Open Repair of a Large Ventral Hernia Requiring Caecopexy and Appendicectomy in an Elderly Patient

Abstract Aim To present an interesting and challenging case of a large ventral hernia repair requiring caecopexy and appendectomy. Material and Methods An 83-year-old woman with hypothyroidism and hypertension but no other comorbidities presented to the outpatient clinic with a very large hernia which she said had been present for 20 years. On clinical examination the hernia was very large and irreducible containing bowel. The CT scan of the abdomen and pelvis showed a defect of 5 cm with a sac of 21 cm width containing loops of both large and small bowel including the entire right and transverse colon. The procedure comprised skin incision followed by dissection of the sac from the skin and subcutaneous fat. The neck of the hernial sac was identified and opened. Safe entry into the abdomen. Minor adhesiolysis of the omentum from the sac. Small bowel was traced from the ileocaecal junction to the duodenojejunal flexure. Appendix identified and removed. Caecum and ascending colon were reduced in the peritoneal cavity and fixed to the lateral abdominal wall with non-absorbable sutures (caecopexy). Small and large bowel were placed in anatomical position. A small part of the omentum was removed. Rives-Stoppa technique was used. The right and left rectus sheaths were opened the posterior rectus sheath was identified and the retrorectus space was developed. Neurovascular bundles were identified and preserved. Dissection continued towards the xiphisternum and pubis. The posterior rectus sheaths (right and left) were sutured together. A 30 × 30 lightweight microporous mesh was deployed into the retrorectus space. The anterior rectus sheath was closed with a non-absorbable suture. Haemostasis was achieved. 2 negative pressure 14 French drains were placed over the mesh in the retrorectus space. Another drain was placed in the subcutaneous space. Results The patient's post-operative course was uneventful, she remained in intensive care for 5 days and was discharged after 2 weeks of ward care. Her discharge was delayed due to the need for extensive physiotherapy. At 6 months follow-up, the patient was well and satisfied with the outcome of the procedure. Conclusion Ventral hernia repair in elderly patients can be challenging and have a long recovery, in some cases a combined intrabdominal approach is feasible with good outcomes. A surgeon with an interest and experience in abdominal wall surgery can offer a safe and efficient approach to these cases.