Large complicated hernias were considered untouchable in the past but due to a combination of treatment modalities has made the treatment now possible
by Suman Gupta
Pune: A 67-year-old man suffering from a hernia and having other comorbidities such as hypertension and heart disease was successfully treated with a combination of treatment modalities by a team of Dr Kedar Patil and Dr Rahul Mahadar both Bariatric and Hernia Surgeons at Apollo Spectra in Pune. The patient has been discharged from the hospital and is comfortably doing his daily activities with ease.
Patient Mr Anil Jadhav(Name Changed), who resides in Pune had been dealing with hypertension and heart disease. About a year and a half ago, he had to undergo emergency surgery due to a colonic perforation which is a hole in his large intestine. In these cases, it’s common to divert the small bowel and create an ileostomy – an opening in the abdominal wall. Unfortunately, he later experienced complications including a peristomal abscess and burst abdomen, which resulted from the sutures failing and leaving him with an open wound in his abdominal wall. In a severely undernourished condition, he sought help from Dr Kedar Patil.
Dr Kedar Patil, a Bariatric and Hernia Surgeon at Apollo Spectra in Pune said, “ When he visited to me in September 2022 he had lost about 10 Kg weight, had pain and was not eating well due to pus over abdominal wall.He was earlier operated elsewhere and then referred to me to treat his condition .He was suffering from complications of an ileostomy, a burst abdomen resulting in a non-healing ulcer on his abdominal wall, and a substantial incisional hernia. We did his CT scan of abdomen and Protein levels in blood and initially treated with antibiotics, intravenous protein and supportive care .He required close monitoring and daily dressing to control the pus around the stoma. Once his nutrition improved the ileostomy was closed as the preliminary stage of surgery. It’s not common to combine open bowel surgery with hernia treatment when dealing with a non-healing wound, so the hernia procedure was postponed.
Dr Patil added, “After enduring an unhealed abdominal wound for 8 months, a CT Scan was repeated to evaluate the specifics of the hernia, such as its size, the condition of the abdominal muscles, contents, and so on. The treatment of the hernia presented difficulty due to a substantial 20-centimeter separation between the two rectus abdominis muscles that are typically joined at the center. The small bowel was situated directly beneath the skin within this 20 cm gap, with no muscle or tissue acting as a barrier.
Botox is a neuroparalytic agent commonly used for cosmetic purposes but in this case, it was used to temporarily paralyze the lateral muscles of the abdomen to facilitate midline closure of the widely separated rectus muscles. This procedure was done 6 weeks prior to hernia surgery. He later was scheduled for Progressive Pneumoperitoneum and bilateral Transversus abdominis release
Large complicated hernias were considered untouchable in the past but a combination of treatment modalities has made the treatment now possible. “Earlier large hernias were untouched as the abdominal contents lying outside the abdomen for a long time if returned back to the abdomen caused a rise in intrabdominal pressures causing renal and cardiac complications. With the advent of Botox and preoperative pneumoperitoneum, the intrabdominal volume can now be expanded to accommodate the extrabdominal contents. Progressive pneumoperitoneum is a procedure where a tube is inserted in the abdomen under laparoscopic vision and air is installed in the abdomen to increase the intraabdominal volume. Volume expansion is necessary to accommodate the intestines lying outside the abdomen for a long time ” said Dr Patil.
After Botox and Pneumoperitoneum, the patient underwent surgery known as bilateral transversus abdominis release a type of component separation technique in which abdominal muscles are separated in layers releasing the lateral pull of abdominal muscles and facilitating midline closure. The ulcer over the abdomen was excised and a functional outcome was achieved. The surgery lasted for six hours and the patient was started on liquids on the third day and discharged after 6 days. After 1.5 months, now patient is now doing well and his abdominal tone has normalized with no more abdominal complaints. Has he gained about 7 kgs weight post surgery and can do his daily activities with ease. Not treating him at the right time could have led to complications.He is advised to wear a abdominal corset for support and not to lift heavy weights for 3 months .Treating large complex hernias requires CT Scan for assessment followed by a thorough planning and execution by team of experts .The post surgical care is equally important
Patient Mr Anil Jadhav recounted, “For nearly two years, I was plagued by pain and abdominal swelling . My weight dropped dramatically and carrying out everyday tasks became a challenge. I found myself relying heavily on my family. Fortunately, I managed to pull through due to the timely intervention by a skilled team of doctors at Apollo Spectra.”
