Aim To present hybrid approach with open/endoscopic extraperitoneal dissection for large lateral-inferior incisional hernias Material and Methods 64 years-old man who underwent left laparoscopic nephrectomy (2019) due to hypernephroma with specimen extraction by a left oblique iliac incision. He presents L3–4 W3 incisional hernia (14×10 cm) Technique description Results After 48 hours ICU admission patient was discharged to hospital ward. Drainages were removed at 2nd-4thpostoperative day and hospital stay was 5 days. Conclusion The hybrid approach to large lateral incisional hernias allowed us to use a large sublay mesh with an increased overlap beyond the hernia defect, trying to reduce hernia recurrence rate.

The best approach for lateral incisional hernia is not known. Among these difficult hernias, those arising from iliac crest harvesting can be particularly challenging. The objective of this video is to illustrate the surgical approach of a multirecurrent case with the need of adding a posterior component separation A 70 years old woman with 2 previous attempts of repair was referred to our center. With the patient in a 45 degrees lateral decubitus, a posterior lumbar approach was initiated through the previous scar. The retromuscular preperitoneal plane was accessed with difficulty due to previous meshes in the subdiaphragmatic, iliac and posterior areas. A big tear on the medial peritoneum changed our plan to add a posterior component separation. As we did not want to enlarge the lumbar incision to denervate more the lateral abdominal wall, we decided to make an accessory midline incision. Probably, an ETEP approach could have been better even before making the posterior incision. Once the retromuscular plane was dissected, the hole in the peritoneum could be closed. The reconstructive phase consisted in making a taco configuration using the combination of a permanent and absorbable mesh. We have learned from this case, that an eTEP dissection of the retromuscular plane could have helped to avoid the accessory midline incision. It is also important to consider the potential iatrogenic denervation we could add in case of enlargement of the incision.

Aim Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model. Material and methods Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated. Results The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. The mean rhomboid area was 35 cm2. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The mean width of the midline prong at the umbilicus was 2.8 cm. It was easier to tear the peritoneum outside the area reinforced by the fatty trident. Conclusions The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

Aim The importance of an appropriate patient optimization (botulin toxin and pneumoperitoneum) and adequate surgical technique is highlighted.The possibility of intraoperative monitoring of the nerves that may be injured during posterior component separation is explained Material and methods We present a 74 years old man, past smoker, with history of hypertension, steatohepatitis and chronic bronchopathy Results This is a disastrous but unfortunately not so uncommon story of a failed repair of a simple umbilical hernia with 3 previous unsuccessful attempts of repair with and without mesh. After the last surgery the patient developed a giant incisional hernia with loss of domain. Optimization consisted of improving nutritional status, respiratory physiotherapy, botulin toxin and pneumoperitoneum. The surgery was made using previous skin scar. After dissecting the retrorectus space, a posterior component separation was made with the aid of monitoring the nerves that come to innervate the rectus abdominis. An overextended overlapped was obtained. A patch of absorbable mesh was used to completely close the peritoneum. A combination of absorbable and permanent synthetic mesh was used as giant reinforcement of the visceral sac. The only points of fixation were the Cooper Ligaments. The patient had a satisfactory recovery without complications and was discharged on the 8th postoperative day. Conclusions Loss of domain incisional hernias is a real surgical challenge. The combination of a good preoperative strategy (preoperative neumoperitoneum) and surgical technique (TAR and pannniculectomy) gives a great opportunity to solve very complex cases of incisional hernia.

Introduction Parastomal hernias (PH) can be a complex surgical problem. When there is a combination of midline and parastomal hernias, an option could be using both posterior component separation technique and an intraparietal Sugarbaker as described by Pauli. We present a case with the combination of midline and parastomal hernias. The aim of this video is to offer the most relevant steps that should be followed for a Pauli repair. Methods This is a 75 years-old man,, that underwent abdominoperineal resection for rectal cancer T3N2 in 2018. He developed a very symptomatic incisional hernia + parastomal and repaired was offered. After adhesiolysis, a retromuscular Rives dissection and a left posterior component separation were made. A Pauli was planned lateralizing the bowel in the retromuscular plane (like an intraparietal Sugarbaker repair) and a biosynthetic mesh was used in the retromuscular preperitoneal plane, making an inner stoma site with the mesh and bringing the colon trough the previous stoma site. Finally, anterior abdominal wall was closed Results The patient was discharged uneventfully on the 6th postoperative day. Discussion Pauli described 3 patients in similar circumstances but leaving the new posterior ostomy site lateral to the mesh. This technique that we describe in this video could be particularly useful in patients in whom a simpler Sugarbaker laparoscopic repair is not adequate and in those cases with PH with concomitant midline defects.