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B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_24,
© Springer Science+Business Media New York 2013
24. What Is a Complex Abdominal
Wall?
Mickey M. Ott and Jose J. Diaz Jr.
The term complex abdominal wall has a number of interpretations
but generally refers to a patient’s abdomen that contains a ventral or an
incisional hernia or defect plus one or more of the following characteristics
(Fig. 24.1 ):
(a) Any additional condition that would be classi fi ed as a clean
contaminated or a contaminated fi eld (including but not limited
to stomas)
(b) An enterocutaneous fi stula
(c) A history of, or an ongoing, mesh or wound infection
(d) A large-sized defect (often de fi ned as >10 cm in diameter)
(e) Loss of domain
(f) One or more recurrences
Patients with complex abdominal walls will seek surgical repair for a
variety of reasons. A surgeon who wishes to approach the repair of a
complex abdominal wall should be trained in and ready to employ a
variety of techniques as needed to achieve a good outcome. One technique
will not be appropriate for every patient, and outcomes will depend on
the choice of technique as well as mesh implant for each individual
scenario.
Techniques employed, and thus outcomes achieved, will vary
depending on the patient and the comorbid conditions, the type of hernia,
and on the skill set of the surgeon. Procedures that may be needed include,
but are not limited to, the ability to perform extensive adhesiolysis, open
component releases, endoscopic component releases, small and large
bowel resections, enterostomies, advancement fl aps, skin grafts, staged
repairs, and laparoscopy. Surgeons must be familiar with a variety of
implantable prosthetic materials, as the appropriate implantable mesh
284
M.M. Ott and J.J. Diaz Jr.
may vary depending on the patient. Materials for complex abdominal
wall repairs include choosing between the synthetics, the biologics, the
absorbable materials, or opting to use no mesh at the time. Finally,
anticipating the aftercare is paramount. Taking on a patient with a complex
abdomen requires that there be an experienced intensive care unit available
that is familiar with these patients and their postoperative management.
The Evolution of Damage Control Surgery
To better understand the complex abdominal wall, it is important to
identify some of the etiologies (Table 24.1 ). One of the primary reasons
why surgeons may be seeing an increased number of these complex
patients is the increasing frequency with which surgeons are using the
open abdomen technique. The term open abdomen technique refers to an
abbreviated operation, leaving the abdominal fascia open, and creating a
temporizing abdominal closure.
In the late 1970s and early 1980s, reports of improved outcomes in
coagulopathic trauma patients who had abdominal packing and
abbreviated laparotomy began to be published [ 1, 2 ] . Dr. Harlan Stone
et al. described this strategy, “…This technique of initial abortion of
laparotomy, establishment of intra-abdominal pack tamponade, and then
completion of the surgical procedure once coagulation has returned to an
acceptable level has proven to be lifesaving in previously non-salvageable
Fig. 24.1. The complex abdominal wall.
285
24. What Is a Complex Abdominal Wall?
situations” [ 3 ] . The technique was further re fi ned in the 1990s and was
eventually coined “damage control” [ 4– 8 ] . This concept recognized that
critically ill patients can only tolerate a certain level of insult before
reaching physiologic exhaustion. In an effort to de fi nitively repair a
patient’s injury, longer operative procedures only contributed to the
development of the deadly triad of hypothermia, acidosis, and
coagulopathy. Damage control surgery is characterized by three distinct
phases: (1) an abbreviated laparotomy that controls bleeding and
intestinal contamination, (2) leaving the OR with the abdomen “open”
and continuing resuscitation with correction of coagulopathy in the ICU,
and (3) returning to the OR for completion of the de fi nitive operation and
staged abdominal wall repair [ 7– 10 ] . Although this approach has clearly
demonstrated improved outcomes, it has resulted in unexpected
consequences. These patients who previously had not survived now have
a complex abdominal wall de fi ned as those patients with a planned
ventral hernia with or without a skin graft, intestinal stomas, fi stulas, and
complicated infections. This can also include loss of domain, loss of
abdominal wall tissue, and/or infected prosthetic mesh.
Table 24.1. Conditions contributing to the complex abdominal
wall hernia.
Intra-abdominal
Trauma—damage control
Emergency general and vascular surgery
Abdominal compartment syndrome
Visceral edema
Pancreatitis
Intra-abdominal sepsis/lack of source control
Intestinal fi stulas, ostomies
Abdominal wall
Loss of domain
Necrotizing fasciitis/loss of abdominal wall tissue
Multiple hernia repair and resultant abdominal wall compromise
Chronic prosthetic mesh infection
Patient comorbidities
Smoking
Malnutrition
COPD
Cardiac/PVD
Diabetes mellitus
Steroid use
286
M.M. Ott and J.J. Diaz Jr.
