Operative management of massive hernias with associated distended bowel

IntroductionHernia patients with a history of recurrent bowel obstructions, chronic bowel dysmotility, and bowel distension have few options for return to a “normal” life. Return of the bowel and adhesiolysis seems the logical surgical solution, but the return of a swollen distended bowel into the abdominal cavity would put patients at a high risk for the development of abdominal compartment syndrome. Hernia repair with large pieces of mesh under tenuous skin flaps to incorporate the bowel into the abdominal cavity has its own set of devastating complications, including mesh infection, extrusion, and fistula formation.MethodsHere we present 4 patients who underwent successful treatment with a combined small bowel resection for volume reduction and simultaneous components separation hernia repair for autogenous closure without mesh.ResultsAll patients had successful abdominal wall closure without major complications and were tolerating enteral feedings upon discharge.ConclusionsA combined approach of small bowel resection and separation of parts hernia repair is a feasible and successful means for approaching challenging abdominal wall defects with chronically distended bowel. A vicious cycle in which postoperative elevation in intra-abdominal pressure leads to severe systemic consequences can be averted. Moreover, bowel function can be restored and excellent cosmesis achieved, leading to significant improvements in patients' quality of life.