[Case Study] Successful Minimally Invasive Repair In High-Risk Patient With Prior Surgery History

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[Case Study] Successful Minimally Invasive Repair In High-Risk Patient With Prior Surgery History

Performing abdominal wall reconstruction or hernia correction in patients with a complex surgical history is one of the most challenging scenarios in modern surgery. When these patients also present with severe cardiopulmonary comorbidities, traditional open surgery carries a high risk of postoperative complications, prolonged ICU stays, and wound failure.

This clinical case study details how a multidisciplinary surgical team successfully utilized a minimally invasive repair strategy to treat a recurrent, large incisional hernia in a high-risk patient with a complex prior surgery history.

Patient Profile and Clinical Presentation

The patient, a 68-year-old male, presented to the outpatient clinic with a large, painful midline abdominal mass that had progressively increased in size over 18 months. The mass was causing intermittent bowel sub-occlusion symptoms, severe localized pain, and a significantly reduced quality of life.

H3: Medical History and Comorbidities

The patient’s medical background presented several major red flags for general anesthesia and major open surgery:

Prior Surgery History: Open sigmoid colectomy for complicated diverticulitis five years prior, which was complicated by a deep surgical site infection (SSI) and subsequent fascial dehiscence.
Cardiovascular Disease: Coronary Artery Disease (CAD) with drug-eluting stents placed two years ago; patient was on dual antiplatelet therapy (DAPT).
Pulmonary Complications: Severe Chronic Obstructive Pulmonary Disease (COPD) on home oxygen therapy, with a forced expiratory volume in 1 second ($FEV_1$) of 48% predicted.
Body Mass Index (BMI): 34.2 $\text{kg/m}^2$ (Class II Obesity).

H3: Diagnostic Findings

A contrast-enhanced CT scan of the abdomen and pelvis revealed:

A midline ventral hernia defect measuring 12.5 cm in width and 18 cm in length.
Loss of domain estimated at approximately 15%.
Incarcerated, but non-strangulated, loops of small bowel and omentum.
Extensive, dense adhesions anchoring the bowel loops directly to the anterior abdominal wall and the old polypropylene mesh fibers from a previous failed repair.

Why Traditional Open Surgery Posed Extreme Risks

For a defect of this size, a traditional open sublay (Rives-Stoppa) or posterior component separation (transversus abdominis release, or TAR) is the classic standard of care. However, in this specific high-risk patient, the open approach carried prohibitive risks.

| Risk Category | Traditional Open Surgery Risk | Minimally Invasive Repair Risk | | :--- | :--- | :--- | | Pulmonary Failure | High risk of postoperative respiratory failure due to large abdominal incision and pain-induced splinting. | Low; minimal incision size preserves diaphragmatic and chest wall excursion. | | Wound Complications | Up to 30% risk of surgical site infection (SSI) or seroma in obese/COPD patients. | Less than 5% risk of surgical site events. | | Adhesiolysis Injury | High risk of enterotomy (accidental bowel nicking) during blind manual dissection. | Low; high-definition visualization allows micro-dissection of dense adhesions. | | Recovery Time | 7 to 10 days of inpatient hospitalization, often requiring ICU monitoring. | 1 to 3 days hospital stay; rapid mobilization. |

The Solution: A Minimally Invasive Approach

To mitigate these risks, the surgical team opted for a robotic-assisted minimally invasive repair utilizing a retrorectus, preperitoneal approach (r-TAPP / r-TAR). Robotic-assisted surgery offers superior articulation, 3D visualization, and precise tension-free suturing, which are invaluable when navigating distorted anatomy from a prior surgery history.

H3: Surgical Planning and Risk Mitigation

Antiplatelet Management: DAPT was bridged carefully in consultation with cardiology. Clopidogrel was held for 5 days preoperatively, while Aspirin (81mg) was continued.
Pulmonary Optimization: The patient underwent 4 weeks of preoperative inspiratory muscle training and aggressive bronchodilator therapy.
Abdominal Wall Preparation: Preoperative progressive pneumoperitoneum (PPP) was deemed unnecessary, but botulinum toxin A (Dysport) was injected into the lateral abdominal wall muscles 4 weeks prior to surgery to paralyze the lateral complexes, allowing for tension-free fascial closure without a massive open release.