Intra-abdominal Hypertension and Abdominal
Compartment Syndrome
Another clinical situation seen with increasing frequency is the use of
the open abdomen technique for the management of intra-abdominal
hypertension (IAH) and the prevention and treatment of abdominal
compartment syndrome (ACS) (Fig. 24.2 ). IAH and ACS lie on a
continuum of disease process and refer to increasing pressure in the
peritoneal space that is subsequently transferred to the abdominal viscera.
The presence of IAH has been shown to be independently associated
with an increase in mortality [ 11– 14 ] . This clinical situation is often seen
in those patients requiring massive resuscitation after signi fi cant trauma
and/or hemorrhage. IAH and ACS are relatively new terms that began to
be reported in the 1980s and 1990s. In 1984, Kron et al. described four
patients after AAA repair who developed abdominal distension, oliguria,
and increasing airway pressures [
15 ] . These symptoms were relieved
with abdominal decompression. Since that time, the understanding and
management of IAH and ACS has continued to evolve and in 2005; the
World Society of Abdominal Compartment Syndrome met to establish a
set of treatment guidelines [
16, 17 ] . These focused on (1) the need for
early serial intra-abdominal pressure (IAP) monitoring when IAH/ACS
risk factors are present; (2) improving abdominal wall compliance
through sedation, analgesia, and/or pharmacologic paralysis; (3)
evacuating intraluminal contents through nasogastric or rectal
decompression; (4) evacuating abdominal fl uid collections via
Fig. 24.2. Abdominal compartment syndrome.
287
24. What Is a Complex Abdominal Wall?
percutaneous drainage; (5) correcting positive fl uid balance through the
use of hypertonic fl uids, colloids, and careful diuresis; (6) supporting
organ function with vasopressors and judicious goal-directed fl uid
resuscitation to maintain an abdominal perfusion pressure [calculated as
mean arterial pressure (MAP—IAP)] of greater than 60 mmHg; and (7)
early surgical intervention when IAP exceeds 25 mmHg. These guidelines
highlight the importance of both nonoperative strategies to prevent and
reduce elevated IAP, as well as early operative intervention for progressive
organ failure. The treatment for ACS is abdominal decompression, but
again, these patients are then faced with the morbidity of the open
abdomen and the possibility of failure to close the fascia in the midline.
Other Indications for the Open Abdomen
The open abdomen technique has been employed not only for trauma
but for general surgery patients as well [ 18, 19 ] . In 1981, John H. Duff et al.
described 18 patients with severe abdominal sepsis treated by leaving the
abdomen open. The technique allowed for wide abdominal drainage, easy
access to the abdomen without re-laparotomy, and avoided the complications
associated with closing an infected wound. Severe pancreatitis has also
been treated in a similar fashion. In 1986, Dr. Michael Wertheimer described
his experience with ten patients with necrotizing pancreatitis [ 20 ] . Use of
the open abdomen technique allowed for optimum wound toilet, prevented
recurrent episodes of sepsis, was able to be performed at bedside in the
ICU and was associated with improved outcomes.
Intestinal Fistulae, Presence of a Stoma,
and Infected Mesh
Frequently, those patients undergoing damage control in the setting
of trauma or emergency general surgery develop complications, and one
of the more morbid is the development of an enterocutaneous or
enteroatmospheric fi stula. The treatment of the patient with an enteric
fi stula is associated with a signi fi cant resource burden, increasing both
intensive care unit and hospital length of stay, and signi fi cantly increasing
hospital charges [ 21 ] . More importantly, they become a signi fi cant
288
M.M. Ott and J.J. Diaz Jr.
burden to the patient who likely requires tedious wound care, long-term
parenteral nutrition, and frequent bouts of sepsis.
The operation to repair an intestinal fi stula is associated with an
increased risk of infection, risk of recurrent fi stulae, and the increased
risk of hernia recurrence. The key management issues are the eradication
of sepsis, drainage of any intra-abdominal abscess, local wound control
of intestinal contents, optimizing nutrition status, and delayed
reconstruction (Fig. 24.3 ) [ 22, 23 ] . Achieving these goals is no easy task,
and many novel techniques have been developed to aid in the management
of a fi stula (Fig. 24.4 ). Restoration of abdominal continuity at the time of
abdominal wall reconstruction has been demonstrated to be safe and is
the preferred treatment for enterocutaneous fi stulas [ 24, 25 ] .
