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M. A. Garcia
sac which is vulnerable to trauma as there is no muscular wall that protects the
abdominal contents [11–14]. In large hernias, the amount of viscera which progressively stretch and hold the hernia sac is such that it can form a “second abdomen”
(Fig.27.4).
Mesentery andIntestinal Loops
The herniated viscera adapt to local and extra-abdominal factors. The mesentery
extends and becomes thickened by the difculty of venous and lymphatic return,
and there is chronic bowel dilatation due to loss of balance between the visceral and
parietal tonus [9, 12]. A chronic inammation of the mesentery and intestine develops, caused by direct mechanical irritation by the continuous friction with the rim
of the ring. This inammation conditions the formation of bowel adhesions, between
mesentery and omentum, to the ring and hernia sac. In addition, there is a decrease
in the venous return of the portal ow and the cava to the thorax due to the decrease
of the intra-abdominal pressure and compression of the hernia ring, which causes
congestion of all the abdominal viscera [11–14] (Fig.27.4).
Skin andSubcutaneous Tissue, Fistulas
The skin and subcutaneous cellular tissue suffer alterations by a mechanical effect
of compression by the large sac, resulting in atrophy. Abreast of a peritoneal sac, the
skin is reduced to a poorly vascularized dermis, devoid of its supporting subcutaneous tissue [7, 12, 14]. The eventual result of this cutaneous hypoxia is the appearance of trophic ulcers which are observed, on occasions, in giant incisional hernias.
A trophic ulcer has precise and corresponding manifestations: always situated at the
midline, symmetrical, and sits at the vertex of the protrusion where the skin is thinnest. In chronic cases, atrophic ulcers may appear that are bacterial or fungal in
origin that can contaminate the operative eld. There will also be a tendency for
infections in the skin folds around the sack [15].
Flament etal. described two types of ulcers in patients with hernias with loss of
domain:
(a) Uncomplicated ulceration: these ulcers are most often infected, despite the
absence of intestinal stula formation.
(b) Complicated ulcers: the trophic ulcer is a prelude to more serious complications
such as stulas and eviscerations.
The rupture of a herniation (“burst abdomen”) is a rather rare complication
which converts a herniation into an evisceration through a breakdown of the peritoneal and cutaneous supportive layers. These events are end results of neglected
trophic ulcers [15] (Fig.27.4).
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Systemic Alterations
Musculoskeletal Dysfunction
As the hernia sac grows excessively, a “second abdomen” is formed, which now
weighs more than the abdomen itself and tends to cause the patient to bend forward
following the weight of the sac. To compensate, it will force the patient to perform
a hyperlordosis of the lumbar spine with its consequent painful lumbar syndrome or
low back pain [13, 14]. When the linea alba is disrupted, the rectus abdominis muscles become dysfunctional, and the columns are mechanically uncoupled. This
results in greater pressure on the posterior column, leading to chronic back pain and
spine curvature disorders.
Ventilatory Dysfunction
As the intestinal loops migrate into the sac, the intra-abdominal pressure decreases
in direct relation to the herniated volume. This alters the balance between intrathoracic and intra-abdominal pressures by modifying the normal diaphragm shape,
which is attened, resulting in inspiratory and expiratory restriction. Ventilation in
these patients depends to a large extent on the capacity of the thoracic muscles
[14]. The low intra-abdominal pressure changes the function of the diaphragm promoting its lowering and progressive lethargy. As a result, patients may have respiratory problems due to the synergistic changes in the abdominal wall, the
discoordination between the chest wall, diaphragm, and abdominal muscles. This
results in a decrease in total respiratory compliance almost entirely due to a
decrease in chest wall compliance—whereas the lung remains substantially
unchanged—which induces an increase in mechanical work of breathing and O2
consumption by accessory respiratory muscles [10]. Patients develop chronic
respiratory failure, often latent, with functional tests and minimal change in blood
gases in the absence of preexisting restrictive or obstructive pulmonary disease
[16]. However, in patients with low respiratory reserve, all preoperative care must
be taken and surgical maneuvers aiming to minimize the increased work of breathing [
16].
Chronic Gastrointestinal Dysfunction
Patients with large hernia sacs develop altered intestinal transit through two mechanisms; the rst is because of the difculty of increasing the intra-abdominal pressure due to abdominal muscles displaced from the midline and with difculty
contracting, and the second as obstructive effect when the intestinal loops are
included in the contents of the hernia sac, which produces obstruction of the passage of intestinal material by a hernia ring that obstructs the ow, in addition to the
compression of the viscera among themselves inside the sac [14].
