Ammar elliptical skin incision was done incorporating any redundant skin and fat. The incision was deepened laterally to expose the musculoaponeurotic abdominal wall of at least 6 cm from the margin of the defect. The sac of the hernia was often quite large, long, and multilocular. The sac was opened and its surface is cleared off all adherent omentum and intestine. Most of the sac was excised except a small part that is used as a flap to close the defect over the replaced content. Where possible, the omentum was spread over the reduced bowel. No attempt at approximation of the muscle to close the de- fect was done. After securing hemostasis, a polypropylene mesh was inserted to cover the area so that at least 3 to 5 cm of the mesh overlapped the edges of the fascia and sutured to the outer surface of musculoaponeurotic abdominal wall (onlay). All redundant skin and fat were removed before in- sertion of two suction drains and skin closure. The patients were closely observed postoperatively for adequate pain control, urine output, and blood gases. As soon as practical, the patient was raised to about 45-degree flexion of the trunk in order to allow maximum pulmonary ventilation. The intravenous infusion was continued until re- turn of bowel sounds. Semisolid and solid diets were then gradually advanced. The patient remained catheterised until he/she can get out of bed. The drains were removed when the output was less than 30 cc within 24-hours period. Statistics Results Data were described by using descriptive statistics as range, mean, standard deviation (SD) and percentage. The study included 35 patients with giant ventral her- nias, 22 men and 13 women. The average age of patients was 52 years (SD = 5.27). Twenty had giant post-operative incisional hernias (Fig. 1) and 15 patients had giant para-um- bilical hernias (Fig. 2). The mean hernia defect size was 16.8 cm (SD = 3.4). All patients were overweight or obese with a mean body mass index 33 (SD = 4.3). Follow up ranged from Figure 1. (a) Preoperative view of giant postoperative incisional hernia; (b) Appearance of the patient after hernial repair by poly- propylene mesh and host tissue barrier. J Clin Med Res • 2009;1(4):226-229 Figure 2. (a) Preoperative view of giant paraumbilical hernia; (b) postoperative view of the same patient. 18 to 36 months. All patients were discharged home within 7 - 15 days. No patient required ventilation after operation. Recurrent seroma, which responded to repeated aspiration, was experienced in 4 patients (11.4%). Minor wound infec- tion was observed in 5 patients (14.2%). Small hernia recur- rence occurred in one patient (2.8%). The recurrence was asymptomatic and the patient declined re-operation. Discussion All hernias, particularly the massive one, should be re- paired unless the patient is unable or unwilling to undergo surgery. Hernias increase gradually in size, unsightly, and are liable for grave complications. There are many options proposed to help repair of massive hernias. For abdominal rooming, musculoskeletal flaps [5-7] and pneumoperitoneum [8, 9] are described. Pneumoperi- toneum is an invasive procedure with occasional complica- tions, such as viscera perforation, air embolism, peritonitis, and hematoma of the abdominal wall [9-11]. Musculosk- eletal flaps require much dissection with the possibility of significant blood loss, flap necrosis and donor site related complications [6]. To decrease the bulk of the contents, parts of omen- tum, small bowel or colon are resected [12]. However, bow- el resection contaminates the field and is liable for serious complications. Historically, the use of synthetic mesh in the presence of potential contaminations has been strongly dis- couraged on the basis of high rates of morbidity [13, 14]. Other options include using the components separation technique initially described by Ramirez et al in 1990 [15]. One of the limitations of this technique is that it requires the availability of viable local tissue to provide the necessary ad- vancement for a durable repair. Often, massive ventral her- nias do not contain sufficient surrounding tissue necessary to perform a component separation during the initial procedure and synthetic mesh is usually needed [16]. Alternatively ex- pansion of available tissue over several weeks could be done using implantable tissue expanders to achieve primary clo- sure [17]. After sequential expansion, the defect is typically closed by using a mesh repair. This method is further limited by the cost of the expanders and infection possibility. Staged Articles © The authors, Journal compilation © J Clin Med Res and Elmer Press™, www.jocmr.org 227