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34 Loss of Abdominal Domain: Defi nition and Treatment Strategies
363
musculoskeletal, gastrointestinal, genitourinary, and
pulmonary systems. This unfortunate cycle leads to
psychosocial issues with overall poor quality of life
that may only be restored with surgical repair.
Complications of Repair
When repairing loss of domain, the challenge is
to restore physiologic, mechanical, and functional capacity of the abdominal wall. Repairing
the cylinder forces and bringing abdominal contents back into the abdominal cavity can increase
intra- abdominal tension which can lead to
abdominal compartment syndrome (ACS) . It also
results in elevation of the diaphragm which can
lead to respiratory insuffi ciency. Component separation, a commonly used method of repair,
increases the size of the cylinder allowing a
decrease in intra- abdominal tension.
Presentation
usually results from crystalloid volume expansion
in the acute phase of injury that leads to bowel
edema and increased intra- abdominal volume.
Third-spacing of fl uids also produces myofascial
wall edema that results in a non-compliant abdominal wall that interferes with midline closure.
These patients are often closed with an absorbable
mesh material with either a skin fl ap advancement closure or skin grafted after a granulation
bed is established. A more complicated open
abdomen scenario is when a prior midline closure
dehisces, a midline wound infection develops, or
traumatic injury occurs that mandates abdominal
wall debridement. In this situation, there is loss of
anterior rectus fascia and rectus muscle. This
problem leads to both an increase of the width of
the hernia defect and less healthy anatomy for a
future abdominal wall reconstruction. Most of
these patients present 8–24 months after hospital
discharge with a skin graft over the midline hernia
defect. Figure 34.2 demonstrates a loss-of-domain
hernia that has a skin graft closure of a traumatic
abdominal injury.
Introduction
Loss of domain hernias seem to be is an increasingly frequent problem. This is a function of the
high-quality trauma critical care that saves lives,
but may yield more complex chronic open
abdominal wounds. Also recurrent hernia and
mesh complications lead to attenuated, distorted,
or destroyed anatomy. Finally, obesity makes a
signifi cant contribution to the incidence and
prevalence of the loss of domain hernia.
Emergency Surgery’s Role
Current trauma and critical care techniques and
protocols have improved survival from acute traumatic and surgical emergencies. The use of open
abdomen techniques for repeated abdominal
washouts has saved lives, but resulted in emergence of unintended challenging consequences.
Based on the individual injury pattern, there may
be a basic mismatch between abdominal content
volume and abdominal wall circumference, preventing primary closure of the midline fascia. This
Fig. 34.2 Loss of domain hernia that has a skin graft closure of a traumatic abdominal injury
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G.J. Mancini and H.N. Le
Recurrent Hernia’s Role
Recurrent hernia and mesh complications can
also contribute to the development of a loss of
domain hernia. Multiple prior surgical procedures with mesh implantation and subsequent
explantation can lead to loss of tissue integrity.
This can be prior motor nerve damage that leads
to muscle atrophy. Conversely, fully integrated
and rigid mesh implants from prior repairs can
reduce body wall compliance that limits myofascial advancement for midline closure. Damage
done by recurrent hernia surgery can create tissue
loss and compromise tissue plans similar to those
of the emergency or traumatic type.
Obesity’s Role
Obesity is highly prevalent and is both a cause and
an effect of hernias. Patients with hernias gain
weight due to physical limitations, and patients
who become obese develop hernias more frequently. Central obesity is a major contributor to
loss of domain hernias due to increased tensile
forces loaded on the abdominal wall musculature.
It is well documented that obesity by defi nition is
a state of chronic intra-abdominal hypertension.
Freeze et al. estimated that for every 1 kg/mm 2
increase in BMI, there was on average a
0.07 mmHg increase in intra-abdominal pressure
[ 2 ]. Similarly, obesity is a major limitation to
proper hernia repair, due to the volume mismatch
between the abdominal viscera and the abdominal
domain. Even though a component separation
technique may increase the volume of the abdominal domain, it may not be enough to allow visceral return into the abdominal cavity with facial
closure. Figure 34.3 demonstrates a loss of
domain hernia related to morbid obesity.
