Dermo-Peritoneal Flap: a Novel, Safe and Effective Technique to Manage Abdominal Defects in Complicated Recurrent Incisional Hernia

Abstract

Recurrences after open surgical or laparoscopic repair of abdominal wall defects are not uncommon. No technique is the “best” solution, and a wide variety of surgical options are being used by surgeons for specific defects or locations with variable results. We describe a new technique “dermo-peritoneal flap,” which can easily be used to manage such difficult incisional hernias. Three patients having difficult recurrent incisional hernia were operated from April 2014 to May 2016 using the “dermo-peritoneal flap” technique. Detailed pre-operative assessment was done by structured questionnaire and ultrasonography (USG) scan to rule out co-existing intra-abdominal pathology and subacute/blind loop obstruction. Also, the approximate size and location of defect were estimated clinically and confirmed by pre-operative USG scan. A vertical ellipse in midline was marked, and the area was de-epithelialized. Bilateral abdominal flaps were elevated, leaving the de-epithelized dermo-fat patch over sac. After reaching the defect, blunt separation of the sac was done from edges of the defect. The sac was reduced into the abdominal cavity without opening. Edges of dermal tissue were sutured to edges of the defect. Onlay prolene mesh-plasty was done, and abdomen was closed with suction drains. Patients were aged 48, 52, and 57 years, and all patients were women. The patients had undergone 6, 5, and 6 surgeries, and duration of hernia was 6, 6.5, and 4.5 years respectively. Two of the patients had undergone resection anastomosis of gangrenous bowel previously. All patients have shown no signs of recurrence. Mild discharge from the suture line was seen in two patients, which resolved spontaneously on dressings. One of them has developed a midline scar similar to natural umbilicus. The concept of de-epithelialization of thinned-out skin over sac makes surgery easier and safe and also provides tough and vascular tissue which plugs the defect. It can also be used universally with any technique of repair for any location and size of defect. This is a case series of 3 lady patients, all of whom had ventral/incisional hernias operated earlier by this new technique of isolated de-epithelialized overlying skin used as a flap strengthened with overlay mesh.