Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана

Large hernias, whether primary or incisional in origin, pose a difcult challenge for repair. Up to 20% of patients undergoing laparotomy may develop an incisional hernia [8], with rates as high as 35% for those patients needing emergency procedures [9]. Additionally, factors such as obesity, diabetes, wound infection, immunosuppression, malignancy, smoking, and previous laparotomy will increase the risk of hernia devel­opment [10]. Simply performing a bridging repair, or closing an abdominal defect under too much tension, has a high rate of failure. Each previous failed hernia repair places a patient at increasingly higher risk of recurrence as the quality of the tissue declines from repeated dissection, mesh explantation, and fascial debridement and retraction [11]. The recurrence rate of incisional hernia was reported as 24% after rst repair, increasing to 35% after second and 39% after third attempted repair [12]. Hernia repair can be further complicated if the patient has “loss of domain.” While there is no explicit denition or precise measurement method for this, a generally accepted deni­tion is where 50% of the abdominal viscera reside outside the abdominal cavity [13]. The upper size limit of hernias that can be repaired takes many factors into consider­ation apart from absolute size, including the location of the hernia, orientation and number of defects, amount and compressibility of intra-abdominal contents, and the quality and compliance of the abdominal wall. If closure of the abdominal fascia is successfully accomplished, additional risks remain. These include abdominal compart­ment syndrome if intra- abdominal pressures are too high after closure, or ap necrosis and donor site morbidity in the case of myofascial cutaneous ap closure [14].