Optimization for Surgery
Introduction
Preoperative preparation of both the surgeon and
the patient is absolutely mandatory to treat loss of
domain hernias. This concept will be addressed
Fig. 34.3 Loss of domain hernia in the setting of severe
morbid obesity
more broadly in other chapters. Here I will focus
on preoperative steps specifi c to cases of loss of
domain.
The Surgeon’s Preparation
Surgeon preparation focuses on three areas: old
chart review, a physical exam, and a radiographic
assessment. Most patients with loss of domain
have a complicated surgical history. Obtaining and
reviewing those notes will help the surgeon to
understand the distorted surgical anatomy that will
be encountered at the time of the planned hernia
repair. Details about the type of sutures placed,
implanted mesh material type, location and size,
as well as any prior facial component layers that
may have been released, are all important facts to
know prior to surgery. The second important step
is a thorough physical exam. Generally, a functional capacity and readiness for surgery can be
assessed during an offi ce exam. Focusing on the
abdomen, matching the abdominal scars with the
past surgical history can build a continuity to the
case. Assessing for open wounds, broad scars, skin
grafts, and stomas provides more data that will be
factored into the surgical plan. A functional exam
of the abdomen can quantify the size of the hernia
defect and assess for the relative compliance of the
abdominal wall. While the patient is supine and
relaxed, I often try to palpate the medial rectus
edges and try to pull them toward the midline. If
34 Loss of Abdominal Domain: Defi nition and Treatment Strategies
365
there is laxity in the abdominal wall, this is a good
predictor of potential midline closure. Also, if a
skin graft is present, the “pinch test” can be performed to assess if the underlying bowel will separate from the graft. The third preoperative step is
obtaining and reviewing an abdominal Computed
Tomography (CT) scan. Again, building congruency between the history, exam, and imaging is
very important to mitigate the chances of intraoperative surprises. I assess the CT for old mesh,
metal tacks, surgical staples, the hernia width and
length, volume of the abdominal contents outside
the abdominal wall, and the quality of the abdominal wall anatomy available for reconstruction.
Once the medical records, physical exam fi ndings, and CT scan are reviewed and correlated,
the surgical technique planning can occur.
Preoperative patient goals for risk reduction, prehabilitation, and recovery timeline can be set in
cooperation with the patient and family.
The Patient’s Preparation
Most loss of domain hernias are not emergency
cases, such as an acute bowel obstruction or meshrelated sepsis. As elective cases, these hernia
repairs allow for maximal preoperative preparation of the patient. I have fi ve main parameters that
must be met prior to surgery. The patient must be
tobacco-free for at least 1 month prior to surgery
and must agree to stay tobacco-free for a minimum of 2 months after surgery. This will reduce
pulmonary and wound complications that are frequent enough in complex hernia repairs without a
smoking history. Nutritionally, the patient must
have an albumin greater than 3.5 g/dL. Dozens of
studies since the late 1990s across all medical specialties have demonstrated worse surgical outcomes and higher mortality rates in patients who
are chronically hypoalbuminemic. For patients
who are nutritionally defi cient, a nutrition consultation and focused plan is developed to correct the
problem before surgery. For diabetics, proper glucose control is critical. A hemoglobin A1c
(HgA1c) of 7% correlates to an average blood glucose level of 150 mg/dL, and 8% correlated to
200 mg/dL. A serum HgA1c greater than 7% is
associated with a increased wound infections and
overall poor wound healing. Collaboration with
the primary care provider or endocrinologist can
greatly improve this metric. For patients with a
poor baseline functional status, a pre-habilitation
plan is established. Though a loss of domain hernia can greatly reduce a patient’s ability to exercise, I place no limitations on their ability to
ambulate. The cardiopulmonary physiologic strain
which will be created after re- establishing a functional abdominal wall requires patients to build a
physiologic reserve prior to elective surgery. I ask
that patients progress to walking a minimum of
30 min per day. Weight loss is a common point of
preoperative discussion with patients. In loss of
domain hernias, the ability to close the fascia is
directly related to the volume of the abdominal
viscera. Preoperative weight loss can reduce the
volume of the liver, omentum, and retroperitoneal
adiposity. Typically, a body mass index (BMI)
above 40 kg/m 2 will trigger a weight loss discussion. This is particularly important for patients
with central obesity and high BMI. No myofascial
advancement surgical technique can compensate
for inadequate preoperative weight loss. The reality is that many of our patients present with one or
more of the above-described risk factors. Once
again, we require smoking cessation, weight control, diabetes optimization, healthy eating, and
daily exercise, to ensure the best possible results.
