Route for a Successful Repair in a Severe Eventration With Loss of Domain: Botox-Pneumoperitoneum and Malmö Repair

Background Highlight the surgical challenge of rehabilitating the abdominal wall in a severe case of ventral hernia. Method We present a video of the safe surgical repair of a midline abdominal incisional hernia with loss of domain, employing component separation and closure according to Malmö’s technique, with previous prehabilitation with botulinum toxin infiltration and pneumoperitoneum therapy. Results 42-year-old patient with obesity and complex abdominal incisional hernia, following a midline laparotomy for intestinal obstruction requiring resection and ileostomy due to strangulated umbilical hernia. Subsequently, an open abdomen surgery resulted when attempting ileostomy closure. Abdominal CT scan showed a large incisional hernia (M1-2-3 W3 + L1 W1) with loss of domain. We indicate prehabilitation with 20 kg weight loss, infiltration of botulinum toxin two months before surgery and progressive pneumoperitoneum therapy 12 days before final procedure involving instillation up to 13 Lt of air. Surgical repair was performed with laborious dissection of the sac and adhered bowels, without evidence of lesions. Lateral eventration of the old ileostomy’s closure is carried out with preperitoneal mesh. For midline reconstruction we choose Malmö’s technique to guarantee tension-free closure, with a retromuscular mesh. The skin was reconstructed with an inverted T incision. Thanks to the meticulous preoperative preparation combined with ERAS program, the patient was discharged on 5th postoperative day. Conclusion Incisional hernias with severe loss of domain require an exhaustive study and preparation, to avoid intra- and post-operative complications. Prehabilitation of the abdominal wall and patient must be taken into account prior to performing this type of reconstruction.