Mesh-Augmented Ventral Hernia Repair Despite Iatrogenic -Peritonitis Due to Progressive Pneumoperitoneum: A Case Report.

[INTRODUCTION] Loss-of-domain in large incisional hernia needs to be addressed by mesh-augmented repair combined with a combination of component separation techniques: progressive pneumoperitoneum (PPP) and chemical component separation with botulinum toxin A. In this case report, successful management of an iatrogenic peritonitis caused by PPP with nevertheless definitive treatment of a giant loss-of-domain ventral hernia is presented.

[CASE PRESENTATION] A female patient with M1-3W3 recurrent incisional hernia with a loss-of-domain of 47% was prepared for definitive ventral hernia repair by chemical component separation with botulinum toxin A-infiltration and PPP via an intraperitoneally placed central venous catheter. A significant increase of inflammatory markers was found after 28 days. An emergency CT scan was performed, which showed the PPP and perihepatic/perisplenic contrast-enhancing fluid collections. Exploratory laparoscopy and laparotomy revealed no bowel perforation but fibrinous peritonitis due to an iatrogenic PPP-catheter-associated peritonitis. Despite the fibrinous peritonitis, we decided to proceed with definitive ventral hernia repair (Rives-Stoppa-Sublay-Herniotomy with transversus abdominis release (left) and anterior component separation (right), 42 × 30 cm permanent polypropylene mesh). Initial calculated antibiotic treatment was performed with piperacillin/tazobactam. Microbiologic examinations revealed in the intraoperative specimens on postoperative day 1 and the antibiotic treatment was changed to intravenous flucloxacillin for 14 days after surgery. The further hospital stay was uneventful and the patient was discharged on the 20th postoperative day.

[CONCLUSIONS] The presented case demonstrates the possibilities in complex ventral hernia repair to achieve a satisfying outcome for the patients. Even in cases with infectious complications, a single-stage procedure might be performed safely and a complete reconstruction of the abdominal wall might be achieved. The risk of chronic mesh infection in contaminated situations, especially during the presence of , remains uncertain and has to be weighed against possible benefits.