Successful Multimodal Approach to Megacolon, Enterocutaneous Fistula, and Chronic Incisional Hernia with Loss of Domain: A Case Report

Our case highlights a 41-year-old male with a past medical history of severe diverticular disease since age 30, diabetes mellitus type 2, hypertension, protein calorie malnourishment, and body mass index of 50 kg/m2 who presented for a large bowel obstruction. Active surgical issues included: chronic incisional hernia, enterocutaneous fistulae, and a megacolon secondary to a recto-sigmoid anastomotic stricture. In collaboration with a colorectal surgeon and by using a multimodal approach, we successfully addressed the patient’s gastrointestinal issues and incisional hernia. The multimodal approach included botulinum toxin A (BTA) injections to the abdominal wall flat muscles (external oblique, internal oblique, and transverse abdominus), installation of an abdominal reapproximation anchor (ABRA) dynamic tissue system (DTS), and porcine urinary bladder matrix (PUBM) xenografts. The patient received BTA injections prior to the index operation, which lasted over 12 hours. The ABRA DTS assisted in achieving primary fascial closures. Definitive closure of this class 4 wound was facilitated by the antimicrobial and accelerated wound healing properties of PUBM as well as a unique multimodal approach to achieve exemplary results in a patient with multiple complex surgical issues.