A 54-year-old woman was referred to our Service from the Morbid Obesity Committee of our Hospital, after having been subjected to dietary treatment and having gone from 165 Kg. weight to 152 Kg.
Only the impression of its clinical aspect raised several questions for different reasons: the psychic in first place because of its deteriorated quality of life and mood without leaving its depression motivated by its exceptional condition, etc.
Then we set out the management of the patient in the conditions in which he was both for his surgical treatment and for his stay in the hospital, diagnostic tests, etc. (we could not sleep in bed, he couldn't move him in certain systems and diagnostic tools...
Finally, a thorough study of its characteristics and precise diagnosis of the faldon and its content, preventing its situation after surgery with respect to its possibility and respiratory pathophysiology and its abdominal condition, both in parietal reconstruction and visceral hyperpressure syndrome.
In the psychiatric-psychiatric aspect, we are faced with a patient with a depressive syndrome, whose quality of life and expectation of changing it was difficult because it did not rely on a strong surgical solution, which required a strong surgical treatment.
Preoperative studies were also performed: pathophysiological tests and respiratory function, complete analytical studies, detailed abdominal computerized axial tomography (CAT).
The latter showed images of the composition and intestinal levels of the abdominal faldon content.
It was necessary to know the content, nature and situation of the wings, presence of enlarged glands, etc. arriving to the conclusion, in the absence of trauma or lymphedema, produced by an irreversible expansion of the intestinal volume, the mechanism of bladder augmentation.
Technically, when resecting the fldón-bultoma, the reconstruction time of the abdominal wall and its rectal diversion with deficient quality of tissues with lymphedematous would begin.
This was aggravated by the inability to reduce abdominal content, which meant increasing continent to accommodate intestinal content.
There was no possibility of resection of enlarged spleens or gastrointestinal resection surgery.
Concretely, the abdominal cavity should be enlarged, similar to multiple pregnancies or pregnancies of sudden but volume, without adaptation period, with a large flap showing a better quality autologous or abdominal wall defect.
Both a firm synthetic solution and an autologous flap (A, or plan B), achieve a postoperative situation that allows the patient's breathing autonomously without displacement other side mechanical intubation without postoperative pain relief and should cause a syndrome.
This pathophysiological approach to increase the domicile, as a pregnancy without adaptation period, abruptly, has supposed an innovative idea based on a rigorous study of the abdominal faldon function and its contents: composition, level of the post-operatory CT scan functional capacity, level of the lung function
The reconstruction with either of the two planes: synthetic or autologous (A or B), represented a new firm and competent abdominal wall, with an increase in the size proportional to the new volume of the continent's 20-abdominal Hg sealant syndrome.
(7).
On the other hand, the strategy to manage the patient in the face of our lack of previous experience consisted of a procedure to control the "phaldon-bultoma" by means of sutures and five wheels introduced into the abdominal wall.
The bibliographic consultations we found were of interest in this regard for the management of the patient (8).
After removing the knife, which was a physical barrier, the reconstruction technique consisted of the following surgical procedures:
1o. Dissection of the lifting bag for abdominal replacement.
2o.- Without removing the dermograsus abdominal flap, perforations in the costal margin and anterior superior iliac spine bilaterally as stable points for passage of the tunnels to the tunnels.
3o.- Placing the mesh beyond the failure of the diastasis of the rectum is fixed and tensioned adapting it to the desired reconstruction with intraoperative control of the tension of the system.
4o.- Placement of several aspiration drains (four); suturing of the tension-free abdominal flap, resecting the dermal pieces that overlap in the adaptation of the resection edges.
The total weight of solids and transudates (lymphedema) exceeded 60 Kg.
The postoperative course was satisfactory. The patient was extubated on the same day after the intervention. After several hours, the patient remained seated and moved to the ICU for 6 days. After normal hospitalization, the patient was able to live a passive complication 11.
She also received psychiatric support treatment.
Comparative images can be seen between the preoperative and postoperative periods at hospital discharge Figs 12-13-14.
Postoperative period at 6 months can be seen in Figs 15-16.
