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C. Horne and A. Prabhu
increases in surgical site infections [33]. Permanent synthetic meshes should be
used in grade 3 hernia repairs in the hands of experienced hernia surgeons with
high-volume practices as studies are still ongoing as to whether this practice may
eventually be considered standard of care [51].
Loss ofDomain
Special consideration must be given to patients with hernias exhibiting loss of
domain, where an equal or greater volume of viscera resides outside of the abdominal cavity compared to that contained within the abdomen [52]. In these cases,
achieving closure of the abdominal wall over the hernia repair can be extremely
challenging and in some cases may even result in respiratory compromise as a result
of intra-abdominal hypertension if the abdomen is closed tightly. While some degree
of intra-abdominal hypertension may be tolerated, care must be taken to avoid what
can ultimately be serious or fatal consequences of abdominal compartment syndrome [53, 54]. Various approaches to loss of domain hernias have been described,
including use of botulinum toxin, tissue expanders, and progressive preoperative
pneumoperitoneum in order to expand the abdominal cavity for replacement of the
herniated viscera [55]. While literature has suggested that such interventions may
be safely performed and relatively well tolerated [55], the authors prefer to perform
a retrorectus approach with bilateral transversus abdominis release and large bridged
repair in the retrorectus space utilizing bare heavyweight polypropylene mesh [56].
In this case, it is particularly important to prepare patients preoperatively with
weight loss where appropriate, as weight loss results in signicant visceral reduction and therefore improved ability to achieve closure of the abdomen without
undue respiratory compromise. In these challenging cases, heroic attempts to
achieve reapproximation of linea alba are avoided in favor of achieving a bridged
repair with strong synthetic mesh and adequate soft tissue coverage over the repair
(Fig. 26.2).
ab
Fig. 26.2 Examples of loss of domain and complex soft tissue problems associated with recurrent
ventral hernia repairs. Panel A: extremely thin skin covering a large recurrent ventral hernia. Panel
B: loss of abdominal domain. Note that most of intra-abdominal organs appear to be outside of the
abdominal compartment. Panel C: loss of abdominal domain with very delicate skin covering the
hernia defect. Panel D: example of the use of tissue expanders prior to denitive hernia repair
26 Recurrent Ventral Hernia Repair
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369
Soft Tissue Coverage
In circumstances where overlying skin and subcutaneous tissue are thin, ulcerated,
or of poor quality due to underlying pressure of the hernia contents or presence of
skin grafts, consideration must be given to achieving soft tissue closure of the hernia
repair. During the initial ofce visit, often the potential for soft tissue closure after
excision of poor quality or devascularized skin can be assessed by having the patient
lay supine on the examination table and attempting to “pinch” the edges of viable
skin together. If the abdominal wall is xed or “woody” in character and the good
quality skin edges do not approximate on exam, strong consideration should be
given for plastic surgery consultation. Potential planned interventions for this problem could include placement of tissue expanders or rotational versus free myofascial aps [57, 58]. Specic attention should be devoted to avoiding ischemic wound
events, as the result of such occurrences may be catastrophic and result in exposure
of the prosthetic device and ultimate compromise of the repair. Such operations are
best undertaken at tertiary or quaternary level referral centers best suited for a multidisciplinary approach. Smoking is considered by the authors to be an absolute
contraindication for such cases.
Summary
Recurrent ventral hernia repairs remain a constant challenge to the general surgeon.
When approaching recurrent ventral hernia repair, preoperative patient optimization
is essential to minimize patient factors that contribute to recurrence. A tailored
approach for each patient is necessary to offer the most successful operative intervention. Careful consideration should be given to prior operative history and prosthetic use, as well as modiable patient factors, soft tissue coverage of repair, and
planned operative approach to ensure the best outcomes. The authors propose the
following logarithm when determining best operative approach for the repair of
recurrent ventral hernias.
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C. Horne and A. Prabhu
Loss ofAbdominal Domain
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27
MarcoAlbanGarcia
Introduction
The surgical resolution of giant hernias represents a challenge for abdominal wall
surgeons. It is necessary to know the anatomical and physiological changes in the
abdominal wall and abdominal cavity, which develop during the evolution of a giant
hernia, in addition to the management of systemic and local changes, to avoid perioperative complications.
The success of surgery depends upon good methodology in the diagnosis, preoperative management with adjuvant techniques, surgical technique, and postoperative care. Also, the multidisciplinary management of these patients is indispensable.
It is ideal that these patients be treated in hospitals with experience in the management of giant hernias.
There are several reasons why patients with hernias can develop giant defects:
limited access to health, poor information, low sociocultural level, and delayed
referral from primary care physicians.
Classification
Classications for ventral and incisional hernias were rst proposed by Chevrel and
Rath, followed by Korenkov etal., Ammaturo etal., Chowbey etal., Dietz etal.,
Muysoms et al., and Hadeed et al. Some agreement exists regarding the basic
Electronic supplementary material The online version of this chapter ( https://doi.org/10.1007/978-
3-319-78411-3_27) contains supplementary material, which is available to authorized users.