It is the surgeon’s responsibility to counsel the
patient on the complexity of a loss of domain hernia and the life-treating risks of surgery done
under suboptimal circumstances. The patient as an
advocate is more likely to prepare than the patient
as an adversary.
Surgical Strategies for Loss
of Domain
Introduction
When approaching a patient with a loss of domain
hernia, several questions need to be answered.
First can the hernia be technically fi xed. This
means that if the patient is fully optimized, is the
proper functional anatomy available to obtain
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G.J. Mancini and H.N. Le
primary fascial closure of the abdomen with
mesh implant reinforcement? If the answer is
yes, then the question whether it should be fi xed
needs to be answered. This means that if the
operation is done, will the patient be functionally
better off? If the answer is yes, the question of
how technically should the repair be done can be
approached. Finally, who is the surgeon to undertake the repair?
There are many techniques that have been
applied to the treatment of complex hernias. The
loss of domain hernia is one of the most challenging hernia scenarios. Often, multiple
advanced hernia techniques will need to be
woven together in order for the repair to be successful. It is important to remember that the core
principles of hernia repair, such as primary fascial closure under physiologic mention, wide
mesh overlap, aseptic technique, and proper
soft- tissue debridement and closure, must be
maintained for the repair to have durability.
Component Separation Techniques
Component separation is a commonly used term
for multiple different surgical techniques applied
to closing abdominal wall defects. At its roots,
component separation is the dismantling of the
individual layers of the abdominal wall in order
to advance innervated and vascularized myofascial tissue across a defect. There are multiple different techniques that will be more thoroughly
covered in other chapters. In cases of loss of
domain hernias, the two most commonly used are
the external oblique release and the transversus
abdominis release (TAR).
The Ramirez technique is the most widely
adopted component separation technique, utilized
by both plastic and general surgeons [ 3 ]. It is
highly reproducible and provides 4–10 cm of
advancement on each side, allowing closures of
midline defects up to 20 cm wide. An important
benefi t to this technique is the fl exibility of potential locations to implant the mesh. Ramirez affords
the option of placing the mesh intra- abdominally,
retro-rectus or as an onlay, to best fi t the repair. In
contrast, a downside to the external oblique
release is the need to mobilize adipocutaneous
fl aps to access the lateral abdominal wall. Skin
fl ap creation can reduce perfusion to the overlying
skin, increasing the risk for fl ap necrosis and postoperative wound complications.
I typically select the Ramirez technique to
repair a loss of domain hernia in two distinct scenarios. The fi rst scenario is when creation of skin
fl aps is adventageous, such a performing a concomient panniculectomy or when removing a prior
large skin graft. In this situation the skin will be
excised, necessitating the adipocutaneous layer
advancement to obtain skin closure over the fascial
closure. Figure 34.4 demonstrates how a pannicu-
lectomy exposes the external oblique aponeurosis.
The second scenario is when the hernia sac extends
laterally past the semilunar line. In this case, the
hernia sac has essentially dissected the skin fl aps,
so when the hernia sac is mobilized, the external
oblique aponeurosis will be exposed, allowing
easy division for myofascial advancement.
The Novitsky technique , also called posterior
component separation or TAR, is a myofascial
release of the transversus abdominis muscle [ 4 ].
Access to the release point is made by entering
the posterior sheath in the retro-rectus location.
