MIS Supplies needed:

• 30˚ Camera (and supporting tower equipment)

• FRED Anti-Fog Solution

• Verres Needle and insufflation capabilities

• 5 mm and 12 mm trocars

• Fan Retractor

• Suction and Irrigation

• 4 x 4 Gauze

• Suture: 3-0 Vicryl on Taper

• Mayo Scissors

• Metzenbaum Scissors

• Laparoscopic Needle Holder

• 2 ratcheted laparoscopic graspers

• 1 laparoscopic scissor

• 2 Debakey (or atraumatic) laparoscopic graspers

• Laparoscopic Maryland

• Unipolar Electrocautery

• “L” hook

• Energy sealing device

• Laparoscopic stapler with vascular and bowel loads

Open supplies needed:

• Lap Sponges

• 0.9% NaCl for Irrigation and Basin

• Yankauer Suction and tubing with Suction Unit

• Balfour Retractor

• #10 Scalpel Blade on #3 Handle

• #15 Scalpel Blade on #3 Handle

• Towel Clamps

• Adson Tissue Forceps

• Halsted Mosquitos

• Allis Tissue Clamps

• Mayo Scissors

• Mayo-Hegar Needleholder

• Curved Crilles

• Metzenbaum Scissors

• Debakey Forceps

• Suture: 3-0 Vicryl on Taper, 0 Chromic on blunt large needle or 2-0 Vicryl, 0 PDS sutures on CT1 or CTX needles, Prolene suture 4-0 or 5-0 for vascular repair

• Various mesh types and sizes for inguinal and ventral hernia repairs

• Electrocautery Unit and Pencil

• Staplers and energy sealing devices for hepatectomy, bowel anastomosis, pancreatectomy

A 28-year-old man presents with 30 hours of abdominal pain that began periumbilically and migrated to the right lower quadrant, associated with anorexia, nausea, and one episode of emesis. He reports low-grade fevers and worsening, localized pain with movement. Vitals: T 38.3°C, HR 104, BP 122/74. Exam: focal RLQ tenderness with guarding and rebound; positive Rovsing and psoas signs; hypoactive bowel sounds; no jaundice or CVA tenderness. Testicular exam normal. Labs: WBC 17,800/mm³ with 87% neutrophils; CRP 120 mg/L; creatinine 0.9 mg/dL; Alvarado score 8. Contrast-enhanced CT abdomen/pelvis shows a 12-mm fluid-filled, noncompressible, blind-ending tubular structure arising from the cecum with wall thickening (3 mm), periappendiceal fat stranding, and an appendicolith; there is a 2.5-cm rim-enhancing fluid collection adjacent to the tip with a small focus of extraluminal gas, and mild reactive free fluid; no diffuse peritonitis or bowel obstruction

A 62-year-old woman with type 2 diabetes, obesity (BMI 33), and hypertension presents with 36 hours of progressive right upper quadrant (RUQ) pain that began after a fatty meal, now constant and radiating to the right scapula, with nausea, two episodes of emesis, subjective fevers, and food intolerance. She denies jaundice, pruritus, dark urine, pale stools, or altered mental status. Medications include metformin, lisinopril, and low-dose aspirin; no anticoagulants. Vitals: T 38.4°C, HR 102, BP 138/76, RR 18, SpO2 98% on room air. Exam: ill-appearing but not toxic; RUQ tenderness with voluntary guarding and a positive Murphy’s sign; no peritoneal rigidity; no palpable mass; sclera anicteric; no confusion. Cardiopulmonary exam unremarkable. No costovertebral angle tenderness.

Laboratory results: WBC 15,900/µL (89% neutrophils), CRP 145 mg/L, total bilirubin 1.3 mg/dL (direct 0.6), AST 42 U/L, ALT 38 U/L, ALP 138 U/L, lipase normal, creatinine 1.0 mg/dL (baseline 0.9), INR 1.1, lactate 1.5 mmol/L. 

RUQ ultrasound: multiple gallstones with an obstructing stone impacted at the gallbladder neck; gallbladder distended (long-axis 9.0 cm), wall thickness 6 mm, pericholecystic fluid, hyperemic wall, and a positive sonographic Murphy’s sign. Common bile duct (CBD) measures 6 mm without visible ductal stones; no intrahepatic ductal dilation. No focal hepatic abscess.

