Honourable Colleague

Well in surgery only the result counts - and that what You got as result was the Best for this patient. Another look of the scar a.s.o.is still only to change by treating the tisue

Your Hans

A hernia in a Chevron incision is not easily adressable with a standard endoscopic anterior components separation (eCST), which works better for midline defects. We have no experience with components separation in this type of incisional hernia, but only rarely is it impossible to close the hernia defect laparoscopically in a subcostal incision. The abdominal wall is most often rather pliable in the cranio-caudal direction. You may have to rely on a bridging intraabdominal mesh if this is not the case. Just remember a large overlap (5cm+) and to cover the whole previous incision (with overlap).

Otherwise endoscopic components separation in a midline hernia is a very useful and easy procedure, where You can expect to gain 4cm from both sides. How it works in immune compromized patients, ie. whether the risk of secondary lateral hernia is increased, has not been researched. We use anterior endoscopic components separation both in laparoscopic and open hernia surgery, but we prefer the posterior separation, TAR, in open midline hernia surgery. Open anterior CST should be avoided.

I would be interested to hear if someone in this forum have experience with CST/TAR in organ transplanted patients?

To use endoscopic/laparoscopic versus laparotomy for  anterior component separation is less traumatic. So It will become the gold standard.

Laparoscopic is to date going to be the best and preferred method

O.k. - so far science - but now to the price. Please use Laser with simple reusable bare fibre You get less comlications, need less instruments and reduce in this way the price

All the Best Your Hainz

I have performed laparoscopic repair in bilateral subcostal incisional hernias but not immunocompromised states. Extensive adhesions after the Chevron incision. May need bridging as suggested above.

Adhesions in immuno-compromized transplanted patients are overall less extensive and hernia defects typically larger according to a published prospective cohort study.

http://onlinelibrary.wiley.com/doi/10.1111/tri.12327/full

Thankyou very much for the comments,I was very much tempted to perform CS to avoid adhesions in a patient on immunosuppression.But I differed my decision as I was not exposed to this procedure.Repeated u/s scans of the lower abdomen were not helpful to find a suitable site as he is obese.However after cathterising the Bladder I chose a point in the umbelicopubc line and insufflated successfully.Open tecinque was an alternative not that comfortable in an obese for access and for closure.Upper abdomen was sealed off.large two blow outs were exposed after adhesiolysis.Both defects were closed and an IPOM with dual mesh 20/15 was deployed and fixed with absorbable tacks.Discharged on the following day.Needs to follow up as this is my first case.

IPOM with dual mesh is the best technique which u have already performed. Component separation in this patient may be difficult although personally I believe in IPOM. Open technique likely to have stormy postoperative period and complications.

Have experience with open mesh repair in this patient population. The problem with the subcostal incision in the liver transplant recipient population is that the quality of the tissue in the anterior abdominal wall is extremely variable such that component separation is not necessarily feasible in the subcostal region. Have seen recurrent hernias post laparoscopic repair when either a) absorbable tacks used or b) the tacks only penetrate the transversus muscle leading to distraction of the internal and external oblique muscles away from the mesh

Dear Deborah. We have, analogously to Your experience, in our study report speculated that, besides choosing a mesh with good ingrowth features - which excludes ePTFE and biological material - a permanent fixation is advisable in immunosuppressed organ transplanted incisional hernia patients repaired with IPOM+. Additionally, allowance of a generous overlap; advises not followed in the presented case. But we are short on scientific evidence.

Thankyou,when the defects are closed,there is always a large space for the generous  over lap of the mesh.This is one of the advantages of closing the defect.Double crowning fixation was done with absorbable tacks as i was not sure about the effects of metal tacks in a immuno compromised patient.Exta corporeal transfixation sutures were not used to avoid skin wounds.Clousre intra corporeal was difficult due to adhesions.

Honourable Colleague

You made a super-perfect "opensurgery" in this case with all tipps and tricks that are known today. Well healing is not yet "reinable". Question is: should we plan from beginning the question " Is minimal invasive Surgery in this case possible". But we are at the border of techniqe and i think X-bosom could lead us to another result. All the Best Your Hainz

Dear Sir,

Had I been in Your place Even I would have done the same. What you have done Is perfectly allright. Lap CST would have been very difficult in this defect. Recently, a couple of days back had a patient with hernia through a subcostal scar. Did a Open CST with  Standard Polypropylene Mesh.

I agree that subcostal makes separation more challenging . I would personally opt for an open operation.