By releasing the transversus abdominis muscle,
the lateral pre-peritoneal location can be accessed
all the way to the paraspinal muscles. This affords
wide area from the diaphragm to the pelvis in the
vertical axis and from paraspinal muscles to
paraspinal muscles in the transverse axis in which
to implant the mesh. Since the mesh will lay
in the pre-peritoneal location, an inexpensive,
non- barrier, macroporous mesh can be used.
A major benefi t of the TAR approach is that no
skin fl aps are raised for the reduction of the hernia, the myofascial advancement, or for mesh
implantation. This may yield lower postoperative
wound complications when compared to other
component separation techniques. Conversely,
the TAR is technically more diffi cult and makes
the peritoneal layer of prime importance in the
repair. The peritoneum is of variable thickness
and can easily tear requiring suture repair or
absorbable mesh interposition.
I apply the TAR technique in two distict settings.
First is in the setting of atypical hernias such as
34 Loss of Abdominal Domain: Defi nition and Treatment Strategies
367
Fig. 34.4 Demonstration of how a lower abdominal panniculectomy will expose the lateral abdominal wall facilitating external oblique fascial release
fl ank, paramedian, subcostal, or subxyphoid hernias. The TAR affords access to the preperitoneal
lateral abdominal and subdiaphragmatic spaces for
wide mesh overlap in these notoriously diffi cult
hernias. Second, Novitsky’s technique is ideal in
settings where skin fl ap creation would cause excessive wound complication risk to the patient. This
may be an obese, smoking, diabetic patient undergoing abdominal wall reconstruction, but without a
need for a panniculectomy. These two patient situations are common within my practice and, therefore, the TAR technique has served as a powerful
tool to help treat loss of domain hernias.
Mesh Location and Choice
In loss of domain situations, there are two main
mesh characteristics that dictate mesh selection.
The prosthetic needs to be both strong in tensile
strength and large in size. Mesh choice for
patients with loss of domain hernias runs coun-
ter to the current trends toward light-weight
mesh. The large hernia size, in both length and
width, mandates large-sized mesh to gain proper
mesh overlap. This may even require quilting
two or more large off-the-self meshes to accomplish this task. If I sew mesh together, I use a #1
suture, that most mimics the mesh material
(polypropylene, polyester, or gore-tex).
Additionally, the increased vector forces of a
loss of domain hernia mandate a mesh with
high tensile strength. For loss of domain hernia
repairs, I often choose a mid-weight, monofi lament, polypropylene or polyester mesh. This is
particularly critical in obese patients, for whom
I avoid light- weight or ultralight meshes all
together. For intra-abdominal placement, the
mesh must have a microporous layer against
the viscera. For retro- rectus or pre-peritoneal
placement, a non-barrier polypropylene or
polyester mesh will suffi ce. For the rare onlay
mesh, I trend toward using monofi lament polypropylene. I have used ePTFE mesh in rare
cases where I have intra-abdominal mesh placement over a stoma, during the Sugarbaker
repairs. The marginal results reported with biologic and absorbable meshes have reduced their
current use in cases of loss of domain hernia
repair.
Drain Placement and Management
Drains in open abdominal wall reconstruction are
a necessity and a nuisance to both the patient and
the surgical care team. Drains require patient
education about care and complications that can
challenge the hygiene, aptitude, and coping skills
of the patient and family. In loss of domain
hernias, the number and location of the drains
greatly depends on the reconstruction technique
used. For the Ramirez technique, I place at least
one drain subcutaneously for each skin fl ap
raised. These drains stay until the drainage
approaches zero. Figure 34.5 demonstrates the
placement of subcutaneous fl ap drain. If the mesh
is retro-rectus, I place a drain between the mesh
and the rectus muscle, and this drain is removed
prior to hospital discharge. I place no drain for
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Fig. 34.5 Placement of subcutaneous fl ap
drain
G.J. Mancini and H.N. Le
intra-abdominal mesh, and the onlay mesh will
be drained by the subcutaneous drains.