M. A. Garcia
Hernia Unit of RedSalud Clínica Bicentenario y Clínica Tabancura,
Department of Surgery, Los Andes University, Santiago, Chile
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_27
373
374
Fig. 27.1 Giant ventral hernia with loss of domain with a defect with transverse diameter of
12–15cm and a hernia sac of 20× 10cm with a volume representing approximately 30% of the
volume of the abdominal cavity and that falls in front of the pubis reaching the thighs
M. A. Garcia
criteria of morphology and size of the hernia gap, although none has gained widespread acceptance in the literature. The classication proposed by the European
Hernia Society (EHS) as (a) small, <5cm in width or length; (b) medium, 5–10cm
in width or length; and (c) large, >10cm in width or length is the result of a comprehensive discussion of the criteria to be included and also of how to precisely
dene them [1]. The EHS classication is generally regarded as an improvement on
the previous classications, but no reference was made to loss of domain hernias in
that classication. This demonstrates the difculty of dening the pathological status and the impossibility of proposing a standardized surgical approach to this clinical condition [2].
The EHS classication takes only the width as a measurement for the defect size
and considers W3 hernias as the largest with more than 10cm. This does not consider the size and volume of the hernia sac and does not consider its reducibility and
loss domain [3] (Fig.27.1).
Giant inguinoscrotal hernias have been dened as those that extend below the
midpoint of the inner thigh when the patient is in the standing position, but there is
no standardized classication. Some authors classify them as type 1, up to the middle third of the thigh; type 2, up to the knee; and type 3, below the knee [4]
(Fig.27.2).
There is usually no correlation between the size of the ring and the volume of the
hernia sac. We can nd small defects with large hernia sacs with abundant intestinal
loops, and on the other hand, we can see hernia defects with rings of large diameter
but with hernia sacs that contain small volume and content. For this reason, there is
no consensus on the denition and classication of giant hernias with loss of
abdominal domain.
27 Loss ofAbdominal Domain
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Fig. 27.2 Giant inguinoscrotal hernia, type 2 (up to the knee)
Definition
“Loss of abdominal domain” is not well dened in the literature. The majority of
authors describe it as a large abdominal wall hernia with a signicant amount of
abdominal content herniated through a defect in the abdominal wall into a hernia
sac of great size that forms a secondary abdominal cavity.
The diameter of the hernia defect is generally greater than 10cm, and the contents of the hernia sac exceed the capacity of the abdominal cavity; technically it is
one in which about 20–50% or greater of the abdominal contents are located outside
of the abdominal cavity (Fig.27.3).
Chevrel described an abdominal ventral hernia whose contents were held in
place by adhesions and not reducible, thus losing their “right of domain” with the
diameter of the wall defect ≥15cm in transverse dimension [5]. Mason dened
them as those in which it was not possible to reintroduce the contents of the sac
into the abdomen with a hernia sac with a volume over a liter or a diameter of the
376
M. A. Garcia
Fig. 27.3 Patients with giant ventral hernia with loss domain. The hernia sac represents a volume
greater than 20% of the volume of the abdominal cavity (Video 27.1)
hernia ring exceeding 12cm [6]. Kingsnorth considers these hernias as those in
which the peritoneal sac has a volume of more than 15–20% of the natural volume of the abdominal cavity [7]. According to Tanaka etal., if the ratio of the
volume of the sac over the volume of the abdominal cavity is greater than 25%,
it is considered a predictor for loss of domain [8]. Herszage considered hernias
large up to 10cm, giant up to 20cm, and monstrous when the defect is more than
20cm.
Pathophysiology
Giant hernias produce a morbid condition with local and systemic alterations during
its development and growth, altering the quality of life of patients.
Local alterations affect the muscles of the abdominal wall and diaphragm, the
intestine, mesentery, subcutaneous tissue, and skin. Systemic alterations produce
postural musculoskeletal dysfunction, chronic gastrointestinal and genitourinary
dysfunction, pulmonary dysfunction, and psychosocial issues.
27 Loss ofAbdominal Domain
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Local Alterations
Muscles ofAbdominal Wall
Large hernias are accompanied by marked reduction of muscle-aponeurotic tissue
of the abdominal wall, muscle atrophy of the abdomen with a large loss of their
anatomical and physiological features that determine severe visceral and respiratory
impairment [9]. The tendency of a giant hernia is to progressively increase the traction of the lateral rectus muscles, caused by the antagonist action of the lateral
muscles of the abdomen, with the consequent enlargement of the hernia brotic
ring, and small resistance offered by the hernia sac and the herniated contents of
their own weight. The low intra-abdominal pressure changes the function of the
diaphragm, and the patients develop respiratory alterations [10] (Fig.27.4).
Volume oftheAbdominal Cavity
The abdominal cavity decreases its volume through the following mechanism: as
the bowel protrudes through the hernia defect, intra-abdominal pressure begins to
decrease, and the abdominal wall muscles contract and retract from the linea alba to
the lateral, thereby increasing the size of the hernia defect and the contents of the
Fig. 27.4 Pathophysiology of the giant hernia with loss of domain: traction of the lateral rectus
muscles, caused by the antagonist action of the lateral muscles of the abdominal wall (red arrow),
enlargement of the hernia ring (blue arrow), abdominal cavity decreases its volume because bowel
protrudes through the hernia defect (green arrow) and the intra-abdominal pressure begins to
decrease, chronic inammation of the mesentery and intestine (yellow circle), the skin and subcutaneous cellular tissue suffer alterations by a mechanical effect of compression by the great sac,
resulting in the atrophy (white arrow) (Video 27.2)
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