Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach

Background: The management of massive ventral hernias with loss of intra-abdominal domain is a challenging surgical dilemma. We report a novel approach for repairing these extremely complicated hernias. Methods: We retrospectively reviewed our experience with the staged resection of Gore Tex Dual mesh (WL Gore and Associates, Flagstaff, AZ) in the setting of massive abdominal wall defects. The initial stage involves reduction of the hernia and placement of a large sheet of Gore Tex Dual mesh secured to the fascial edges. Subsequent stages involve serial excision of the mesh until the fascia can be approximated in the midline without tension. Finally, the mesh is excised, and the fascia is reapproximated with component separation and AlloDerm (Lifecell Corporation, Branchburg, NJ) underlay. Results: We have performed this procedure on 8 patients, with a mean age of 53 years (range 35-76). All patients had multiply recurrent ventral hernias with an average of 4.3 prior laparotomies (range 2-9). The fascial defect averaged 535 cm² (300-884 cm²), and on average 6 serial operations were necessary to achieve fascial closure. The average length of stay was 36 days (range 9-90). One patient developed a postoperative wound infection requiring operative debridement, and 1 recurrence was identified during follow-up after an early wound complication. Conclusions: Serial Gore-Tex excision to facilitate primary fascial closure with AlloDerm sublay is an effective treatment for massive, incisional hernias with loss of abdominal domain and avoids the risks associated with long-term prosthetic fascial closures.