In 2014, a 47-year-old woman from Kolkata underwent surgery to repair a ventral hernia which is an opening in the abdominal wall through which the intestines and other organs push outward. The repair held for less than a year. The hernia returned, and over the years that followed, it grew steadily larger. By the time she presented at CK Birla Hospitals, CMRI, she was carrying a massive recurrent hernia that had been with her for nine years, complicated by a body mass index of 49, type 2 diabetes, hypertension, and hypothyroidism.
The clinical picture she presented was one that makes surgeons pause. The hernia had reached what is known as loss of domain, a condition in which so much of the abdominal contents have moved outside the cavity that simply pushing them back in and closing the wall becomes mechanically and physiologically hazardous. Operating on a patient at this weight, with this degree of hernia complexity and these metabolic comorbidities, carries a significantly elevated risk of wound breakdown, infection, recurrence, and respiratory complications following surgery. Attempting the repair without preparation would have been doing her a disservice.
Dr Sarfaraz J Baig and his team made a different decision. Before any hernia repair was attempted, the patient underwent bariatric surgery, specifically a laparoscopic sleeve gastrectomy, to reduce her weight and improve her metabolic condition. Over the seven months that followed, she lost approximately 27 kg. Her diabetes came under better control. Her abdominal wall, previously thickened by fat and stretched to its limit, became progressively more manageable. The biological environment that the surgical team would be working in changed substantially for the better.
Dr Sarfaraz J Baig, Senior Consultant, GI Surgery, CK Birla Hospitals, CMRI, said, "This case demonstrates why staged planning matters in complex hernia surgery. A hernia of this size and complexity, in a patient with this degree of obesity and metabolic burden, carries a very high risk of failure and serious complications if addressed immediately. The 27 kg of weight loss the patient achieved before surgery fundamentally changed what was possible. It reduced the technical difficulty of the repair, improved her metabolic resilience, and gave us the conditions to achieve an outcome that would have been considerably harder to sustain without that preparation."
With the patient optimised, the definitive repair was planned. The procedure Dr Baig performed was a Transversus Abdominis Release with Peritoneal Flap Repair, known as TAR Plus, combined with a vertical panniculectomy to remove the redundant abdominal skin that had accumulated over years of a stretched and protruding hernia. The TAR Plus technique involves releasing specific muscle layers on both sides of the abdomen to create space, allowing the abdominal wall to come together in the midline without tension. The preserved hernia sac was used to reconstruct the inner lining of the abdomen. A large mesh was then placed behind the muscles to reinforce the repair, and the anterior abdominal wall was closed over it. The panniculectomy performed alongside improved access to the surgical field and produced a significantly better functional and cosmetic outcome.
The postoperative course was uncomplicated. The patient recovered with a restored abdominal wall contour and without the wound complications that this class of repair carries when it is performed without adequate preparation.