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 signicant 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).

hernia repair. J Surg Res. 2016;206:214–22.