https://orcid.org/0009-0007-7121-1752
Abstract
Postoperative abdominal wound dehiscence following mesh hernia repair presents a severe surgical challenge. In comorbid elderly patients, definitive abdominal wall reconstruction after mesh explantation carries prohibitive mortality risks. We present a 72-year-old homebound female with a chronic, dehisced midline abdominal wound (17.0 × 2.0 × 1.0 cm) following complicated hernia surgery and subsequent mesh removal at an outside facility. To minimize perioperative risks, a staged, non-reconstructive soft-tissue salvage approach was utilized. The patient underwent two serial operative debridements under monitored anesthesia care and two weeks of continuous negative pressure wound therapy at −125 mmHg. After achieving clean granulation bed over a structurally intact and closed deep fascia, a dehydrated human amniotic membrane allograft (AmnioAMP-MP) was applied. Complete wound closure was achieved within six weeks without secondary mesh reconstruction or complications. Amniotic allografts represent an effective salvage modality for complex abdominal soft-tissue wounds over intact fascial planes.
Introduction
Postoperative wound dehiscence and tissue infections following complex ventral hernia repair represent severe surgical challenges [1]. The surgical eradication of severe mesh infections typically requires complete prosthetic explantation, leaving behind highly compromised, structurally unstable abdominal wall defects [2]. In elderly patients with extensive multi-organ comorbidities, a subsequent formal return to the operating theater for complex abdominal wall reconstruction under general anesthesia carries prohibitive perioperative mortality risks [3]. Therefore, identifying alternative, low-risk surgical protocols to manage large midline soft-tissue defects without relying on major myofascial reconstructions is vital for clinical optimization [4]. We present a case of a 72-year-old homebound female with multiple comorbidities who presented with a chronic, dehisced abdominal wound following mesh explantation. The defect was successfully managed via low-risk serial operative debridements under monitored anesthesia care (MAC), temporary negative pressure wound therapy (NPWT), and sequential amniotic membrane allografting, resulting in rapid, complete epithelial closure over an intact anterior fascial layer.
Case report
A 72-year-old homebound female with a past medical history of coronary artery disease, peripheral vascular disease, benign essential hypertension, chronic kidney disease, chronic anemia, hypothyroidism, major depression, and baseline intellectual disabilities presented with a chronic, non-healing midline abdominal wound. Her surgical history was notable for a prior tracheostomy, percutaneous endoscopic gastrostomy tube insertion, and a ventral hernia repair with synthetic mesh performed in January 2025. The hernia repair had been severely complicated by an emergency intestinal obstruction and bowel perforation, requiring bowel resection, complete mesh explantation, and extensive excisional debridement at an outside facility due to a gross necrotizing surgical site infection.
Upon presentation to our service, clinical examination revealed a chronic midline abdominal wound measuring 17.0 × 2.0 × 1.0 cm (calculated initial surface area of 34 cm2). The wound exhibited complete disruption of the cutaneous and subcutaneous tissue layers with exposure of the underlying subcutaneous fat. Crucially, the deep anterior abdominal wall fascia and linea alba were structurally intact and closed; there was no fascial dehiscence, exposure of the peritoneal cavity, or visceral evisceration (Fig. 1). Significant three-dimensional tissue undermining was present along the margins, measuring 4.0 × 3.0 × 2.0 cm. The wound had remained open, stagnant, and refractory to traditional treatments for over 30 days.
Clinical photograph showing a large midline abdominal soft-tissue wound with exposed subcutaneous tissue and extensive wound undermining; the deeper fascial layer remains intact.
Given her severe multi-organ cardiopulmonary and renal risk profile, definitive open myofascial abdominal wall reconstruction under general endotracheal anesthesia was contraindicated. Instead, a low-risk, staged surgical wound-salvage strategy was initiated. The patient was taken to the operating theater a total of two times for formal sharp wound debridements managed safely under MAC sedation to mitigate perioperative risk. Following adequate operative source control, intermediary stabilization was achieved utilizing NPWT at a continuous setting of −125 mmHg for a duration of two weeks, with dressing changes performed every 48 to 72 hours (Fig. 2).
