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357
30. Loss of Abdominal Domain
While the latter group had slightly higher BMI (39 kg/m
2
vs. 37 kg/m
2
),
this was not an independent predictor of postoperative compartment
syndrome. The surface area of the hernia was not useful in predicting the
feasibility of the operation.
Preoperative Preparation
Preoperative preparation is an important part of repairing large
hernias. Patients’ quality of life should be taken into account in setting
realistic postoperative expectations with regard to the rehabilitation
process, goal activity level, and aesthetics. Patients must be warned of
the very high likelihood of wound complications, which will require
additional time and effort on their part throughout the recovery period.
Serious systemic complications and even mortality are more than just
theoretical risks in major abdominal wall reconstructions.
Preoperative weight loss can dramatically aid the success of the
operation and lower the incidence of postoperative complications.
Reduction in the intraabdominal fat content will effectively result in
lower intraabdominal pressures after return of hernia sac contents into
the peritoneal cavity and can reduce the need for component separation.
Cardiovascular, pulmonary, and endocrine bene fi ts of weight loss reduce
the risk of anesthesia-related complications, and improved baseline
mobility hastens postoperative rehabilitation and lowers the incidence of
deep vein thrombosis. Weight loss reduces intraabdominal pressure [ 18 ] ,
which correlates with a signi fi cant incidence of recurrence [ 1 ] . There are
also studies that have demonstrated a correlation with an increased
infection rate in patients with a higher body mass index. Preoperative
weight loss should be attempted, whether through lifestyle modi fi cation
or surgically—unfortunately, the latter option is often not feasible.
Smoking cessation is a must. Given the ultimate increase in
intraabdominal pressure when a large hernia is repaired, maximizing a
patient’s pulmonary function is appropriate. Cigarette smoking effect on
tissue perfusion is an extremely important concern. Wound infection rates
are signi fi cantly higher in smokers. However, if a patient quits smoking for
as little as 3 weeks prior to a major operation, he can reduce the possibility
of infection as much as 50% [ 19 ] . In our specialized hernia center, we
conduct preoperative urine cotinine testing (positive for approximately
2 weeks after smoke exposure) prior to proceeding with a restoration of
abdominal domain. If it is positive, the operation may be canceled.
358
V.B. Tsirline et al.
In addition to the standard preoperative antibiotic and thromboembolic
prophylaxis, many surgeons prescribe a bowel prep the day before
surgery in order to minimize contamination in case bowel resection has
to be performed, although the incidence of central volume-related
problems at the time of surgery carries its own set of risks. Some advocate
low- fi ber diet the week prior to surgery [ 16 ] . Routine use of prophylactic
inferior vena cava fi lters has been described, particularly with the use of
preoperative progressive pneumoperitoneum (PPP) [ 9 ] .
Preoperative Progressive Pneumoperitoneum
Pioneered by an Argentinian surgeon Ivan Goni Moreno in 1940s,
this technique is based on the principle of progressive stretching of the
abdominal wall in order to lengthen the musculofascial tissues that are
used for subsequent abdominal reconstruction. Three weeks prior to
surgery, a tunneled, intraperitoneal catheter is inserted with a subcutaneous
port or penetrating the skin. Every other day, the abdomen is insuf fl ated
with sterile air, with the gas acting as a tissue expander. There is no
consensus on the type of gas, the optimal amount of insuf fl ation, or
duration of therapy.