A 74-year-old man with hypertension and COPD presents with 36 hours of diffuse, crampy abdominal pain that began periumbilically and progressed to marked distension, persistent bilious vomiting, and obstipation (no flatus or bowel movement for 3 days). Past surgical history included an open sigmoid colectomy for diverticulitis 15 years ago; no prior SBO episodes. Medications: amlodipine, tiotropium; no anticoagulants or opioids. Vitals: T 38.1°C, HR 112, BP 132/74, RR 20, SpO2 96% on 2 L nasal cannula. Exam: dehydrated with dry mucous membranes; tympanitic, distended abdomen with diffuse tenderness, maximal periumbilically; focal involuntary guarding in the right lower quadrant without generalized rigidity; high-pitched tinkling bowel sounds; no palpable hernias. Rectal exam without masses; vault empty. SIRS criteria met (fever, tachycardia).

Laboratory evaluation: WBC 16,800/µL (91% neutrophils), CRP 128 mg/L, lactate 3.1 mmol/L, Na 131 mmol/L, K 3.2 mmol/L, Cl 93 mmol/L, HCO3 20 mmol/L, BUN 38 mg/dL, creatinine 1.6 mg/dL (baseline 1.0), venous pH 7.33. LFTs and lipase normal. UA negative. Blood cultures drawn.

Imaging: Upright chest radiograph without free subdiaphragmatic air. CT abdomen/pelvis with IV contrast: multiple dilated fluid-filled small-bowel loops up to 4.0 cm with collapsed distal ileum/colon; single transition point in the mid-ileum tethered to the anterior abdominal wall with a beak configuration and mesenteric swirl, consistent with adhesive closed-loop obstruction. Degree of obstruction high-grade with no contrast passage beyond the transition. Moderate peritoneal free fluid estimated >500 mL, mesenteric edema/congestion, and small bowel wall thickening to 4 mm at the transition with segmental hypoenhancement relative to adjacent loops. No pneumatosis or portal venous gas. No small bowel feces sign. No evidence of external hernia or mass.

A 44-year-old woman is referred to the metabolic-bariatric surgery clinic for refractory class III obesity. Height 165 cm, weight 138 kg, BMI 50.7 kg/m². Comorbidities include long-standing type 2 diabetes mellitus (on metformin and basal insulin; most recent HbA1c 8.6%), hypertension (on lisinopril), hyperlipidemia (on high-intensity statin), obstructive sleep apnea on CPAP, and nonalcoholic fatty liver disease. She reports chronic knee pain limiting activity. She has completed a 12-month, medically supervised weight-loss program (nutrition, physical activity, anti-obesity pharmacotherapy with GLP-1 RA for 6 months), with net weight loss of 4% and early regain. No tobacco or alcohol misuse. Psychiatric history notable for well-controlled generalized anxiety disorder; psychosocial and behavioral evaluation deems her a suitable surgical candidate with good adherence expectations. She denies dysphagia, odynophagia, hematemesis, melena, or prior upper GI surgery. She reports intermittent heartburn 1–2 times/week responsive to low-dose PPI; no nocturnal regurgitation.

Preoperative assessment:

• Vitals: BP 138/82, HR 86, SpO2 98% on room air.

• Laboratories: CBC normal; CMP notable for ALT 58 U/L, AST 44 U/L, ALP 96 U/L, bilirubin 0.7 mg/dL; fasting glucose 162 mg/dL; HbA1c 8.6%; lipid panel: LDL 138 mg/dL, HDL 38 mg/dL, TG 210 mg/dL; TSH 2.4 mIU/L; iron 48 µg/dL (transferrin saturation 16%), ferritin 55 ng/mL; vitamin B12 360 pg/mL; folate normal; 25-OH vitamin D 18 ng/mL; calcium 9.1 mg/dL; PTH 56 pg/mL. H. pylori stool antigen negative. Micronutrient plan initiated per bariatric protocol.

• Nutrition consultation confirms protein-focused dietary education; preoperative very-low-calorie diet planned for 2 weeks. Sleep medicine confirms effective CPAP use.

• Cardiorespiratory evaluation low-intermediate risk; functional capacity ~4 METs; ECG normal.

Imaging and endoscopy:

• Abdominal ultrasound: hepatomegaly with steatosis, no focal lesions; gallbladder with multiple small stones without cholecystitis; CBD 5 mm.

