Case 196 Enunciado A 54-year-old female patient, diabetic, BMI of 59.6 kg/m², subjected to bariatric surgery under Fobi-Capella technique by xifoumbilical laparotomy. It evolved with incisional hernia after 4 months (her BMI was 45.4 kg/m²), and it was opted to wait for more weight loss before intervention. After three years, there was stabilization of weight (BMI 37.8 kg/m²), but with greater volume hernia. Requested abdominal computed tomography (CT) to pre-surgical planning (see below). Abdominal CT, axial cut at the level of the L1 vertebra, without contrast. Abdominal CT scan, non-contrast axial (at the level of T12 vertebra) and sagittal cuts, respectively. It shows maximum dimensions at each axis defect in the abdominal wall: transverse axis: 12,1cm; longitudinal: 12,3cm. Three-dimensional reconstruction of images obtained by abdominal CT, since T8 vertebra to the root of the thighs. Abdominal CT: Analysis of abdominal cavity dimensions (upper cuts) and the hernia sac (lower cuts). Dimensions of abdominal cavity: anteroposterior: 18.4cm; longitudinal: 31,3cm; transverse: 22.9cm. Dimensions of hernia sac: anteroposterior: 9,9cm; longitudinal: 26,7cm; transverse: 27,7cm. Question:Given the clinical presentation and CT images attached, which would be the most appropriate approach? Hernia repair with prosthesis Primary herniorrhaphy followed by abdominoplasty Preoperative progressive Pneumoperitoneum and hernia repair with prosthesis Separation of external oblique muscle and primary herniorrhaphy Time is Up! Time's up