McAdory et al. described using medical grade air insuf fl ated to the
degree tolerated by patient, every 1–2 days for 7 days, followed by repeat
CT scan; based on whether the abdominal viscera returned into the
abdomen or not, the therapy was continued, or surgery was undertaken
[ 9 ] . Dumont et al. in France used every other day insuf fl ation of air for
2 weeks, as long as the patients remained asymptomatic of shoulder pain,
shortness of breath, or subcutaneous emphysema [ 14 ] . Mayagoitia and
colleagues in Mexico used Seldinger technique to place a percutaneous
catheter, with daily insuf fl ation of atmospheric air at 1,000–2,000 cc, not
to exceed the abdominal pressure of 15 mmHg, continued for 9–15 days
for ventral abdominal defects [ 20 ] . Toniato et al. from Italy performed
progressive pneumoperitoneum on an outpatient basis using a
percutaneous catheter inserted in the left iliac region to insuf fl ate nitrous
oxide every other day for 8–16 days, each session using 1,000–1,500 cc
more than the previous, for a total of up to 38 L [ 16 ] . A similar approach
was reported by Caldironi et al. 10 years prior [ 21 ] . Willis et al. from
Aachen, Germany used daily injections of air via percutaneous catheter
placed in the left upper quadrant, ranging from 1,000 to 4,000 cc based
on patient symptoms of shoulder pain or maximum intraabdominal
pressure of 15 mmHg [ 22 ] .
359
30. Loss of Abdominal Domain
Effects of Progressive Pneumoperitoneum
Despite over two dozen reports in the literature describing the utility
of progressive preoperative pneumoperitoneum in the treatment of
patients with loss of abdominal domain, little quantitative data has been
collected. A recent CT-based analysis of 61 patients undergoing
preoperative pneumoperitoneum for 2 weeks showed an increase of
rectus abdominis muscle width from approximately 10–11 cm on each
side and the length of anterolateral muscles from an average of 20–24 cm,
despite insuf fl ation of a total of 13 L of air on average [
14 ] . Such small
geometric yield could hardly facilitate bridging of giant ventral defects
measuring on average 10 cm across in this study. Therefore, it has been
suggested that progressive preoperative pneumoperitoneum works
primarily by forcing preoperative physiologic adaptation to higher
intraabdominal pressures, allowing the patients to tolerate greater
aponeurotic tension postoperatively. We fi nd it most effective in patients
with loss of domain through small defects. A venous thromboembolic
event is a possibility during progressive pneumoperitoneum. Inability to
tolerate progressive pneumoperitoneum may be a marker of postoperative
inability to tolerate increased intraabdominal pressures and may be a
contraindication for proceeding with the operation [ 16 ] .
Surgical Techniques
Surgeons performing complex abdominal wall reconstructions should
have in their arsenal a number of techniques speci fi cally developed for
such extreme ventral hernias. The goals are similar to any hernia repair:
restoration of the abdominal wall continuity with native tissues and/or
permanent prosthesis with ample mesh-fascial overlap and without
excessive tension or intraabdominal pressure. The challenges in patients
with loss of domain stem from (1) excessive extra-abdominal visceral
content, (2) lack of lateral musculofascial tissue for adequate mesh
fi xation, (3) altered abdominal wall mechanics and three-dimensional
nature of the defect, and (4) the presence of contamination either from
wound infections or exposure to intestinal contents via fi stula, stomas, or
concomitant bowel resection [ 8 ] .
Many techniques have been developed to address the above challenges.
Native tissue coverage for loss of domain restoration is important but not
360
V.B. Tsirline et al.
always attainable. It provides not only a durable, adaptive, and fairly
infection resistant barrier but, importantly, an innervated musculofascial
anterior mechanical support. To accomplish this task, surgeons have used
fascial tissue expanders to stretch receded fascia, progressive
pneumoperitoneum, and serial prosthesis placements such as with a repair
of a congenital gastroschisis. Many authors recommend separation of
component whenever possible to achieve midline fascial reapproximation.
Pedicle fl aps have been utilized but do not maintain true muscle contraction
and will stretch or protrude with time.
Prosthetic Mesh Reinforcement
The use of mesh in repair of incisional and ventral hernias has been
shown to reduce recurrence by 50% or more compared to primary repair
[ 23 ] . In the case of giant ventral hernias and loss of abdominal domain,
some form of reinforcement is mandatory in order to provide supporting
framework for the newly reconstructed abdominal wall [ 24 ] . Still prosthetic
reinforcement is not a simple and complete answer in these patients. Inlay
fascial reinforcement has been shown to have inferior durability compared
to fascial sublay or onlay mesh placement [ 25 ] and has a limited role in
the reconstruction of the abdominal domain. While the onlay mesh
technique has the advantage of ease of placement for small ventral hernias,
its use in complex abdominal reconstructions is more dif fi cult to justify
due to the higher risk of postoperative wound complications [ 7 ] .