• Upper endoscopy: normal esophageal mucosa without Barrett’s; Hill grade II valve; 2-cm sliding hiatal hernia; mild antral gastritis (biopsy negative for H. pylori); no peptic ulcer disease or masses.

• Upper GI series: confirmatory small sliding hiatal hernia; no significant esophageal dysmotility, no delayed gastric emptying. Manometry not performed given absent dysphagia.

A 48-year-old man with 2 years of PPI-refractory regurgitation presents for operative consideration. He completed an optimized PPI trial (omeprazole 40 mg twice daily taken 30–60 minutes before meals for 8 weeks) with persistent regurgitation and nocturnal symptoms. BMI 28 kg/m²; no prior foregut or bariatric surgery; no tobacco or alcohol misuse. No red-flag weight loss or anemia; no extraesophageal atopy.

Endoscopy off PPI x14 days: Los Angeles grade C erosive esophagitis; 4-cm sliding hiatal hernia; no Barrett’s. Barium esophagram: 4–5 cm axial hernia, adequate esophageal length, no stricture. High-resolution manometry: normal LES relaxation, intact peristalsis with preserved multiple rapid swallow contractile reserve; no achalasia or major motility disorder. Ambulatory pH-impedance monitoring on PPI: abnormal acid exposure time 9.2%, elevated DeMeester, and symptom association for regurgitation. CBC/CMP/TSH normal.

An 82-year-old man presents with progressive bilateral groin bulges and heaviness, worse late in the day and with coughing or prolonged standing, associated with aching groin pain limiting ambulation. Over the past year he has required manual reduction several times; in the last 2 months, the left-sided bulge has become scrotal in extent and the right bulge has enlarged. He reports intermittent constipation and urinary frequency from mass effect, but no obstructive GI symptoms, fever, or weight loss. Past history: three prior open anterior mesh repairs (Lichtenstein) for right inguinal hernia (20 and 8 years ago) and left inguinal hernia (10 years ago), insulin-treated type 2 diabetes, COPD, obesity (BMI 33), active smoker, and ASA III. He previously declined laparoscopy after a postoperative urinary retention episode; he desires definitive repair. No prior pelvic radiation or lower midline laparotomy. Medications: insulin glargine, metformin, tiotropium, aspirin 81 mg; no anticoagulants.

Exam: standing and supine with Valsalva reveals large, partially reducible left inguinoscrotal hernia with stretched but viable scrotal skin; right-sided broad-based bulge extending medial to the inferior epigastric vessels with palpable impulse on cough. Both sides mildly tender; no overlying skin changes. No femoral pulses abnormalities. Digital rectal exam normal. Classification: bilateral complex inguinal hernias—left giant scrotal (C) and right recurrent direct (B, recurrent), consistent with a complex phenotype per contemporary schemes. Features of complexity include bilaterality, giant scrotal component, and multiple recurrences with prior anterior mesh repairs.

Laboratory studies: CBC within reference except mild leukocytosis 11,200/µL; BMP normal except fasting glucose 162 mg/dL; A1c 8.2%; albumin 3.6 g/dL; creatinine 1.0 mg/dL. Preoperative risk: COPD with moderate obstruction, current smoker; ASA III. ECG normal sinus rhythm.

Imaging: because of recurrence and bilaterality, targeted groin ultrasound demonstrates bilateral defects with bowel-containing sacs: left indirect component with sac diameter ~5.5 cm into scrotum and right direct hernia with a 3.5-cm posterior wall defect; no femoral hernia. CT pelvis with Valsalva (obtained for operative planning and to exclude occult femoral/obturator hernia) shows: bilateral inguinal hernias, left giant inguinoscrotal containing small bowel without obstruction; right direct hernia with attenuated transversalis fascia; prior anterior mesh in situ bilaterally; no intraabdominal pathology; bladder displaced but uninvolved. No ascites.

Indications and approach selection: The combination of bilaterality, giant inguinoscrotal component, and multiple recurrences after anterior mesh makes an open posterior preperitoneal mesh repair appropriate. A midline Stoppa repair offers wide preperitoneal exposure (spaces of Retzius and Bogros) to cover both myopectineal orifices with a large low-tension prosthesis, avoiding re-dissection through scarred anterior planes and facilitating management of occult femoral defects. Mesh-based repair is recommended as standard for adult groin hernias; open versus minimally invasive selection is tailored to patient and hernia complexity. While endoscopic/laparoscopic approaches are advantageous for bilateral primary hernias, prior anterior mesh and giant scrotal hernia increase operative difficulty; open posterior repair is an accepted strategy for complex/recurrent disease.

