Case Spotlight

Surgery Case Study

General Surgery

Summary

  • 54 year old male with prior abdominal wall repair with mesh with persistent abdominal wall defect interested in repair.
  • PCP wanted to know the efficacy of surgical repair and appropriate follow-up.
  • Specialist suggested weight loss and other dietary/lifestyle changes regardless of whether or not the patient gets surgery.
  • Specialist also recommended referring the patient to a MIS surgeon who has expertise in complex abdominal wall reconstruction in case new laparoscopic procedures may be useful in their case.

eConsult transcript

PCP submission:

54 male with prior abdominal wall repair with mesh (likely for hernia but unclear) with persistent abdominal wall defect interested in repair. See photo. CT/AP report reveals:  moderate retained colonic stool with multiple loops of bowel are adherent to the abdominal wall mesh likely on the basis of adhesions with dystrophic calcifications in the superior abdominal wall. There is abdominal wall diastases with intact mesh adherent to loops of underlying small bowel. The defect measures approximately 7.8 cm in transverse diameter. 

Is this something that could be repaired easily or would it be a highly morbid surgery with potential worse outcome. If repairable – would this be by plastics or general surgery?

Specialist response:

Thank you for this consult and for involving me in your patient’s care. This is an excellent question regarding the ability to repair and the morbidity of such a surgery. Indeed this is a complex recurrent ventral hernia. Here are a few recommendations: Whether or not the patient moves forward with surgery then can reduce the morbidity of this recurrent ventral hernia/diastases by working on weight loss. Weight loss will also definitely be important if the patient does undergo surgical repair to help reduce the risk of complications. A few suggestions include increasing protein intake to 60 to 80 grams per day, decreasing carbs to a maximum of 70 grams per day, avoiding simple carbs like white bread, rice, and fried foods, starting with protein in the mouth first, reading labels and avoiding foods that have sugar in the first three ingredients, avoiding sugary drinks and beverages, exercise (even walking) 3 x per week at least, aiming for increased water intake.

I also recommend the patient keep their bowels moving and start a bowel regimen to avoid constipation. The CT in 2020 revealed constipation which can worsen hernia symptoms. We use a capful of mirilax daily and keep hydrated. Finally, recommend referring to an MIS surgeon who has expertise in complex abdominal wall reconstruction. There are new laparoscopic procedures that may be useful in this case where the hernia is repaired in the preperitoneal (retrorectus) space avoiding the bowel altogether. The patient will most likely require a new CT with contrast to plan surgical repair. And, discussing good nutrition prior to surgical repair is also of help. Hoping this is helpful and wishing the patient well.

Tags: community resources, efficacy of treatment, abdominal wall defect, hernia