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M. A. Garcia
Dysfunction forUrination
Rarely, the bladder is inside a hernia sac and causes obstructive dysfunction. Most
of the time, it is simply due to dysfunction of the bladder detrusor muscle due to
the inability to raise the intra-abdominal pressure and favor the action of the bladder [14].
Psychosocial Issues
The deterioration of the quality of life due to the alterations that the giant hernia
causes in the patient, such as the low self-esteem due to the aesthetic alteration and
the poor access to a hernia specialist in some places, makes the patients and their
family environment have a signicant emotional commitment with psychological
alterations that also require professional support.
Management oftheHernia withLoss Domain
The objectives of surgical management in an incisional hernia are the recovery of
the anatomy and functionality of the abdominal wall, prevention of recurrence, and
adequate tissue cover. For this the closure of the midline is of vital importance, since
the restructured wall functions as the primary support and the abdominal continent
and prevents excessive stress on the mesh. Achieving these three goals in a parietal
reconstruction (in the case of a giant hernia) is a major surgical challenge, so all
available resources must be used.
Different methods for the closure of the midline in giant hernias have been
described in order to reduce the operative morbidity, especially the possibility of
the development of the intra-abdominal compartment syndrome due to the closure of a giant defect and the concomitant increase of the intra-abdominal
pressure.
The most used surgical techniques, in order to achieve an increase of the perimeter of the abdominal cavity based on relaxation incisions in the lateral muscles of
the abdominal wall, are the anterior separation of components [17] and the transversus abdominis release techniques [18]. Another option is the Albanese technique, with good results [19]. There are modications of the anterior separation of
components technique widely used as Carbonell-Bonafe modication [20], endoscopic assisted minimally invasive release of the external oblique [21], and subcutaneous endoscopic approach described by Daes etal. [22]. In the same way, the
transverse abdominal release technique can be done by minimally invasive and
robotic approach.
The common objectives of these techniques are (1) to avoid the tension on
the midline closure and (2) to increase the abdominal capacity permitting an
easy return of the viscera to the abdominal cavity, thus achieving domain
recovery.
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Anterior Separation ofComponents
The technique of anterior component separation was rst described by Ramirez etal.,
whereby the muscular layers of the anterior abdominal wall could be separated and
medially mobilized in order to close the midline in large ventral defects, restoring the
anatomy. Ramirez et al. described development of the avascular plane between the
external and internal oblique muscular layers through relaxing incisions lateral to the
rectus sheath, combined with mobilizing the posterior rectus sheath to the midline.
Combined with freeing the rectus from its attachments to the posterior sheet [17]. The
technique is extensively described in previous chapters.
Carbonell etal. describe a variation of the Ramirez technique with the installation
of a 30×50cm mesh between the plane of the external and internal oblique muscles,
reinserting the medial border of the external oblique muscle toward the mesh and
internal oblique muscle (Level 1) and if needed releasing the rectus from its aponeurosis through its posterior face using another retromuscular mesh (Level 2) [20].
Endoscopic assisted minimally invasive [21] release of the external oblique has
also been described as a technique that reduces complications of soft tissues of open
technique, and Daes etal. [22] described a subcutaneous endoscopic approach, in
his series of hernias between 6 and 10cm only required the release of unilateral
external oblique muscle, through a supraaponeurotic subcutaneous dissection with
balloon and only one working port apart from the optical port. The closure of the
defect and reinforcement with mesh was performed by IPOM technique.
Transverse Abdominal Release Technique TAR
Novitsky etal. described the transverse abdominal release technique. The TAR procedure is a continuation and modication of the traditional retrorectus Rives—Stoppa
repair. It is a myofascial release of the transversus abdominis muscle. This technique
involves a wide area from the diaphragm to the pelvis and from paraspinal muscles
of both sides. A major benet of the TAR approach is that no skin aps are raised for
the reduction of the hernia, which may yield lower postoperative wound complications. The technique is extensively described in previous chapters [18].
Albanese Technique
Albanese designed his “triple incision” on the oblique major muscles (OM), the
minor oblique, and the posterior leaf of the rectus sheath, respectively. This can be
associated with the use of a mesh [19].
