Complex parastomal hernia repair combining double mesh and abdominal wall component separation – A case report and tips for success

Abstract INTRODUCTION: The development of post-operative abdominal compartment syndrome is one of the major risks associated with the repair of massive parastomal hernias. Minimizing the occurrence of such post-operative complications is imperative but challenging. Plastic surgery techniques in complex hernia repairs can offer significant advantages in such complex surgeries. CASE PRESENTATION: We present a case of a 26-year-old, obese, non-smoking male with a massive left-sided parastomal hernia extending below the inguinal region. The hernia was confirmed on a pre-operative computed tomography (CT) and seen to include most of the remaining bowel area. Pre-operative optimization of the abdominal wall was performed by ultrasound-guided botulinum toxin injections to all three abdominal wall muscles bilaterally. The surgery was performed in three steps involving the reduction of the hernia, abdominal wall component separation, closure of the abdominal wall with dual mesh placement, de-epithelization and folding of excess abdominal skin, and repositioning of the stoma. Post-operatively, the patient was followed-up for pain, ventilatory problems, and increasing abdominal pressures. CONCLUSION: Massive parastomal hernia repair avoiding post-operative abdominal compartment syndrome can be achieved by application of a multi-dimensional surgical approach. The use of pre-operative Botox represents an innovative approach that may reduce the risk of post-operative complications.