The Modified Lázaro Da Silva Procedure (mALS): A Bail-out Technique For Complex Ventral Hernia Repair

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Abstract During large ventral hernia repair, primary closure of the defect may not be feasible or desirable due to the risk of severe adverse effects associated with intra-abdominal hypertension. We present a variation of the Lázaro da Silva procedure (1971) for the repair of a massive and bulky midline incisional hernia. The initial steps of the original procedure—including the dissection of the hernial sac and the creation of relaxing incisions in the rectus sheath—were maintained, as were the first and third suture layers. However, the second layer, intended for midline closure and reconstruction of the linea alba, was replaced by an interposed standard polypropylene mesh. The mesh was anchored to the medial edges of the relaxing incisions and encapsulated between the peritoneofibrous leaflets of the hernial sac. This modification resulted in a wide, controlled diastasis that maintained the abdominal contents within an expanded, normotensive cavity. At the two-year follow-up, there was no recurrence, the diastasis remained stable, and the patient had returned to full occupational activity. The modified Lázaro da Silva procedure (mALS) with an interposed mesh is an effective “bail-out” strategy when preoperative expansion measures are insufficient to achieve tension-free closure of large ventral defects.