A 67-year-old man with hypertension and stage 3a CKD (baseline creatinine 1.4 mg/dL) presents with 36 hours of worsening abdominal distension, colicky left-sided abdominal pain, obstipation (no flatus or BM for 3 days), nausea with nonbilious emesis, and progressive crampy pain. He notes unintentional 15-lb weight loss over 3 months, decreased appetite, and intermittent hematochezia for several weeks. No prior colonoscopy. No anticoagulants. In the ED: T 38.1°C, HR 112, BP 98/62 (improves to 112/68 after 2 L LR), RR 20, SpO2 98% on room air. Exam: distended, tympanitic abdomen with focal tenderness in the left lower quadrant and suprapubic region, mild involuntary guarding without generalized rigidity; hyperactive high-pitched bowel sounds; no palpable hernias. Digital rectal exam shows heme-positive brown stool. No jaundice.

Labs: WBC 15,600/µL (90% neutrophils), Hgb 10.4 g/dL (MCV 78 fL), platelets 430,000/µL; Na 133 mmol/L, K 3.4 mmol/L, HCO3 20 mmol/L, BUN 36 mg/dL, creatinine 1.9 mg/dL (baseline 1.4); lactate 2.8 mmol/L; AST/ALT normal; total bilirubin 0.8 mg/dL. INR 1.1.

CT abdomen/pelvis with IV contrast: circumferential, irregular 5-cm sigmoid colon mass causing high-grade large bowel obstruction with shouldering and apple-core appearance; proximal colon markedly dilated (cecum 10.5 cm) with air-fluid levels; multiple small-bowel loops mildly dilated from incompetent ileocecal valve; pericolic fat stranding and small volume pericolic fluid; no free intraperitoneal air; no discrete abscess. Two subcentimeter indeterminate hypodensities in the liver; no bulky adenopathy; no peritoneal carcinomatosis.

Flexible sigmoidoscopy performed for decompression attempt is aborted due to near-complete obstruction at 28 cm; biopsies obtained show moderately differentiated adenocarcinoma. CEA pending.

Diagnosis and Indication for Emergent Surgery

Obstructing left-sided colon cancer with impending cecal compromise and physiologic derangement (tachycardia, leukocytosis, lactatemia) requiring urgent operative management to treat obstruction, perform oncologic resection, and facilitate timely recovery for systemic therapy as indicated. Stenting as a bridge to surgery is considered but not pursued due to high-grade obstruction, equivocal local expertise, and sepsis risk; a diverting stoma alone would not treat the index malignancy in a fit, operable patient.

Operative Decision-Making

• Tumor location: sigmoid. Hemodynamics stabilized after resuscitation; no diffuse peritonitis or gross contamination; bowel viability uncertain but no perforation. In this context, plan for emergent open sigmoid colectomy with oncologic principles (high ligation of IMA branch to the segment, proximal and distal margins, and adequate lymphadenectomy). Given improved perfusion after resuscitation, absence of gross contamination, and viable ends, proceed with primary colorectal anastomosis; be prepared to add a proximal diverting loop ileostomy if intraoperative risk factors for leak are present (edematous bowel, tension, marginal perfusion, intraoperative hypotension). If unexpected ischemia or contamination is found, perform resection with end colostomy (Hartmann) per intraoperative judgment.

• Right-sided obstructing tumors generally undergo right hemicolectomy with primary anastomosis when feasible; left-sided obstruction requires individualized choice among resection with anastomosis, stoma, or stent based on patient factors and institutional expertise, consistent with the American Society of Colon and Rectal Surgeons guidance and broader literature. 

Intraoperative and Postoperative Considerations

• Perioperative antibiotics: broad gram-negative and anaerobic coverage (e.g., ceftriaxone 2 g IV plus metronidazole 500 mg IV; or piperacillin-tazobactam 3.375–4.5 g IV) timed within 60 minutes pre-incision; continue 24 hours postoperatively in clean-contaminated cases, longer if perforation/contamination.

