What is the management of a patient presenting with abdominal pain and a large 20cm ventral hernia containing stomach, small, and large intestine, with negative acute findings on computed tomography (CT) scan?

Management of Large Ventral Hernia with Abdominal Pain

Surgical repair is recommended for this large 20cm ventral hernia containing stomach, small and large intestine, even in the absence of acute findings on CT, to prevent potential complications including strangulation, bowel obstruction, and ischemia. 1

Initial Assessment and Stabilization

• Evaluate for signs of:

  • Hemodynamic instability
  • Peritonitis
  • Bowel obstruction symptoms (vomiting, distention)
  • Pain characteristics (constant, worsening, positional)

• Laboratory studies:

  • Complete blood count (elevated WBC may indicate strangulation)
  • Fibrinogen levels (elevated levels associated with incarceration) 1
  • Basic metabolic panel
  • Lactic acid (if suspicion for ischemia)

Imaging Interpretation

• CT scan with oral and IV contrast is the gold standard for hernia evaluation 1
• Despite negative acute findings, be aware that:
  • CT has limitations in detecting early strangulation
  • A negative CT scan should not rule out potential complications 1
  • CT sensitivity for detecting complications varies (61% for perigastric collections, 28% for contrast leak) 1

Management Algorithm

1. Non-Surgical Management (Temporary)

• NPO status
• IV fluid resuscitation
• Pain management
• Nasogastric tube decompression if significant distention present
• Consider proton pump inhibitors to reduce gastric acid production 2

2. Surgical Planning

• Timing:

  • Elective repair is appropriate given absence of acute findings
  • Schedule within weeks, not months, due to size and organ involvement

• Preoperative Optimization:

  • Consider botulinum toxin A injections into lateral abdominal muscles to facilitate closure of large defect 3
  • Progressive pneumoperitoneum may help increase abdominal cavity volume before repair 3
  • Nutritional optimization
  • Weight management if applicable

3. Surgical Approach

• Recommended technique:

  • Laparoscopic approach is feasible for incarcerated hernias without strangulation 1
  • Consider open approach for very large hernias or if extensive adhesiolysis anticipated
  • Combined laparoscopic-open approach may be necessary

• Repair components:

  • Complete reduction of hernia contents
  • Careful adhesiolysis
  • Mesh repair with 5-cm overlap is recommended 1
  • For defects that cannot be closed with direct suture, mesh is suggested 1
  • Biosynthetic, biologic or composite meshes are preferred due to lower recurrence rates and higher resistance to infections 1

Postoperative Care

• Close monitoring for:
  • Respiratory compromise (due to increased intra-abdominal pressure)
  • Pain control
  • Early mobilization
  • Fluid collections that may mimic recurrent herniation 4
  • Recurrent symptoms, dysphagia, weight loss 2

Important Considerations and Pitfalls

1. Loss of Domain: Large ventral hernias containing multiple organs may have significant "loss of domain," making reduction challenging and increasing risk of abdominal compartment syndrome after repair 5

2. Mesh Selection: Proper mesh selection is crucial for reducing recurrence rates while minimizing infection risk 1

3. Staged Approach: For extremely large hernias, a staged approach may be necessary to avoid abdominal compartment syndrome

4. Diagnostic Vigilance: Despite negative CT findings, maintain high suspicion for complications as clinical deterioration may precede radiological findings 1

5. Gastroesophageal Reflux: With stomach involvement in the hernia, anticipate and manage GERD symptoms post-repair 2

This patient requires definitive surgical management due to the size of the hernia and involvement of critical organs, despite the absence of acute findings on CT. The risk of future complications including strangulation, obstruction, and ischemia outweighs the risks of surgical intervention.