Comprehensive treatment of gallstone ileus associated with giant incisional hernia with loss of domain

Abstract

Gallstone ileus and incisional hernias are independent causes of acute intestinal obstruction. We report the case of a female patient with gallstone ileus associated with a giant, incarcerated incisional hernia with loss of abdominal domain over the past 3 years that was irreducible and tender. On admission, non-operative treatment was decided with placement of a nasogastric tube and injection of botulinum toxin. After 48 hours, the patient underwent exploratory laparotomy with enterotomy, stone extraction, bowel closure, placement of a K30 tube for pneumoperitoneum and temporary closure of the incisional hernia sac. After 72 hours, pneumoperitoneum was established using the Goñi-Moreno technique with an insufflated volume of 12,000 mL and administration of botulinum toxin. A median incisional hernia repair was performed with placement of a polypropylene mesh in the retromuscular space followed by dermolypectomy. We used a three-step strategy: initial medical management, surgical treatment of the acute abdominal obstruction, and delayed ring incisional hernia repair.