Know Your Hernia: Concurrent Panniculectomy with Complex Abdominal Wall Reconstruction

How is this a tension free repair? I do not see how gluing mesh in the pre-peritoneal space achieves long term hernia repair? The fascial closure is performed under tension as there was no mesh reinforcement on the fascia. Placing mesh without some anchoring into the abdominal wall will not prevent hernia recurrence

Here is what I would have done differently:

1. Teach the resident to learn to sew without using her fingers in the needle-holder's holes. They'll be more efficient.
2. Teach the resident to use an appropriately sized forcep--it will make him/her more efficient.
3. The midline fascia was closed over (unfixed) mesh using running suture. I would have used a running locking technique and permanent suture material.
4. I would have tacked the mesh, trans-fascially, using permanent suture.
5. The midline fascia was closed, over the mesh. There is no protection, here, as shakovmd says above, for the development of recurrent tension in the native fascia--as such the hernia will likely recur and the underlying mesh, because it is not fixed, probably won't support the abdominal contents in the event of a strong cough--or recurrent weight gain (likely).
6. Whenever I use mesh, I prep the patient's abdomen with alcohol to "de-fat" the skin, kill surface bacteria, then scrub with betadine. The betadine is allowed to dry for a few minutes then cover the entire operative site with an Ioban (iodine-impregnated) plastic drape.
7. Congratulations on getting the patient to stop smoking! Key to success more than anything.
8. Pre-op shower with Hibiclens/chlorhexidine scrub/shower.

These are the things I would have done differently. Other surgeons will approach it differently--and that's okay. That's why there is a comment section here! Tough hernia and panniculectomy. Can we see post-op results?