Preoperative Pneumoperitoneum
The main concern about repairing a hernia with
a loss of domain is fi guring out if the fascia can
be closed primarily. Preoperative progressive
pneumoperitoneum has been described as a
technique that could help increase abdominal
wall compliance to aid fascial closure [ 5 ]. Like
a tissue expander, progressive pneumoperitoneum may place a pressure load on the abdominal wall to stretch the abdominal wall
musculature. This is done over a 5–14-day preoperative period by placing a tunneled catheter
into the abdomen and adding a volume of air
each day as the patient tolerates. I have not
been an advocate of this technique for the following reasons. First, a 5–14-day hospital stay
prior to abdominal wall reconstruction elevated
the patient’s risk for wound infections, pulmonary complications, deep vein thrombosis, and
pulmonary embolus. Second, in loss of domain
patients, I believe the giant hernia sac is where
the instilled air will decompress, applying little
pressure to stretch the abdominal wall. Finally,
the patient rarely tolerates the progressive
instillation of air due to the sensation of being
short of breath. Therefore, for me, progressive
preoperative pneumoperitoneum is a method of
discouraging patients from undergoing repair
of a loss of domain hernia.
Postoperative Care
and Complications
Complications of repair are common and include
respiratory compromise, ACS, and wound complications, in addition to the usual surgical
complications.
ACS and Pulmonary Complications
As discussed earlier, repairing the cylinder can
cause respiratory compromise and ACS. The
abdominal contents are forced back into the
abdominal cavity and this results in increased
intra-abdominal tension with elevation of the diaphragm. Component separation increases the size
of the cylinder, allowing a decrease in
intra- abdominal tension and prevention of
ACS. Typical signs of ACS, including high peak
pressures on the ventilator, a hard distended
abdomen, increased bladder pressures, and
decreased urine output, should alert the surgeon
of the possible diagnosis [
promise can result in diffi culty with extubation
immediately postoperatively and pneumonia due
to the inability to cough and clear secretions well.
Ventral hernia repair has been shown to increase
6 ]. Respiratory com-
34 Loss of Abdominal Domain: Defi nition and Treatment Strategies
369
intra- abdominal pressures that negatively impact
pulmonary function [ 7 ]. Aggressive pulmo-
nary toilet must be stressed perioperatively for
optimal results.
Wound Complications
Wound complications are common in the short
term, reaching up to 40%, and even higher in
the obese population. This includes surgical site
infections, seroma, hematoma, and skin fl ap
necrosis. Surgical site infections can be minimized with appropriate preoperative antibiotics,
sound surgical technique, and optimizing the
patient preoperatively, as discussed above.
Seroma or hematoma can develop due to the
extensive fl ap dissection and the cavity left
behind from repair. Most of those collections
are sterile, usually do not require drainage, and
resorb spontaneously. Suction drains can be
useful, but if left too long can result in infection
of the prosthesis. Skin fl ap necrosis causes
much of the morbidity associated with the component separation repair. It is related to ischemia of the skin fl aps after division of the
perforators arising within the rectus sheath and
supplying the anterior abdominal wall skin.
Minimizing skin fl ap dissection may reduce
rates of necrosis. Figure 34.6 demonstrates skin
necrosis and wound infection after abdominal
wall reconstruction.
Intestinal Complications
As most patients undergoing repair in the setting
of a loss of domain usually require extensive
adhesiolysis, they are at risk for postoperative
obstruction and leak/fi stula. Careful tissue handling and meticulous dissection can reduce
bowel injuries. It is also imperative to assure that
all layers are satisfactorily re-approximated, as a
breakdown of the posterior sheath with exposure
of mesh can lead to recurrence of herniation or
bowel erosion. Incomplete adhesiolysis may
lead to unresolved obstruction with failure to
progress in the postoperative period. It may ben-
Fig. 34.6 Skin necrosis and wound infection after skin
abdominal wall reconstruction
efi t the patient to maximize all conservative
treatments, as re- operation is almost prohibitive
in these patients.