Alternatively, a two-layer reinforcement of the abdominal wall has
been described [ 26 ] . This technique involves intraperitoneal placement
of a coated synthetic sublay and a second synthetic fascial onlay. The
advantages of this approach are wide mesh-tissue overlap and more even
distribution of tension forces between tissue planes. The use of a
lightweight, large pore polypropylene may lead to a reduced foreign body
sensation and a reduced risk of infection [ 27 ] . Advocates of this approach
argue that it obviates the need for native tissue reinforcement vis-a-vis
component separation; however, no comparative data are available.
Preperitoneal Reinforcement
In most patients with loss of abdominal domain, despite often far
lateral recession of the musculofascial tissues, the peritoneum is present
and typically readily identi fi able throughout the visceral coverage. Once
361
30. Loss of Abdominal Domain
identi fi ed, the preperitoneal plane can be developed laterally to the psoas
muscles, inferiorly below the pubis, and onto the diaphragm superiorly.
The peritoneum can then be closed over the intestine with a running
absorbable suture [ 28 ] . Such wide preperitoneal dissection and closure of
the peritoneum yields several advantages. Closing the peritoneum makes
it so no bowel retraction is needed while the components’ separation is
performed or, more importantly, the mesh is placed. Additionally,
dissection and closure of the peritoneum allows the surgeon to separate
the mesh from the intestine and, therefore, select a mesh without the
costly barriers that are designed to prevent intestinal ingrowth. As well,
mesh can be placed to cover the entire abdomen and beyond—the fl ank
and diaphragm. It allows a surgeon to cover or reinforce an aggressive
components separation with mesh, extending it beyond the cut edges of
the external oblique. An attempt is made to close the fascia in the midline,
in order to restore functional abdominal wall and provide a native tissue
barrier between the underlying mesh and the super fi cial tissues, as the
risk of wound complication is high in these patients. Panniculectomy is
performed as necessary, and talc is applied subcutaneously as a rule to
reduce seroma formation and lower the risk of subsequent wound
infections and breakdown [ 29 ] .
Mesh Fixation
Loss of domain repairs is often hindered by the need for suf fi cient and
strong tissue on which to anchor the mesh. The use of metal supports to
secure mesh to bone has been suggested [ 30 ] ; however, long-term
discomfort, technical complexity, and complications inherent to the use
of prosthetic materials have limited the widespread use of this method
[ 2 ] . The standard for fi xation in large hernias, whether performed open or
laparoscopically, is full thickness, permanent sutures. Their holding
strength is 2.5-fold greater than tacks [ 31 ] , they can be easily applied at
the pubis, edge of the ribs, or iliac crest, and they are truly cost effective.
Biologic Mesh for Loss of Domain
The role of biologic mesh for abdominal wall reconstruction is fairly
specialized, and its use should be judicious [ 32 ] . Biologic prostheses can
stretch over time when used as a bridge, and most will eventually lose
structural strength and event rate. Data for cases where it is used as a
362
V.B. Tsirline et al.
buttress for fascial reinforcement appear more promising. The patients
should be counseled about the goals and expectations of mesh selection,
especially in light of very high costs of bioprosthetics.
Separation of Components
Various authors advocate the use of temporary, biologic, or composite
materials [ 33 ] , but most agree that native tissue coverage should be
maximized during abdominal wall reconstruction for loss of domain [ 8 ] .