Clinical photograph showing the abdominal wound after two operative debridements and NPWT, with a clean, healthy-appearing granulation tissue bed.
Once a clean, highly vascularized granulation bed free of necrotic tissue or slough was established, the patient was transitioned to outpatient advanced wound care. A dehydrated human amniotic membrane allograft (AmnioAMP-MP, processed by J4 Biologics, San Antonio, TX) was selected as a non-reconstructive definitive closure matrix. Due to the severe undermining beneath the wound margins, sequential 2 × 2 cm allograft patches (total product volume of 58 cm2 utilized, 4 cm2 wastage) were operatively packed directly into the undermined tissue planes and mapped seamlessly across the visible midline wound bed (Fig. 3). This technical modification ensured direct contact with the compromised margins, successfully eliminating dead space. Weekly clinical assessments tracked progressive wound contraction and robust marginal epithelialization (Fig. 4). Complete, stable epithelial wound closure and mature scar formation were achieved within approximately six weeks of the index graft application, without any graft-related complications, recurrent infection, or fascial failure (Fig. 5).
Clinical photograph showing a midline abdominal wound with a ruler demonstrating its dimensions and visible placement of 2 × 2 cm dehydrated human amniotic membrane allograft patches within the undermined wound planes.
Clinical photograph of the healing midline abdominal wound showing progressive contraction and narrowing, with advancing epithelialization from the wound margins.
Clinical photograph at six-week follow-up showing complete epithelial closure of the midline abdominal wound with a stable, mature scar and no visible open wound.
Discussion
Managing extensive midline abdominal soft-tissue dehiscence following a complicated mesh explantation presents a formidable surgical challenge. Traditional approaches rely heavily on prolonged NPWT or complex abdominal wall component separation surgeries [1, 3]. However, in elderly patients with substantial multi-organ comorbidities, repeated returns to the operating theater for extensive fascial mobilization carry a prohibitive mortality risk [4].
In this case, a staged surgical management algorithm was successfully utilized to maximize patient safety. The initial phase focused on aggressive local source control through sequential operative debridements and the application of NPWT. Utilizing MAC sedation for these procedures allowed for thorough surgical clearance while effectively avoiding the hemodynamic instability associated with general endotracheal anesthesia.
Because the synthetic mesh had been entirely removed during her prior treatment, the abdominal midline lacked a prosthetic reinforcing domain. Crucially, while the deep anterior abdominal wall fascia and linea alba remained structurally sound and completely closed, the overlying cutaneous and subcutaneous tissues failed to heal. Since the wound remained open and stagnant for over 30 days despite traditional NPWT, a secondary biological strategy was mandatory to accelerate tissue growth. Dehydrated human amniotic membrane allografts (dHAMA), such as AmnioAMP-MP, serve as a structural extracellular matrix scaffold delivering key growth factors like transforming growth factor-beta (TGF-beta) and vascular endothelial growth factor (VEGF) [5, 6]. These components actively downregulate chronic inflammatory pathways while accelerating localized neovascularization.
A unique challenge in this case was the presence of severe tissue undermining (4.0 × 3.0 × 2.0 cm) beneath the wound margins. To address this structural defect, sequential 2 × 2 cm allograft patches were operatively packed directly into the undermined tissue planes and mapped seamlessly across the visible midline wound bed. This technical modification ensured complete, three-dimensional contact with the compromised margins, stimulating deep tissue regeneration and avoiding dead-space fluid accumulation [7]. Ultimately, transitioning from NPWT to dHAMA facilitated rapid wound contraction and complete epithelial closing within approximately six weeks. This outcome highlights the clinical value of utilizing advanced biological scaffolds as a definitive salvage modality for complex, dehisced surgical wounds, safely avoiding high-risk re-laparotomy or fascial reconstruction in exceptionally vulnerable patients.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Funding
No funding was received for this case report.
References
CellGenuity. Extracellular matrix regulatory proteins and nutrient growth factor retention. CellGenuity Technical Report. 2026. Available from: https://cellgenuity.com (14 June 2026, date last accessed).
Schmiedova I, Dembickaja A, Kiselakova L et al. . Using of amniotic membrane derivatives for the treatment of chronic wounds.