Not unlike an enteric fi stula, just the presence of an ileostomy or
colostomy can increase operative morbidity during ventral hernia repair.
Fig. 24.3. Intestinal fi stula complicating the open abdomen fl ow diagram.
289
24. What Is a Complex Abdominal Wall?
In 2009, a multi-institutional trial was undertaken, examining 240
patients with a complex ventral hernia repair [ 26 ] . The authors
demonstrated that although ostomy takedown and/or fi stula takedown
can be performed at the same time as ventral hernia repair, this was
associated with an increased risk of hernia recurrence and wound
infection. The group concluded that if the microbiologic burden is too
high, the surgeon can consider a staged procedure, performing the ostomy
takedown, but repairing the ventral hernia at a later date. The use of mesh
in this clinical situation is controversial as there is a high probability of
chronic mesh infection (discussed in Chap. 44 ).
Patient Comorbidities
Smoking has been shown to increase the risk of hernia recurrence
signi fi cantly [ 27 ] . It is imperative that surgeons insist on abstinence prior
to undergoing a complex abdominal wall reconstruction. Obesity causes
increased tension on the abdominal wall, both externally from a large
panus, and internally from a large visceral mass. This too has been
Fig. 24.4. A “ fl oating stoma” has been created using multiple ostomy wafers to
create a cylinder around the fi stula opening and then surrounding the “stoma”
with a VAC dressing. The VAC will control any spillage and assist with wound
healing, and an ostomy bag can be placed on the fl oating stoma to collect
intestinal contents by dependent drainage.
290
M.M. Ott and J.J. Diaz Jr.
associated with increased risk of wound infection and hernia recurrence
[ 26 ] . Malnutrition signi fi cantly increases overall patient morbidity and
mortality, and every effort should be made to optimize a patient’s nutritional
status prior to tackling their complex abdominal wall [ 28 ] . If the patient
has a proximal fi stula or proximal diverting ostomy, this may require long-
term parenteral nutrition. Chronic obstructive pulmonary disease (COPD)
and diabetes mellitus (DM) have also been identi fi ed as risk factors for
hernia development and recurrence [ 28 ] . Medications such as corticosteroids
or chemotherapeutic agents may also inhibit wound healing [ 27 ] .
Treatment Options: The Open Abdomen
Figure 24.5 refers to a treatment algorithm for closure of the open
abdomen.
Early de fi nitive abdominal closure (EDAC) refers to those techniques
that result in a de fi nitive repair during the initial hospitalization. Three
techniques have been described to achieve EDAC: (1) delayed pimary fascial
closure, (2) fascial bridge closure, and (3) acute components separation.
Fig. 24.5. The closure of the open abdomen in trauma, emergency general, and
vascular surgery fl ow diagram.
291
24. What Is a Complex Abdominal Wall?
Delayed Primary Fascial Closure
Delayed primary fascial closure refers to the bringing together of the
patient’s native fascia by maintaining tension on the fascia until visceral
edema resolves or serially tightening the abdominal wall until closure is
achieved. Three major techniques to achieve delayed primary fascial
closure have shown to be safe and effective including vacuum-assisted
closure devices (VACD), the Wittmann Patch (WP), and dynamic/serial
fascial tightening with or without the use of temporary mesh. Greater
than 80% of patient’s will achieve fascial closure using these techniques
[
9, 29– 32 ] . Ideally, this is achieved within the fi rst week after the initial
operation, as the risk of complications dramatically increases after
1 week [ 32 ] .
Fascial Bridge Closure
When delayed primary fascial closure fails, bridging the fascia with
biologic mesh can be considered [ 9, 26 ] . Occasionally, this type of repair
will be “de fi nitive,” and the patient will never need another operation.
However, recent data suggests that the likelihood of abdominal wall
laxity and recurrent hernia is high [ 33, 34 ] .
Acute Components Separation
Performing component separation procedure in the acute setting of
failed primary fascial closure has been described [ 35 ] . However, in the
setting of ongoing peritonitis, or systemic in fl ammatory response
syndrome (SIRS), this is not recommended. Moreover, if this procedure
fails, the surgeon has now lost the chance to perhaps achieve fascial
closure at a later time when conditions are more optimal.
Treatment Options: Planned Ventral Hernia
Once it has been determined that the EDAC cannot be performed due
to either massive visceral edema, loss of domain, and/or loss of abdominal
wall tissue, the only option left is a planned ventral hernia (Fig. 24.6 ).