PUNE: A 32-year-old man suffering from a giant abdominal hernia, in which nearly one-fifth of the abdominal contents had moved outside their normal cavity, has undergone a complex minimally invasive abdominal wall reconstruction at Inamdar Multispeciality Hospital, Pune.
The patient, Chinmay Shirish Patki, had been living with a progressively enlarging swelling around the umbilicus for nearly two years. The swelling became prominent while standing, coughing or straining and had eventually grown to the extent that the overlying skin began peeling, bleeding intermittently and developing ulceration.
Imaging revealed an abdominal wall defect measuring approximately *12 cm × 8 cm, with a large hernia sac extending to nearly **35 cm × 20 cm. The sac contained mesentery as well as loops of both small and large intestine. Doctors classified it as a *giant irreducible ventral hernia with loss of domain, a condition in which a substantial proportion of the abdominal organs remains chronically outside the abdominal cavity.
“Loss-of-domain hernias are very different from routine hernias. When abdominal contents remain outside for a prolonged period, the abdominal cavity effectively adapts to a smaller volume. Simply pushing everything back and closing the defect can produce excessive intra-abdominal pressure and may affect breathing or organ function,” said Dr Abhijit Gotkhinde, who treated the patient.
The procedure was additionally challenging because the patient had obesity and diabetes mellitus, both of which increase the risk of wound complications and infection following conventional open surgery.
After pre-operative optimisation, doctors performed an advanced laparoscopic reconstruction combining eTEP-RS — enhanced-view totally extraperitoneal Rives-Stoppa repair — with Transversus Abdominis Release (TAR).
The eTEP approach allows surgeons to operate within the layers of the abdominal wall rather than entering through a large external incision. TAR is a component-separation technique that releases deeper abdominal wall muscles, providing additional mobility so that large defects can be closed without excessive tension.
Extensive adhesiolysis was required to separate bowel and other tissues that had become adherent within the hernia sac. A partial omentectomy was also performed before the abdominal wall was reconstructed.
“The objective in a giant hernia is not merely to cover the opening with a mesh. We have to restore abdominal wall anatomy, achieve adequate medialisation of the muscles and create a strong, tension-controlled repair while protecting the bowel,” Dr Gotkhinde said. “A minimally invasive retromuscular approach is particularly useful in selected obese and diabetic patients because it can reduce the large wound burden associated with open reconstruction.”
Following surgery under general anaesthesia, the patient was initially observed in the medical intensive care unit for haemodynamic monitoring and blood-glucose control. He was subsequently shifted to the ward and mobilised with an abdominal binder.
By the second postoperative day, bowel function had returned, his abdominal pain had markedly reduced and his laboratory parameters remained stable, including a white blood cell count of 9,150/mm³. He was discharged home four days after the reconstructive surgery.
“For two years we watched the swelling become larger and became increasingly worried, especially when the skin started breaking down,” the patient’s parents said. “We knew this was no longer a simple hernia. Seeing him walking after such a major procedure and being discharged within a few days was a huge relief for our family.”
Doctors said giant ventral hernias should not be ignored, as progressive enlargement can lead to chronic dragging discomfort, incarceration of internal organ,skin breakdown, bowel obstruction, incarceration and increasingly difficult abdominal wall reconstruction.