Adjuvant Techniques
There are other nonsurgical techniques whose purpose is to increase the perimeter
and capacity of the abdominal cavity based on the elongation of the muscles of the
abdominal wall; these techniques called “adjuvants” are progressive preoperative
382
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M. A. Garcia
pneumoperitoneum (PPP) [23], tissue expanders [24], and botulinum toxin [25, 26].
Other more radical techniques have been described for the treatment of giant
inguinoscrotal hernias with loss of domain, like debulking of abdominal contents
with extensive bowel resections in the form of total or hemicolectomy, omentectomy, splenectomy, and even small bowel resections [27].
Progressive Preoperative Pneumoperitoneum (PPP)
Progressive preoperative pneumoperitoneum gradually elevates intra-abdominal
pressure, achieving the following systemic and local changes in the cavity and
abdominal wall [13, 23, 28–31] (Fig.27.5):
• Stabilizes diaphragmatic function and improves ventilatory mechanics
• Distends the muscles of the abdominal wall, which increases the capacity of the
abdominal cavity
• Allows pneumatic lysis of adhesions facilitating dissection of the hernia sac and
its contents
• Improves portal, mesenteric, and intestinal circulation
• Produces peritoneal irritation through the ambient air, optimizing the inamma-
tory response, and improves healing
• Allows to identify other areas of weakness in the abdominal wall not evident
• Decreases midline tension
• Decreases the visceral volume up to 40% [13]
• Improves tolerance to herniary content reduction, reducing immediate hemody-
namic, ventilatory, and postoperative complications related to intra-abdominal
compartment syndrome
PPP requires frequent insufation of air into the abdominal cavity. Goñi Moreno
used oxygen in his rst case and later changed to ambient air. You can use oxygen, CO2,
nitrous oxide, and ambient air, which has less absorption than oxygen and CO2 [31].
Fig. 27.5 (a) Ventral Hernia, prior to initiation of PPP, (b) after 15days of PPP (Video 27.3)
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The procedure can be performed in the operating room or in the patient’s bed
under aseptic conditions, local anesthesia, and sedation, by a detachable Veres needle or by Seldinger technique; you can use a double lumen catheter or a pigtail
catheter placed percutaneously at Palmer’s Point or other remote site from the hernia. Once the catheter is in the abdominal cavity, ambient air is passed through it.
The catheter can be inserted under ultrasonographical or CT-guided control by the
interventional radiologist. The subsequent insufation of the abdominal cavity can
be performed as an inpatient or ambulatory procedure. Air is insufated daily in an
amount of 500–1500cm3 [12–14, 31].
Intra-abdominal pressure should not exceed 15 mmHg. The duration of PPP
depends on hernia type and size; approximately 1–2weeks in giant inguinoscrotal
hernia, 2–3weeks in giant ventral hernia, and the total volume will range from 5000
to 10,000cm3. If the patient manifests a feeling of fullness, pain, nausea, shortness
of breath, tachycardia, hypertension, hypotension, or decreased blood O2 saturation, the PPP must be suspended.
PPP has a low rate of complications (7%): hematoma, seroma, abdominal wall
emphysema, pneumothorax, pneumomediastinum, pneumopericardium, deep
venous thrombosis, pulmonary thromboembolism, intestinal obstruction, hemoperitoneum, peritonitis, catheter dysfunction (local emphysema, infection, displacement
to preperitoneum), pneumonia, and metabolic acidosis.
Botulinum Toxin
Botulinum toxin (BTX) is a neurotoxin that is isolated and puried from Clostridium
bacteria which produce eight different serotypes. Only A and B serotypes are commercially available for clinical use, with type A being the most commonly utilized. BTX
blocks the release of acetylcholine in addition to pain and inammatory mediators at
the presynaptic cholinergic nerve terminal. The injected skeletal muscle with BTX
becomes accidly paralyzed with diminished pain sensations resulting in 4–6months
of reversible paralysis or chemical muscle denervation. In the abdominal lateral wall,
BTX should result in improved abdominal wall compliance, decreased lateral abdominal wall retraction with less midline tension, and pain modulating benets, with potential applications in abdominal wall reconstruction settings in patients with loss of
domain. Ibarra-Hurtado etal. demonstrated in patients with ventral hernia with loss
domain a 50% reduction in transverse hernia diameter at week 3 [25]. Another study in
inguinoscrotal giant hernias resulted in a 26% gain of intra-abdominal volume [26].