The value of primary fascial closure in large ventral defects with loss of
abdominal domain has been documented in multiple studies [ 34, 35 ] . In
patients with loss of abdominal domain, lack of native, innervated tissue
leads to diminished mobility and can result in increased mesh sensation
and impaired dynamics of the trunk. Component separation, fi rst
described in the US literature by Ramirez in 1990, is the fi rst-line strategy
to extend the musculofascial coverage of the abdomen [ 36 ] . Component
separation may be performed in several ways: by dividing the anterior or
posterior rectus sheath, the external or internal oblique fascia, or
transversus abdominis or certain combinations of Fig. 30.1 . Patients with
loss of abdominal domain must be carefully assessed intraoperatively for
the presence and integrity of the rectus abdominis and oblique muscle
bilaterally, and the feasibility of component separation in the light severe
lateral recession and the choice of procedure must be made accordingly
[ 37 ] . The risk of lateral recurrence must not be ignored; in patients with
loss of domain, this is especially pertinent and is yet another reason for
wide prosthetic reinforcement. The major limitation of this technique in
the face of domain loss is lack of suf fi cient native tissue to afford a
durable abdominal closure [ 33 ] . Patient satisfaction and quality of life
improvement are high [ 38 ] .
Tissue Grafts and Abdominoplasty
The inability to accomplish native skin and subcutaneous closure has
been correlated with an up to 30% recurrence rate [ 39, 40 ] , although the
causal relationship has not been proven. When the residual abdominal
tissue is insuf fi cient to provide coverage, autologous tissue grafts may be
an appropriate alternative, but they are infrequently used. These may be
musculofascial or musculocutaneous fl aps and are usually supplied by one
major artery. Tensor fascia lata fl ap was the earliest, described in 1946,
363
30. Loss of Abdominal Domain
Fig. 30.1. Anatomic diagram of abdominal components separation techniques.
364
V.B. Tsirline et al.
and may be suitable for lower abdominal wall defects [ 41 ] . It may be
performed as a simple, rotational, or free fl ap; however, they are extremely
painful. Other options include latissimus dorsi and rectus femoris fl aps;
however, up to 50% shrinkage of the denervated muscular component
results in high recurrence rate [ 42 ] . Recently, the use of anterolateral thigh
free fl ap has been reported with promising results [ 43, 44 ] . Overall, the
results of the tissue transfer fl aps have been discouraging because of the
insuf fi cient tensile strength, risk of fl ap necrosis, donor site complications,
and lack of muscle innervation, which results in eventration.
In addition to preoperative pneumoperitoneum described earlier,
tissue expanders have been used with moderate success. These can be
placed subcutaneously, between internal and external oblique or
transversus abdominis muscles [ 42 ] . There are case reports of autologous
tissue expansion by virtue of pregnancy leading to successful primary
repair with fair outcomes. The role of endogenous hormones in facilitating
tissue expansion and long-term effects remains unclear. In general, tissue
expansion is more effective for subcutaneous tissues compared to
musculofascial components.
Reconstruction in a Contaminated Field
Abdominal wall reconstruction should be performed acute in the
presence of a contaminated fi eld or bowel edema. In such cases, various
strategies have been used, all providing the temporary coverage while
the bowel edema subsides and the infection resolves. The simplest acute
method is the use of negative pressure closure, where the omentum or
arti fi cial protective covering is placed over the bowel and the abdominal
wall is bridged with a sponge or towel and gentle continuous suction is
applied over the top, such as with the use of the wound VAC [ 45 ] . Vicryl
mesh may be used as temporary coverage, with a later skin graft, when gross
infection or contamination is present. Because the material dissolves in
2–4 weeks, 100% hernia recurrence rate is to be expected. Despite its
temporary nature, Vicryl stimulates a signi fi cant in fl ammatory reaction,
and bowel fi stulization has been reported [ 46 ] . Biologic mesh provides
another coverage option in a contaminated fi eld, leading to at least 80%
hernia recurrence without subsequent de fi nitive reconstruction. Traditionally,
the use of heavyweight polypropylene mesh in contaminated fi eld was
contraindicated due to high infection rates, mesh extrusion, and
fi stulization rates of up to 50% in the acute management [ 47 ] . The newer
lightweight polypropylene prostheses are less in fl ammatory and more
amenable to bacterial eradication.
