Repair of massive abdominal wall defects. Combined use of pneumoperitoneum and Marlex mesh

The most important aspects of repairing massive hernias, eventrations, or surgically created abdominal wall defects are preoperative preparation of the patient and conservative judgment in indications for use of prosthetic material. Before operation, most patients (excluding those with trauma or severe sepsis) can be prepared electively by progressive preoperative pneumoperitoneum. The procedure is safe, simple, and effective. As described, it involves no special techniques or equipment and may be carried out as an inpatient or outpatient procedure. Prosthetic material should be used only to obviate tension on a suture line, for this must scrupulously be avoided. It should not be used routinely as onlay grafts in small or moderate hernias as primary fascial suturing gives better results with few wound complications when closure without tension is possible. Progressive preoperative pneumoperitoneum, combined when necessary with Marlex mesh to obviate tension, enables closure of even gigantic defects. The technique avoids the severe and sometimes fatal preliminary complications resulting from sudden increase in abdominal pressure and diaphragmatic elevation that accompany replacement of abdominal viscera that have lost their "right of domain" with large hernias or abdominal wall defects. This technique also markedly diminishes postoperative pain and aids satisfactory pulmonary management and thus permits early postoperative mobilization and discharge from the hospital.