Tissue Expanders
Expansion of musculofascial tissue using temporarily implanted expanders as a precursor to reconstructing the abdominal wall was rst described by Hobar, Byrd, and
colleagues for congenital defects and later by the same group for posttraumatic
defects. Gradual expansion should allow for reapproximation of autogenous,
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M. A. Garcia
innervated, healthy tissue. Possible locations for the expanders are subcutaneous,
intermuscular sites between the external and internal oblique muscles, intramuscular sites between the internal oblique and transverse abdominis muscles, and intraabdominally. Placing expanders in the plane between the transverse and internal
oblique muscles appears ill-advised because this area contains the nervous and arterial supplies for these two muscles and the rectus [32].
Measurement ofAbdominal Cavity Volumes andHernia Sac
The treatment of giant ventral hernia with loss of domain is considered to be dangerous because fascia closure under tension is life-threatening due to the risk of
intra-abdominal hypertension (also known as abdominal compartment syndrome).
To mitigate this postoperative risk, the adjuvant preoperative techniques have been
used in the work-up of large incisional hernias. Predictive preoperative factors for
these complications (including compartment syndrome) have been poorly described.
It is essential that these patients have imaging, such as CT scan without contrast that
evaluates the anatomy of the wall and abdominal cavity, in addition to measuring
the volumes of the abdominal cavity and hernia sac.
The volumes to be measured are the incisional hernia volume (IHV), the abdominal cavity volume (ACV) excluding the IHV, the total peritoneal volume (PV, i.e.
IHV˖ ACV), and the IHV/PV.The height and width of the hernia should also be
calculated.
Dumont etal. [23] described in 2009 the increase of the length of the muscles of
the abdominal wall and hernia ring after PPP and coined the concept of passive
extension in the muscles. Sabbagh etal. [33] in their study in 2011 described that an
IHV/PV ratio ≤20% was predictive of tension-free fascia closure of ventral hernias
with loss domain. He showed that 89% of the patients meeting this criterion had
tension-free fascia closure and no need for resection to decrease the intra-abdominal
pressure. When the ratio was ≥20%, only 12.5% of the patients had tension-free
fascia closure without resection. Meir etal. [34] considered a high IHV/PV ratio to
be an indication for PPP but did not quantify the parameter. Kingsnorth etal. [7]
suggested that physiological respiratory adaptation is necessary if the volume is
above 15–20%. Sabbagh adopted the threshold of 20% suggested by Kingsnorth
etal. This value may have been chosen as a result of the systematic use of PPP.In
2009, Tanaka etal. [8] reported on their use of peritoneal volume expansion prior to
the surgical treatment of ventral hernias with loss domain. They used the IHV/ACV
ratio to determine the extent of PPP. Tanaka etal. [8] applied a threshold of 25% for
the IHV/ACV ratio but did not specify how they had decided on this value. Rappoport
etal. [13] in 2014 demonstrated similar results in their study. They measured the
elongation of the rectus muscles and lateral muscles of the abdominal wall after PPP
and also demonstrated a decrease in visceral volume of approximately 47% after
PPP, a signicant change, attributable to a clear diminution of the caliber of the
intestinal loops and the thickness of intestinal wall (Fig.27.6).
The determination of abdominal cavity and hernia sac volumes and measurement of the length of the abdominal wall muscles, before and after the application
ab
27 Loss ofAbdominal Domain
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Fig. 27.6 (a) CT scan previous PPP, with the abdominal cavity and the hernia sac totally occupied
by bowels. MR anterior rectus abdominis muscle and MO oblique muscles, with their length measures in centimeters. (b) CT scan after 2weeks of PPP, with change of length of the rectus and
oblique muscles and reduction of the visceral volume in 46.9%
385
of adjuvant techniques, allows for correct surgical planning, selection of technique
for each case, and prediction of feasibility of the closure of the midline without
tension.
The Sum oftheForces
During the perioperative period of the approach of a giant hernia with loss of
domain, a symbiosis between the different adjuvant and surgical techniques is
required. The decrease in the diameter of the hernia ring and the elongation of the
muscles of the abdominal wall reached after the application of Botox, plus the
elongation of the muscles and decrease of the visceral volume that is achieved
with the PPP, allows the patient to reach his surgery with a accid and elongated
abdominal wall that facilitates the closure of the midline. If we add the advancement of the myofascial aps of both sides with the techniques of anterior or
posterior separation of components applied in a more manageable abdominal
wall, the union of the rectus muscles in the midline is feasible in large defects of
the abdominal wall.
