Klewitz Robin, Menzel Magdalena, Holzner Philipp, Fichtner-Feigl Stefan, Hipp Julian
Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0099. Epub 2025 Jul 11.
Loss-of-domain in large incisional hernia needs to be addressed by mesh-augmented repair combined with a combination of component separation techniques: progressive pneumoperitoneum (PPP) and chemical component separation with botulinum toxin A. In this case report, successful management of an iatrogenic peritonitis caused by PPP with nevertheless definitive treatment of a giant loss-of-domain ventral hernia is presented.
A female patient with M1-3W3 recurrent incisional hernia with a loss-of-domain of 47% was prepared for definitive ventral hernia repair by chemical component separation with botulinum toxin A-infiltration and PPP via an intraperitoneally placed central venous catheter. A significant increase of inflammatory markers was found after 28 days. An emergency CT scan was performed, which showed the PPP and perihepatic/perisplenic contrast-enhancing fluid collections. Exploratory laparoscopy and laparotomy revealed no bowel perforation but fibrinous peritonitis due to an iatrogenic PPP-catheter-associated peritonitis. Despite the fibrinous peritonitis, we decided to proceed with definitive ventral hernia repair (Rives-Stoppa-Sublay-Herniotomy with transversus abdominis release (left) and anterior component separation (right), 42 × 30 cm permanent polypropylene mesh). Initial calculated antibiotic treatment was performed with piperacillin/tazobactam. Microbiologic examinations revealed in the intraoperative specimens on postoperative day 1 and the antibiotic treatment was changed to intravenous flucloxacillin for 14 days after surgery. The further hospital stay was uneventful and the patient was discharged on the 20th postoperative day.
The presented case demonstrates the possibilities in complex ventral hernia repair to achieve a satisfying outcome for the patients. Even in cases with infectious complications, a single-stage procedure might be performed safely and a complete reconstruction of the abdominal wall might be achieved. The risk of chronic mesh infection in contaminated situations, especially during the presence of , remains uncertain and has to be weighed against possible benefits.
大型切口疝的区域丧失需要通过网片增强修补术结合多种组织分离技术来解决：渐进性气腹术（PPP）和肉毒杆菌毒素A化学组织分离术。在本病例报告中，介绍了由PPP引起的医源性腹膜炎的成功处理方法，同时对巨大的区域丧失性腹疝进行了确定性治疗。
一名患有M1-3W3复发性切口疝且区域丧失达47%的女性患者，准备通过肉毒杆菌毒素A浸润化学组织分离术和经腹腔内放置中心静脉导管进行的PPP，来进行确定性腹疝修补术。28天后发现炎症标志物显著升高。进行了急诊CT扫描，显示有PPP以及肝周/脾周对比增强液体积聚。探查性腹腔镜检查和剖腹手术未发现肠穿孔，但发现因医源性PPP导管相关腹膜炎导致的纤维蛋白性腹膜炎。尽管存在纤维蛋白性腹膜炎，我们仍决定继续进行确定性腹疝修补术（采用腹横肌松解（左侧）和前入路组织分离（右侧）的Rives-Stoppa-Sublay疝修补术，使用42×30 cm永久性聚丙烯网片）。最初计算使用哌拉西林/他唑巴坦进行抗生素治疗。微生物学检查在术后第1天的术中标本中发现了 ，术后抗生素治疗改为静脉注射氟氯西林14天。后续住院过程顺利，患者于术后第20天出院。
本病例表明，在复杂的腹疝修补术中，有可能为患者取得满意疗效。即使在有感染并发症的情况下，也可以安全地进行一期手术，并实现腹壁的完全重建。在污染情况下，尤其是在 存在时，慢性网片感染的风险仍不确定，必须与可能的益处相权衡。
