (4 with chronic liver disease and 2 with history of perforated peptic ulcer). Lower endoscopy was done in 2 patients.
The mean width of hernia defect was 11.3 ± 2.1 cm and the mean length was 10.8 ± 3.6 cm. Complete components separation technique (anterior external oblique aponeurosis release incision ) was performed in 13 patients (defect width > 9-12 cm), complete technique (anterior external oblique aponeurosis release incision and posterior rectus sheath release) was performed in 7 patients (defect width >12-15 cm) and partial technique (anterior external oblique aponeurosis release incision) was performed in 10 patients (defect width 6-9 cm).
Tensionless midline fascial closure was successfully performed in all the cases. The peak airway pressure showed no change when measured pre-, intra- and postoperatively. The mean of external oblique aponeurosis gapping was 4.9 ± 0.6 cm on the right side and 4.7 ± 0.7 cm on the left side. A significant correlation was found between the width of the defect and the maximum gapping of external oblique aponeurosis till certain width >12-15 cm when the maximum gapping became constant and hence, posterior rectus sheath release incision was required to compensate this difference between the defect width and the maximum gapping allowing for tensionless midline closure (23.3% of the patients). This correlation helped to tailor progressive steps of components separation release incisions for tensionless fascial closure according to the width of the defect.
Hernia repair was associated with; panniculectomy in 16 patients, cholecystectomy in 6 patients, left nephro-uretrectomy and left hemi-colectomy with primary anastomosis in one patient and colo-rectal anastomosis after hartmann’s procedure.
Complete components separation technique was done in 20 patients with a mean operative time of 166 ± 21.9 min and partial components separation technique was done in 10 patients with a mean operative time of 135 ±15 min. The mean hospital stay was 4.8 ± 1.4 days and the mean time of drain removal was 14.7 ± 1.4 days.
Postoperative complications occurred in 33.3% of patients with more than one complication in one patient, seroma in 13.3% of the patients which was managed conservatively by US guided aspiration, subcutaneous haematoma in 10% which was managed conservatively, superficial skin gangrene in one patient, partial wound dehiscence in 20% which was managed conservatively with daily dressing and left open to heal with secondary intention and superficial wound infection in 10% which was treated with daily dressing and antibiotics after culture and sensitivity.
There was no hernia recurrence in our study with a mean follow up of 14.7 months.