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Aim Large incisional hernia treatment is challenging for surgeons especially when there is loss of domain. Its management require an appropiate preoperative optimization of the patient. We present a complex case that provides an exhaustive review of different measures in order to treat this type of hernias. Material and Methods A 61-year-old, smoker and diabetic patient consulted because of a large ventral hernia. He underwent an umbilical hernia surgery which recurred three more times. The patient had a M1-M5 W3 hernia with active suppuration through fistulous orifices. The abdominal wall planning CT scan showed a large eventration with 23 cm of transverse defect diameter and a Tanaka index of 92%. Results The patient received support to quit smoking and he lost weight due to an intragastric balloon. Botulinum toxin was administered six weeks before surgical intervention. An andominal pneumeperitoneum catheter was placed, reaching 12.400 liters of ambient air insufflated during 13 days. Finally, surgery was performed, finding a 27 x 35 cm wall defect that required the performance of: After these maneuvers, the posterior abdominal wall could be completely closed. A double preperitoneal mesh (BioA and polypropylene) was placed. After 16 days, he was discharged without mayor complications. Conclusions Loss of domain hernias are a complex entity which requires a multidisciplinary approach and abdominal wall experienced surgeons since it may require extreme measures.

P023 MANAGEMENT OF MASSIVE INCISIONAL HERNIA WITH LOSS OF DOMAIN