Incarcerated and eventrated abdominal wall hernia reconstruction with autologous double-layer dermal graft in the field of purulent peritonitis. A case report

• Published in: International journal of surgery case reports 2017-01, Vol.30, p.126-129
• Main Authors: Martis, Gábor, Rózsahegyi, Máté, Deák, János, Damjanovich, László
• Format: Article
• Language: English
• Subjects: Case Report; Dirty wound; Double-layer dermal graft; Eventrated hernia; Incarcerated hernia; Low tension reconstruction; Surgery
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2016.12.002

Highlights • This presentation is the first, successfully applied double-layer autologous dermal graft for eventrated and loss of domain hernia in an emergency case. • Terminal ileum and ascending colon were incarcerated and perforated into the hernia sac causing a CDCP IV (dirty) operating field. • It was impossible to close the 223 cm2 abdominal wall hernia with direct sutures, implantation of synthetic mesh was contraindicated and biological mesh was not available. • Redundant, specially prepared grafts were applied to reconstruct the abdominal wall gap in a double- layer (external perforated one and internal homogeneous), tension free fashion. • No hernia recurrency was observed 8 months after the surgery. INTRODUCTION Double-layer dermal grafts are used for the management of complicated abdominal wall hernias in obese, high risk patients. The method has not yet been used in case of emergency in septic/dirty environment. CASE REPORT A 76-year old female patient (BMI 36.7 kg/m2 ) was admitted with mechanical bowel obstruction and sepsis caused by a third time recurred, incarcerated and eventrated abdominal wall hernia. During the emergency surgery perforation of the terminal ileum and the ascending colon was detected, along with a feculent peritonitis and extended abdominal wall necrosis. Extended right hemicolectomy and necrectomy of the abdominal wall were performed. The surgery resulted in an abdominal wall defect measuring 223 cm2 , for the management of which direct closure was not possible. Using a specific method, an autologous dermal graft was prepared from the redundant skin. The first dermal graft was placed under the abdominal wall with 5 cm overlap, and the second layer was placed onto the first layer with 3 cm overlap in a perforated fashion. The operating time was 250 minutes. No significant intra-abdominal pressure elevation was measured. No reoperation was performed. On the fifth postoperative day, the patient was mobilised. She was discharged in satisfactory general condition on the 18th postoperative day. There is no recurrent hernia 8 months after the surgery. DISCUSSION Abdominal wall reconstruction was possible in a necrotic, purulent environment by using a de-epithelised autologous double layer dermal graft, without synthetic or biological graft implantation. The advantage of the procedure was cost-effectivity, and the disadvantage was that only in an obese patient is the sufficient quantity of dermal graft available. CONCLUSION A