This symbiosis is called “the sum of the forces” in our unit of hernias (Fig.27.7).
This allows patients to have less chance of complications secondary to a tension
repair, such as intra-abdominal compartmental syndrome and recurrences. The
effect of Botox also decreases postoperative pain with less analgesia requirements
and better and faster ambulation and return to activities. During PPP, there is an
adaptation to high intra-abdominal pressures of up to 15mmHg, which allows a
better tolerance after surgery, without respiratory or hemodynamic compromise.
The sum of the forces offers signicant advantages compared to the individual
advantages of each surgical technique and adjuvant.
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b
c
M. A. Garcia
e
Fig. 27.7 Giant ventral hernia. (a) BTX inltration in lateral abdominal wall. (b) After 5days of
PPP. (c) Dissection of the hernia sac with the abdominal cavity with pneumoperitoneum. (d)
Anterior component separation. (e) Abdominoplasty (Video 27.4)
According to our experience and as demonstrated in our study of 14 patients with
giant hernia with loss of mastery with a mean age of 69years and a BMI of 31.5, the
“sum of the forces” have achieved safe results with 6% of relapse with a follow-up
at 24months, without major morbidity, without mortality, and improving the quality
of life of our patients.
Optimization ofSurgery by aMultidisciplinary Team
The management of a giant hernia with loss of domain requires preparation of the
patient and the multidisciplinary team that is treating the patient.
Rarely does a hernia with loss of domain present as an emergency case—the
giant hernia diameter decreases the possibility of an intestinal obstruction. Therefore,
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the vast majority are elective cases, allowing sufcient time for optimal preparation
of the patient and their comorbidities.
The patient must stop smoking at least 1 month before and 2–3 months after
surgery, reducing respiratory and wound complications. They must have optimal
nutrition, with albumin greater than 3.5g/dL; otherwise there must be nutritional
optimization. Diabetics with HgA1c greater than 7 have a greater possibility of
wound infection and poor wound healing. In these cases, the intervention of the
endocrinologist is indispensable.
For patients with poor baseline functional status, a preoperative rehabilitation
plan is established.
Decreased weight is critical. Obese patients are more likely to have surgical wound
complications and a chronically high intra-abdominal pressure that favors tension in
the midline closure, increasing the possibility of recurrence. Preoperative weight loss
reduces the volume of the liver, omentum, and retroperitoneal fat. Patients with obesity should be previously managed by the nutritionist of the obesity/bariatric team.
Therefore, the patient should be treated by a team of multidisciplinary professionals.
The patient’s work-up should include a complete collection of information from
their clinical history, surgical history, postsurgical complications, any open abdomen, and/or recurrences. Operative records should be accessed to obtain information of the types of sutures and meshes used.
The evaluation with CT scan in Valsalva should include the measurement of volumes of the abdominal cavity and hernia sac to determine the percentage of loss of
domain, in addition to 3D images of the abdominal wall. For this reason, it is essential to have a radiologist with interest in abdominal wall imaging.
Likewise, the interventional radiology team must have experience in the installation of PPP catheters and evaluate the patient during the period of insufation of the
PPP, due to possible dysfunction of the catheter by displacements or other causes.
The use of botulinum toxin should be by surgeons with experience in this management for its correct dosage and inltration in the abdominal wall. Subsequent
radiological tests to determine changes in the abdominal wall and hernia and to plan
the surgery are also advised. Approximately 1month after inltration, surgery can be
performed and the patient hospitalized according to each case in a period of
5–10days. During the PPP period, patients should have antithromboembolic measures such as compression stockings and low-molecular-weight heparin, as well as
respiratory and motor kinesiotherapy. The nursing team must have enough experience to recognize signs of intra-abdominal hypertension and to know the initial
actions to avoid complications.
The surgical team may, if necessary, include plastic surgeons for an abdominoplasty in case of large dermal aps that require resection and better aesthetic results
(Fig.
27.7).
In the immediate postoperative period, patients should be closely monitored due
to the possibility of intra-abdominal compartment syndrome, especially in those
cases in which no adjuvant measures were used. Due to the possibility of operative
wound complications, the team must have specialized nurses in the advanced management of wound complications. For this reason, these patients must be referred to
hospitals that have professionals with experience in giant hernias.
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