• Exploration: assess entire colon for synchronous lesions, palpate liver for metastases, and document peritoneal surfaces; obtain peritoneal fluid cultures if contamination. Oncologic technique: en bloc resection if adjacent organ adherence suggests T4 disease, aiming for R0 resection and adequate nodal yield where possible even in emergency settings.

• Anastomosis: hand-sewn or stapled colorectal anastomosis with intraoperative perfusion assessment (e.g., ICG if available), tension-free, well-vascularized ends; consider diverting loop ileostomy selectively in high-risk settings. Place NG tube only if severe ileus; Foley for strict I/O.

• Postoperative plan: early mobilization, VTE prophylaxis, monitor for anastomotic leak, ileus, and AKI; expedite staging (contrast-enhanced chest imaging, definitive liver assessment) and oncology referral for adjuvant therapy decision-making based on final pathology.

A 29-year-old man is brought after a high-speed motor vehicle collision with driver-side impact 60 minutes prior. Prehospital: hypotensive to 70/40 mmHg with tachycardia 140 bpm; received 1 unit PRBC and 500 mL crystalloid with transient improvement. On arrival: GCS 15, T 36.0°C, HR 132, BP 86/54 (improves to 110/58 after 2 units of whole blood initiation), RR 26, SpO2 95% on NRB. Primary survey notable for abdominal distension and left upper quadrant (LUQ) tenderness with guarding; pelvis stable; no long-bone deformity. FAST positive in RUQ and LUQ. No external hemorrhage. Associated injuries: left lower chest wall tenderness with crepitus; portable CXR shows left 8th–10th rib fractures without hemopneumothorax.

Initial labs: Hgb 8.2 g/dL (prior unknown), platelets 168,000/µL; INR 1.6, aPTT 37 s; lactate 5.8 mmol/L; base deficit −9 mEq/L; AST 1,240 U/L, ALT 1,080 U/L; bilirubin 1.2 mg/dL; fibrinogen 160 mg/dL; creatinine 1.3 mg/dL. Type and cross ordered.

Given initial response ot blood resuscitation, a rapid contrast-enhanced trauma CT is obtained. CT abdomen/pelvis with IV contrast demonstrates a high-grade left hepatic laceration involving segments II–III with deep parenchymal disruption >10 cm, active contrast extravasation along the left hepatic vein and segment III arterial branches, large hemoperitoneum, and devitalized parenchyma across most of the left liver; porta hepatis patent; no major right hepatic injury. No hollow viscus pneumoperitoneum. No retroperitoneal hematoma.

The blood pressure declines and MTP is activated, and the continued need for resuscitation prompts progression to the OR...

A 31-year-old man is brought after a high-speed bicycle-versus-car collision 90 minutes prior. Prehospital: hypotensive to 78/46 mmHg, HR 138; received 1 unit PRBC and 500 mL crystalloid with transient response. On arrival: alert, anxious, GCS 15. Vitals: T 35.6°C, HR 132, BP 86/54 (rising to 110/58 after 2 units of whole blood), RR 24, SpO2 97% on nonrebreather. Primary survey notable for abdominal distension and left upper quadrant/epigastric tenderness with voluntary guarding; no external bleeding. Secondary survey: left lower chest wall tenderness with crepitus (ribs 9–11 suspected), mild thoracolumbar paraspinal tenderness, no long-bone deformity. E-FAST: free fluid in LUQ and pelvis, no pericardial effusion.

Laboratory results: Hgb 8.6 g/dL, platelets 162,000/µL; INR 1.7, aPTT 39 s, fibrinogen 155 mg/dL; lactate 6.1 mmol/L; base deficit −10 mEq/L; Na 138 mmol/L, K 4.6 mmol/L, creatinine 1.3 mg/dL; AST 720 U/L, ALT 680 U/L; total bilirubin 1.1 mg/dL; amylase 268 U/L, lipase 412 U/L.

CT abdomen/pelvis: focal transection through the pancreatic neck/body junction with deep parenchymal laceration extending >50% depth into the body, peripancreatic hematoma, moderate hemoperitoneum, and active contrast extravasation along the pancreatic tail bed; fluid and stranding in the lesser sac; associated grade III splenic lacerations with subcapsular hematoma and contrast blush; no pneumoperitoneum. No major vascular injury identified. 

The blood pressure drops to 84/60 despite activation of 1:1:1 massive transfusion and the patient is brought to the operating room...

