Small Bowel Herniation Into a Post-bariatric Pannus After Cesarean Delivery Managed With Single-Stage Panniculectomy...

Redundant pannus after massive weight loss can impair function and obscure abdominal wall pathology. Incisional hernia after cesarean delivery is uncommon, and extension of the small bowel into a post-bariatric pannus is particularly unusual. We report a 42-year-old woman with three prior cesarean deliveries and prior bariatric surgery who presented with a functionally limiting grade 3 pannus and a long-standing, nonreducible lower abdominal bulge. Computed tomography (CT) demonstrated a 12.3 cm × 5.6 cm low ventral incisional hernia with a 6.7 cm neck containing small bowel loops extending into the pendulous pannus. A single-stage operation involving plastic and general surgery was planned for combined panniculectomy and Rives-Stoppa repair. The patient underwent panniculectomy with umbilical sacrifice for exposure, bilateral retrorectus dissection with myofascial release, posterior sheath closure, and Rives-Stoppa repair using a 20 cm × 25 cm retrorectus mesh. She was discharged on postoperative day 1. A symptomatic retrorectus seroma developed within the first postoperative month and was successfully managed with image-guided percutaneous drainage; cultures were negative, and no recurrence or wound breakdown was present at three-month follow-up. This case highlights the value of multidisciplinary planning and carefully selected single-stage panniculectomy with retromuscular hernia repair for complex abdominal wall defects concealed by a post-bariatric pannus.