Summary
In summary, loss of domain hernias represent the
highest complexity defects to repair. The impairment caused by this condition makes a hernia
repair an important surgical option to help
alleviate patient suffering. The complexity of
the disease and the morbidity that accompanies
the surgical risks places tremendous pressure on
the surgeon to get it right. With proper patient
selection, surgeon preparation, preoperative
patient optimization, advanced hernia repair techniques, and solid general surgery postoperative
care protocols, loss of domain hernias can be
repaired with reasonable results. It is up to the
surgeon, who wants to take care of this disease, to
create and maintain a high- quality system to
ensure good patient outcomes.
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G.J. Mancini and H.N. Le
References
1. Stokes IA, Gardner-Morse MG, Henry SM. Intraabdominal pressure and abdominal wall muscular
function: spinal unloading mechanism. Clin Biomech.
2010;25(9):859–66.
2. Frezza EE, Shebani KO, Robertson J, Wachtel
MS. Morbid obesity causes chronic increase of
intraabdominal pressure. Dig Dis Sci. 2007;52(4):
1038–41.
3. Ramirez OM, Ko MJ, Dellon AL. “Components separation” method for closure of abdominal wall defects:
an anatomic and clinical study. Plast Reconstr Surg.
1990;86:519–26.
4. Novitsky YW, Elliott HL, Orenstein SB, Rosen
MJ. Transversus abdominis muscle release: a novel
approach to posterior component separation during
complex abdominal wall reconstruction. Am J Surg.
2012;204(5):709–16.
5. Mcadory RS, Cobb WS, Carbonell AM. Progressive
preoperative pneumoperitoneum for hernias with loss
of domain. Am Surg. 2009;75(6):504–8.
6. Agnew SP, Small W, Wang E, Smith LJ, Hadad I,
Dumanian GA. Prospective measurements of intraabdominal volume and pulmonary function after
repair of massive ventral hernias with the components separation technique. Ann Surg.
2010;251(5):981–8.
7. Gaidukov KM, Raibuzhis EN, Hussain A, Teterin AY,
Smetkin AA, Kuzkov VV, Malbrain ML, Kirov
MY. Effect of intra-abdominal pressure on respiratory
function in patients undergoing ventral hernia repair.
World J Crit Care Med. 2013;2(2):9–16.
Enterotomy During Hernia Repair:
Prevention and Management
Brent D. Matthews
35
Challenges of Adhesiolysis
The most common risk factor for enterotomy is a
previous laparotomy. The risk increases with
subsequent laparotomies. In fact, patients with
three or more previous laparotomies have a tenfold increase in experiencing an enterotomy
compared with patients with one or two previous
laparotomies [ 1 ] (Fig. 35.1 ). An enterotomy
alters the wound classifi cation from Clean (Class
I) to Clean/Contaminated (Class II) or
Contaminated (Class III). Higher rates of surgical
site infection (SSI) are observed when progressing from clean to clean/contaminated to contaminated wounds. The consequence of a wound and/
or mesh infection is a recurrence after ventral
hernia repair [ 2 ]. Adjuncts placed at the time of
surgery to minimize adhesiolysis-related complications during subsequent surgery have been disappointing. In a clinical trial of loop ileostomy
closure, sodium hyaluronate and carboxymethyl
cellulose membrane (Seprafi lm ® , Genzyme
Biosurgery, Framingham, MA, USA) signifi -
B. D. Matthews , M.D. (*)
Surgery Care Division, Carolinas HealthCare System
Medical Group, Department of Surgery , Carolinas
Medical Center and University of North Carolina—
Charlotte Campus ,
1000 Blythe Boulevard, 2nd Floor Administrative
Suites , Charlotte , NC 28203 , USA
brent.matthews@carolinashealthcare.org
e-mail:
cantly reduced postoperative adhesions at the site
of application, but did not have an effect on the
rate of enterotomy [ 3 ]. This was confi rmed in a
Cochrane Analysis evaluating intraperitoneal
prophylactic agents for preventing adhesions and
adhesive intestinal obstruction after nongynecological abdominal surgery [ 4 ].