A 72-year-old woman with atrial fibrillation (not anticoagulated), coronary artery disease, and peripheral atherosclerosis presents with 8 hours of abrupt, severe, diffuse abdominal pain “out of proportion” to exam, followed by progressive nausea and 2 episodes of emesis. She now reports increasing pain with mild distension and minimal flatus. No prior abdominal surgery. Vitals: T 36.2°C, HR 128 (irregularly irregular), BP 92/58 (MAP 65 after 1 L lactated Ringer’s), RR 24, SpO2 97% on 2 L NC. Exam: ill-appearing, cool extremities; abdomen moderately distended with diffuse tenderness and focal peritonitis in the right lower quadrant with rebound and involuntary guarding; hypoactive bowel sounds. Rectal exam: heme-negative brown stool.

Laboratory results: WBC 19,800/µL (92% neutrophils), Hgb 12.0 g/dL, platelets 310,000/µL; lactate 5.6 mmol/L; Na 136 mmol/L, K 4.9 mmol/L, HCO3− 17 mmol/L (anion gap metabolic acidosis), BUN 38 mg/dL, creatinine 1.8 mg/dL (baseline 1.1); AST/ALT mildly elevated; INR 1.2. Broad-spectrum antibiotics initiated; unfractionated heparin bolus and infusion started.

Contrast-enhanced CT angiography of the abdomen/pelvis (arterial and portal venous phases): abrupt occlusive filling defect in the proximal superior mesenteric artery just distal to origin, consistent with embolus; poor opacification of multiple jejunal branches; long segment of mid–distal small bowel with decreased mural enhancement and luminal dilation up to 28 mm; mesenteric stranding and small-volume ascites; no pneumatosis intestinalis or portal venous gas; celiac and IMA patent; no aortic dissection. Radiologist’s impression: proximal SMA embolic occlusion with downstream hypoperfusion and CT features concerning for evolving transmural ischemia; high risk for necrosis if not rapidly revascularized.

Operative plan prompts to guide toward emergent SMA repair:

• Midline laparotomy with immediate assessment of bowel viability. Obtain proximal and distal vascular control of the SMA at the base of the mesentery; use intraoperative palpation and, if available, on-table angiography or duplex to confirm inflow/outflow after repair.

• Perform open SMA embolectomy (Fogarty) with restoration of flow. If persistent inflow compromise or proximal thrombosis at the origin: perform bypass (antegrade from supraceliac aorta or retrograde from infrarenal aorta/common iliac) with single-vessel revascularization to the SMA as definitive therapy. 

• Bowel management and damage control: resect all frankly necrotic bowel; leave marginal segments in discontinuity and plan a second-look laparotomy in 24–48 hours given the high rate of delayed demarcation. Avoid primary anastomosis in an unstable, acidotic patient with edematous bowel; restore continuity at re-look if physiology and bowel allow.

A 34-year-old man sustains multiple gunshot wounds to the epigastrium and right flank 20 minutes prior to arrival. Prehospital: SBP 70s, HR 150, received 1 unit whole blood en route with transient improvement. On arrival: GCS 14, T 35.4°C, HR 142, BP 82/48 (MAP 59) despite initiation of 1:1:1 massive transfusion protocol, RR 28, SpO2 96% on nonrebreather. FAST is positive in Morrison’s pouch and pelvis. Primary survey shows no external extremity hemorrhage. Secondary survey: distended, tense abdomen with diffuse tenderness and involuntary guarding; ballistic entry at epigastrium without back wound; right flank entry and exit wounds. Pelvis stable. No neurologic deficit.

Initial laboratories: Hgb 7.6 g/dL, platelets 128,000/µL, INR 1.9, aPTT 43 s, fibrinogen 135 mg/dL; lactate 7.2 mmol/L; base deficit −12 mEq/L; creatinine 1.4 mg/dL; ionized calcium 0.96 mmol/L. Two large-bore peripheral IVs and a rapid infuser are in use; calcium chloride 1 g IV is given with MTP; tranexamic acid 1 g IV bolus is administered per institutional protocol early in resuscitation.

Intraoperatively, an expanding zone 1 retroperitoneal hematoma centered along the infrarenal aorta and IVC with active extravisation from the infrarenal aorta and infrarenal IVC. 