365
30. Loss of Abdominal Domain
Staged Repair with Serial Excisions
Aside from the added time, resources, and expenses, the use of serial
mesh excisions provides a robust method for loss of domain reconstruction
[
10, 33 ] . This approach takes advantage of the adaptive elasticity of the
muscle and fascia of the abdominal wall, in a sense, reversing the process of
loss of abdominal domain. The fi rst operation proceeds similarly to other
techniques. Once the eviscerated contents are reduced into the abdomen, the
dimensions of the ventral defect are measured, and exactly shaped Gore-Tex
prosthesis is sutured in the inlay position under moderate tension to produce
gradual medialization of the edges of the defect. The super fi cial wound is
closed in the usual fashion. Patients are taken back to the operating room
repeatedly every 2–4 days. At surgery, the tension on the mesh is qualitatively
ascertained, and several centimeters of mesh are excised from the middle,
and the mesh is sutured together to maintain medial tension on the edges of
the defect. In the fi nal stage, the mesh is completely excised, and the fascia
is closed primarily in the midline, with optional sublay mesh reinforcement.
Component separation may be added to facilitate midline closure [ 33 ] .
Laparoscopic Repair
Patients with loss of abdominal domain are often not considered
minimally invasive candidates, and most surgeons use open repairs for
these hernias. Nonetheless, the feasibility of a laparoscopic repair of giant
ventral hernias has been demonstrated in multiple studies [ 2, 48 ] .
Laparoscopic approaches carry low wound complication rate, which can
bene fi t patients who otherwise suffer 30–50% complication rates. The
laparoscopic technique is an intraperitoneal sublay—similar to conventional
ventral hernia repairs. Please refer to the Laparoscopic Repair chapter in
this text. The laparoscopic approach for loss of domain requires an
alteration of this technique including trocar placement above the mesh.
Outcomes and Complications
Postoperative Management
Patients with loss of abdominal domain who undergo extensive
abdominal wall reconstructions are particularly prone to wound-related
complications. The use of JP drains, subcutaneous and over the mesh, are
366
V.B. Tsirline et al.
commonplace. Abdominal binders are used for patient comfort only and
have not been shown to impact rates of seroma formation. The use of
subcutaneous talc after fascial closure has proven to reduce the
postoperative seroma formation, decrease drain duration, and lower
subsequent wound complications [ 29 ] . Previously, wound complication
rates of 30–50% were not uncommon. Fortunately, most wound problems
are limited in nature and respond to local wound care and antibiotics.
Early mobilization, respiratory therapy, and rehabilitation are important
in this population. Pain control can be an issue, and epidural anesthesia is
often employed.
Long-Term Outcomes
Although wound complications are common in the short term, the
majority of patients are fully recovered by 6 months after the operation.
Satisfaction levels are high among patients, even those who suffer wound
complications, because of the dramatically improved quality of life. The
literature suggests good results long term after staged abdominal
reconstructions using a combination of prosthetic reinforcement and
separation of components. DiCocco et al. reported at a mean follow-up
of 5 years, recurrence rate of 14%, with approximately half occurring
within 18 months and the rest within 48 months after the abdominal
reconstruction. They showed no association of recurrence with
comorbidities, defect size, or time to reconstruction; however, female
gender and BMI were associated with higher recurrence rates [ 49 ] . Long-
term quality of life is similar among patients undergoing conventional
open ventral hernia repairs and those with components separation [ 38 ] .
References
1. Heniford BT, et al. Laparoscopic repair of ventral hernias: nine years’ experience with
850 consecutive hernias. Ann Surg. 2003;238(3):391–9. discussion 399–400.
2. Baghai M, et al. Technique of laparoscopic ventral hernia repair can be modi fi ed to
successfully repair large defects in patients with loss of domain. Surg Innov.
2009;16(1):38–45.
3. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a
comparison study. Surgery. 1998;124(4):816–21. discussion 821–2.
4. Chevrel JP, Caix M. Surgery of the abdominal wall. Berlin: Springer; 1987.