The rate of enterotomy during abdominal surgery is perhaps underreported. A recent audit of
operative notes revealed that only 1 in 7 enterotomies was dictated in the operative report [ 5 ]. This
underreporting could also have a signifi cant
infl uence on risk-adjusted outcomes as the
accountability of value-based care becomes central to reimbursement. Risk factors for an enterotomy in abdominal wall hernia patients have
been well-documented. In a prospective study of
133 patients undergoing an abdominal wall hernia repair, ten Broek et al. reported 33 enterotomies in 17 patients (12.8%) [ 6 ]. Predictors of
enterotomy were adhesiolysis time, mesh in situ
and hernia wider than 10 cm. An extended adhesiolysis time and increasing ventral hernia size
are likely surrogates of a more complex ventral
hernia. The impact on patient outcomes in this
study of an enterotomy was an increased incidence of sepsis, reinterventions, need for parenteral nutrition, prolonged intensive care unit and
hospital stay as well as increased medication
cost. In another study over a 5-year period in 16
tertiary Veterans Affairs medical centers, Gray
et al. reported an overall incidence of 7.3% for an
enterotomy or unplanned bowel resection during
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_35
371© Springer International Publishing Switzerland 2016
372
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Fig. 35.1 Relationship
between the percentage of
reoperation with and without
enterotomy and the number of
previous enterotomies.
Reprinted from van der
Krabben AA, Dijkstra FR,
Nieuwenhuijzen M et al.
(2000) Morbidity and
mortality of inadvertent
enterotomy during
adhesiolysis. Br J Surg
87:467–71
B.D. Matthews
elective incisional hernia repair [ 7 ]. The inci-
dence of enterotomy or unplanned bowel resection was signifi cantly greater in patients after a
previous mesh-based repair (20.3%) versus prior
suture repair (5.7%) (Fig. 35.2 ). In a study more
specifi cally defi ning the risk of enterotomy after
mesh placement, Halm et al. reported a small
bowel resection rate of 20.5% and a fi vefold
increase in SSI as a consequence of reoperation
after intraperitoneal polypropylene mesh [ 8 ]. A
recent presentation at the 1st World Conference
on Abdominal Wall Hernia Surgery in Milan,
Italy, described the consequences of an inadvertent enterotomy that occurred in 46 of 1842
patients who underwent open ventral hernia
repair [ 9 ]. Risk factors for an enterotomy were
previous abdominal surgery, prior hernia repair,
mesh placement in a prior hernia repair and an
infection present at the time of open ventral hernia repair. A higher rate of wound infections,
mesh infections (12-fold), and hernia recurrences
(6-fold) were reported in the enterotomy group
compared to patients not experiencing this
event, even when controlling for the use of synthetic mesh in clean/contaminated and contaminated wounds.
Absorbable and nonabsorbable barriercoated meshes were designed for intraperitoneal
placement during both laparoscopic and open
ventral hernia repair in order to minimize visceral adhesions to mesh. There is a paucity of
outcomes studies evaluating the effectiveness of
these barriers in clinical trials. Jenkins et al.
reported on 69 patients who underwent laparoscopic surgery after prior intraperitoneal mesh
placement for ventral hernia repair [ 10 ].
Characterization of adhesions and complexity
of adhesiolysis were measured as adhesion
tenacity, adhesion surface area percentage over
the mesh, and the ratio of adhesiolysis time to
mesh surface area. An enterotomy was avoided
in all patients with intraperitoneal absorbable
and nonabsorbable barrier-coated meshes.
However, adhesion characteristics and the complexity of adhesiolysis appeared to be associated with the unique properties of the barrier
and/or mesh (Table 35.1 ). Two of 12 patients
with intraperitoneal bare polypropylene mesh
suffered injuries to the bladder and small intestine, respectively. Thus, the hollow viscus injury
rate was similar to previously published studies.
The study was underpowered to allow for defi nitive conclusions, but provocative nonetheless.
A multicentered, prospective clinical trial of
comparative effectiveness of barrier-coated
meshes ( Comparative Effectiveness Multicenter
Trial for Adhesion Characteristics of Ventral
Hernia Repair Mesh , ClinicalTrials.gov
Identifi er: NCT01355939) is ongoing.
A survey to assess practices and opinions
regarding incisional hernia repair queried surgeons about enterotomy risk and management
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