A 36-year-old man is brought to the trauma bay after a high-speed motor vehicle collision with left lateral impact. He is tachypneic and hypotensive (BP 84/52, HR 128), with oxygen saturation 92% on a nonrebreather mask. He is alert but in respiratory distress, reporting severe left-sided chest and upper abdominal pain. Physical exam reveals decreased breath sounds at the left base, abdominal distension, and ecchymosis over the lower chest. There is no external bleeding. He has multiple left lower rib fractures and mild tenderness over the left flank. No obvious long bone or pelvic injuries are noted.

Initial laboratory studies show: hemoglobin 9.2 g/dL, WBC 18,400/µL, platelets 210,000/µL, lactate 5.2 mmol/L, base deficit −8 mEq/L, INR 1.4, and creatinine 1.1 mg/dL. Arterial blood gas reveals pH 7.28, PaCO₂ 32 mmHg, PaO₂ 68 mmHg on 100% oxygen. 

Chest X-ray demonstrates an elevated left hemidiaphragm, blurring of the left heart border, and a large gastric bubble in the left hemithorax with mediastinal shift. There is a moderate left pleural effusion and multiple left-sided rib fractures. 

Contrast-enhanced CT of the chest and abdomen reveals discontinuity of the left hemidiaphragm with herniation of the stomach and omentum into the thoracic cavity (“collar sign”), associated left lower lobe atelectasis, and moderate hemoperitoneum. There is no evidence of aortic injury. The spleen is lacerated (AAST grade II) with a small perisplenic hematoma. No solid organ injury is seen on the right. 

The patient remains hypotensive despite 2 units of whole blood...

A 58-year-old man with BMI 36 kg/m², hypertension, insulin-dependent diabetes, and a 30 pack-year smoking history presents with a progressively enlarging, painful midline abdominal bulge and intermittent skin erythema over the lower abdomen. He has a history of two prior midline laparotomies for bowel resection and a failed mesh repair for incisional hernia three years ago. He reports difficulty with mobility and intermittent episodes of subacute bowel obstruction, but no acute incarceration or fistula. He has been unable to lose weight despite dietary counseling and has recently stopped smoking.

On examination, there is a large, non-reducible midline ventral hernia extending from the epigastrium to the suprapubic region, measuring approximately 18 cm in width and 22 cm in length, with visible loss of domain and thinning of overlying skin. The hernia is tender but without signs of acute incarceration or necrosis. There is no active fistula, but the skin is attenuated and mildly erythematous in the infraumbilical region. No lateral or flank extension is noted.

Laboratory evaluation reveals: WBC 8,900/µL, hemoglobin 12.8 g/dL, albumin 3.2 g/dL, creatinine 1.0 mg/dL, HbA1c 7.9%, and CRP 2.1 mg/L. 

Preoperative CT scan with 3D reconstruction demonstrates a midline hernia defect measuring 17.5 cm in transverse diameter and 21 cm in length, with herniation of omentum and small bowel. The volume of herniated contents is 2,200 mL, with a VIH/VAC ratio of 24%, indicating significant loss of domain. The abdominal wall musculature is thinned, with rectus width <4 cm bilaterally and poor lateral muscle quality. No mesh infection, fistula, or bowel compromise is seen. There is no evidence of intra-abdominal abscess or active contamination. The prior mesh is in the sublay position.

Preoperative optimization has included smoking cessation, glycemic control, nutritional supplementation, and physical therapy. Botulinum toxin injection into the lateral abdominal wall muscles was performed resulting in increased lateral muscle length and improved abdominal compliance.

Notes: The indication for component separation with retrorectus mesh placement is established by the large defect size (>10 cm), loss of domain, failed prior repair, and poor muscle quality. Posterior component separation (transversus abdominis release) is preferred to maximize medialization of the rectus muscles and facilitate tension-free midline closure, while preserving neurovascular bundles and minimizing wound morbidity. Retrorectus mesh placement (Rives-Stoppa technique) is chosen for its durable reinforcement, wide overlap, and lower risk of infection and recurrence compared to onlay or intraperitoneal mesh. A lightweight, macroporous synthetic mesh is planned, with at least 5 cm overlap beyond the defect margins and fixation to the posterior sheath. Intraoperative strategies will include meticulous dissection to avoid enterotomy, complete reduction of hernia contents, and careful management of the prior mesh. In the absence of contamination, primary skin closure is planned; in case of intraoperative contamination, delayed skin closure or negative pressure therapy may be considered.