AUTHOR=Fortelny René H. , Froehlich Sandra , Kapitanov Teodor 
  
TITLE=Case Report: Sequential posterior and anterior intraoperative fascial traction in extreme loss-of-domain incisional hernia
  
JOURNAL=Journal of Abdominal Wall Surgery
  
VOLUME=Volume 5 - 2026
  
YEAR=2026
  
URL=https://www.frontierspartnerships.org/journals/journal-of-abdominal-wall-surgery/articles/10.3389/jaws.2026.17341
  
DOI=10.3389/jaws.2026.17341
  
ISSN=2813-2092
  
ABSTRACT=BackgroundIncisional hernias with loss of domain (LOD) following open abdomen management, visceral surgery, and cutaneous grafting present an extreme reconstructive challenge. Intraoperative fascial traction (IFT) using the Fasciotens® Abdomen device has been established as an effective adjunct to reduce fascial gaps in large ventral hernias (EHS W3). Conventional application targets the anterior rectus sheath. We describe a sequential double-layer IFT approach, first applied to the posterior and then to the anterior layer, in an extreme LOD case, and report whether posterior-layer traction allowed closure of the posterior layer without a bridging mesh.Case PresentationA 35-year-old male (BMI 24, DM II, nicotine abuse, polytoxicomania) presented with a massive LOD incisional hernia following polytrauma (2011) with right nephrectomy, transverse colon resection, colostomy/ileostomy, open abdomen, split-skin grafting, and a prior failed IPOM bridging repair (2021). After multimodal prehabilitation (weight reduction, drug detoxification, partial tissue expansion, and botulinum toxin A [BTA] 8 weeks preoperatively), definitive reconstruction was performed in March 2025 using a combined Rives–Stoppa/Madrid/bilateral TAR approach. IFT applied to the posterior layer for 30 min (up to 18 kg) allowed closure of this layer from the caudal margin to the umbilicus, but not in the cranial segment, where peritoneum was absent after open abdomen management and skin grafting; a bridging mesh, OviTex® S2 (30 × 25 cm, ≥5 cm overlap), was therefore placed cranially as a visceral separation layer. A second IFT phase targeting the anterior sheath (30 min) then allowed primary closure of the remaining 10-cm anterior defect. A retromuscular mesh DynaMesh®-CICAT (30 × 35 cm) was placed, and the linea alba was reconstructed using the small-bites technique (Monomax 2.0). A seroma at 6 months was aspirated once (400 mL, sterile); CT at 12 months confirmed no recurrence.DiscussionTo our knowledge, this is the first reported case of sequential posterior–anterior IFT using the Fasciotens® device. Posterior-layer traction allowed closure of the caudal posterior layer but did not avoid a bridging mesh in the cranial segment. After anterior IFT, the anterior fascia was closed primarily. Whether posterior IFT reduces the bridged area cannot be determined from a single case.