H3: Intraoperative Techniques and Technology Used

Robotic Platform: DaVinci Xi system.
Access Point: Left lateral flank (Palmer’s Point) was used for initial safe optical entry to avoid midline adhesions.
Mesh Selection: A lightweight, macroporous, self-gripping monofilament polyester mesh ($30 \times 30\text{ cm}$) was chosen to minimize foreign body sensation and optimize tissue integration.

Step-by-Step Surgical Execution

[Safe Entry at Palmer's Point] ➔ [Targeted Robotic Adhesiolysis] ➔ [Retrorectus Space Dissection] ➔ [Primary Fascial Closure] ➔ [Mesh Placement & Fixation]

Safe Port Placement: Under direct vision, a 5mm optical trocar was introduced at the left subcostal margin. After establishing a low-pressure pneumoperitoneum (10 mmHg to protect the patient's compromised pulmonary system), three additional robotic ports were docked laterally.
Robotic Adhesiolysis: Using robotic monopolar curved scissors and bipolar forceps, the surgeon performed a meticulous "top-down" adhesiolysis. The small bowel loops were carefully dissected away from the old hernia sac and the anterior abdominal wall. Thanks to the 10x magnification, no enterotomies occurred.
Development of Retrorectus Space: The posterior rectus sheath was incised 1 cm lateral to the defect. The retrorectus space was developed bilaterally. To bridge the 12.5 cm gap without tension, a unilateral right-sided Transversus Abdominis Release (TAR) was performed.
Closure of the Posterior Sheath: The posterior rectus sheaths were sutured closed using a 2-0 slowly absorbable running barbed suture, completely isolating the abdominal viscera from the upcoming mesh space.
Mesh Deployment: The $30 \times 30\text{ cm}$ mesh was introduced, unfurled, and positioned to cover the defect with at least a 5 cm overlap in all directions.
Anterior Fascial Reconstruction: The anterior rectus sheath was closed under physiological tension using a #1 running loop barbed suture.
Desufflation: The abdomen was desufflated slowly under direct vision to ensure no active bleeding occurred at the dissection sites.

Postoperative Recovery and Clinical Outcomes

The patient’s recovery profile validated the decision to proceed with a minimally invasive repair rather than an open reconstruction.

Operative Time: 195 minutes.
Estimated Blood Loss: Less than 50 mL.
Pain Management: Managed successfully with a scheduled non-opioid regimen (acetaminophen and IV ketorolac) combined with a preoperative bilateral transversus abdominis plane (TAP) block.
Ambulation: The patient was out of bed and walking 6 hours postoperatively. This early mobility prevented pulmonary stasis and deep vein thrombosis (DVT).
Length of Stay: The patient was discharged home on Postoperative Day 2 without requiring an ICU stay.
Follow-Up (12 Months): At the one-year mark, clinical examination and ultrasound confirmed a stable abdominal wall with no recurrence, no chronic pain, and no mesh-related complications.

Key Takeaways for Surgical Teams and Patients

This case demonstrates that a prior surgery history and high-risk comorbidities do not automatically mandate a highly morbid open procedure.

H3: Best Practices for Managing High-Risk Reoperations

Preoperative Optimization is Mandatory: Utilize multidisciplinary teams (cardiology, pulmonology, and physical therapy) to optimize cardiac and respiratory reserves before stepping into the operating room.
Leverage Advanced Technology: Robotic platforms provide the precision, stability, and visualization needed to perform complex adhesiolysis and retrorectus dissection safely.
Minimize Pneumoperitoneum Pressures: Keep insufflation pressures between 10–12 mmHg in patients with severe COPD to prevent hypercapnia and hemodynamic instability.
Chemical Component Separation: Consider preoperative botulinum toxin A injections to facilitate fascial closure without the need for extensive, bilateral surgical component release.

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