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Deltona, FL
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Ok. The following is the op report that one of our surgeon's performed. The mesh rep was in the OR at the time of the procedure and simply suggested coding 15734 (X2). Ugh. Any and all thoughts and/or suggestions are welcome. This was a rather extensive case (compared to our usual) and I don't want to miss anything.

Recurrent Incisional Hernia.

Recurrent incisional hernia with fistulization of the small bowel to the hernia mesh.

Exploratory laparotomy, repair of ventral hernia, mobilization of infected mesh with en bloc resection of small bowel and additional small bowel resection for the bowel obstruction.

Approximately 5 hours

The patient was brought to the operating room. After attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. We made a midline incision trying to get in the abdomen. Midline of this hernia was this subcutaneous big, hard mass which I assumed had something to do with the underlying mesh. As we made our incision, it really was hard to get in. We had to extend the incision infraumbilically, got into the abdominal cavity, we could reach up and we could feel the bowel adhesed to the mesh and this was an old Gore-Tex mesh. The patient had multiple previous repairs and he had an extra abdominal polypropylene mesh as well. We reached up, could feel the mesh from below, extended our incision and then came in from up top and extended our incision down to the mesh once again from the top, this around the xiphoid. Then, took the skin down, realized that we could come down. There was no obvious defect in this area and we were left with our wound being bridged by this large bulky rock hard mass. Eventually we elected to cut into it and there was just a lot of fibrotic material that looked to be avascular, and as we cut down into this area we found an abscess, and that was our clue that we probably had some degree of fistulization of the small bowel. We took some cultures. Cultures came back eventually showing many wbc's and some gram-positive cocci. We irrigated that area up but what we elected to do was that we realized we were going to have to remove all of this mesh, so we made an incision laterally on the wound, took out all that mesh and then as we flipped it up to one side we could see the small bowel adhesed up to the mesh. Some of this material, this was a Gore-Tex mesh, came right out but some of it, the small bowel and probably the area that had fistulized because it was right adjacent to this abscess, was just glued up against that mesh. It defied our ability to find a plane and we realized if we persisted we were going to get into an uncontrolled situation with spillage which we really did not want, and so what we elected was a relatively small area, probably about 8 cm or so, if that, may be 7 cm. We fired a GIA both proximally and distally using green staples and then we took down the mesentery and that freed the area up in its entirety. We then could roll right back over and then we continued to mobilize this mesh. What it really was, was that the mesh had fistulized. There was an abscess within the mesh that had percolating through to the top and this whole area of fibrosis was probably reactive change that we were experiencing on the basis of this infected Gore-Tex. We unscrewed as made at the ProTacks as we could and then just stripped the mesh away and also just cut away a good portion of this defect and handed off the small bowel and the mesh en bloc. Once that was done, we had a much nicer looking situation. We did find one area of small bowel that had been adhesed to the mesh and it looked like it was dilated proximally and collapsed distally. I was not sure if it was obstructed, given this patient's history and the fact that I knew that we are going to have an interesting time getting all this closed. I did not want to come back in so I resected that length of bowel, as well firing a GIA both proximally and distally, mobilizing the small bowel with the Harmonic scalpel. 2-0 silk ties. We did not use the Harmonic scalpel. We reapproximated the mesentery in both areas. Made our anastomoses by opposing the mesentery, then introducing GIAs in both locations, firing them and closing the resulting rents with TA-60 and making sure there were no mesenteric defects. We then irrigated copiously with about 3 liters of antibiotic containing solution and then we turned our attention to the repair.

We mobilized the abdominal wall very generously, going way laterally to the external obliques on both sides. We thought about doing a component release but we thought we could get it without. We went ahead and put this back together again with very minimal tension using figure-of-8 sutures of #1 Prolene. Once we got it approximated it actually looked quite good. We irrigated once again. Some of poly the polypropylene mesh was well incorporated; it was even hard to tell if it was there. We took out whatever we could see grossly that was obviously mesh so that we had left no or very little mesh behind. We then used an AlloMax graft. A 20 cm x 16. We fixed it kind of in a diamond shape to the apices of the wound, then came in quadrants, trimming some of the lateral aspects to fit so we had really good coverage. This, we did with 2-0 Prolene, and then once we had thing fixed in multiple quadrants probably using 8 or 10 interrupted Prolene, we then ran short runs of Prolene between these areas to make sure that we had this mesh nicely in place. We irrigated and then closed the deep tissues. We covered the mesh with Vaseline gauze, covered over some of this with subcutaneous tissues and then placed a wound VAC in place with the pressure turn down to about 70.

The patient tolerated the procedure quite well.