Loss of domain and reduction in median suture tension

Abstract

Abdominal wall reconstruction in large incisional hernia/laparostoma poses aparticular challenge. A loss of domain is the extreme form of intestinal volume displacement. The challenge lies in overcoming retraction of the lateral abdominal muscles. Experienced surgeons have access to avariety of techniques aimed at gaining lateral length along the abdominal wall or reducing suture tension at the midline. These techniques are intended to facilitate reconstruction even in complex cases and are outlined in this article from apractical perspective. The application of botulinum toxinA (BTA) and progressive pneumoperitoneum (PPP) are described as preoperative methods to gain abdominal wall length. Peritoneal flaps, intraoperative fascial traction (IFT) and component separation including transversus abdominis muscle release (TAR) are available for the surgical reconstruction of the abdominal wall. Bridging and the intraperitoneal onlay mesh approach are fallback techniques. All these techniques were integrated into apractical algorithm for complex abdominal wall reconstruction including preoperative and postoperative care and assessed by the authors with respect to effort, effectiveness and complexity. In the opinion of the authors, the status of complex abdominal wall reconstruction is currently best described by acombination of the most effective and proven techniques in terms of a"categorical algorithm". The combination of BTA, IFT and TAR presently appears to be the most effective method; however, experience and expertise are aprerequisite.