Repair Of Large Ventral Hernias Research Articles

Short-term safety of preoperative administration of botulinum toxin A for the treatment of large ventral hernia with loss of domain.

Preoperative intramuscular-administered botulinum toxin A (BTA) in the lateral abdominal muscles prior to abdominal wall reconstruction has been reported to produce a flaccid paralysis and improve the primary closure rate of large ventral hernias with loss of domain. Complications to this treatment remain sparsely described. The aim of the current study was to report safety and short-term outcome of abdominal wall reconstruction aided by BTA administration. This was a retrospective two-center study including all patients undergoing abdominal wall reconstruction for ventral hernia aided by preoperative BTA administration to the lateral abdominal muscles. Data were retrieved from patient charts and included preoperative demographic and perioperative information as well as postoperative 30-day complications and readmissions. A total of 37 patients underwent BTA administration prior to hernia repair. The mean age and body mass index were 59.5 (SD 10.1) years and 31.1 (SD 5.2) kg/m2. The BTA injections were administered mean 31.6days (SD 10.0) prior to the hernia repair. One (2.7%) patient reported pain as a complication immediately after the BTA administration. Subsequent to the hernia repair, six (16.2%) patients were readmitted within 30days. Nine patients (24.3%) had wound complications and medical complications occurred in seven (18.9%) patients. We found early preoperative administration of BTA a safe adjunct to large ventral hernia repair, without adverse events related to the administration preoperative. Future studies should further highlight the efficacy of preoperative BTA for reconstruction of otherwise untreatable hernias.

Lateral release in the repair of large ventral hernia

Lateral release in the repair of large ventral hernia

Synthetic Mesh for Large Ventral Hernia Repair Correlated with Evaluation of Quality-of-life A 5 years retrospective study

Ventral hernia mesh repair is considered a standard procedure in most countries and widely accepted as superior to primary suture repair. We conducted a 5 years retrospective observational study on large and giant incizional hernia repair in our Clinics. 176 consecutive patients who had a ventral hernia repair with mesh implant in 2012-2016 were evaluated in terms of demographic characteristics, comorbidities, surgical conditions (defect size, mesh type, positioning of the mesh, length of hospital) and surgical outcomes by means of EuraHS-QoL score pre- and 30 days postoperative to assess quality of life (Qol). Alloplastic substitution with polypropylene, polyester and Dacron mesh has been used in all cases. Polypropylene mesh has been used in most of cases (91%). Most preferred mesh position was intraperitoneal (78%), then retromuscular (15%) and preperitoneal (7%). Immediate postoperative complications appeared in 41 cases (23.3%). Mean hospital length was 14,3 days. We could notice a double pre- and postoperative difference for the pain, with statistical significance (2.71�1.70; p=0.23) and the same pattern of distribution for restriction of activities and for cosmetic discomfort.

Laparoscopic hernioplasty of large ventral hernia with transfascial sutures: short term utility and outcome

Introduction: The laparoscopic approach to repairing ventral and incisional hernias has gained increasing popularity worldwide. The approximation of the hernia defect during laparoscopic ventral hernia repair, prior to mesh fixation, provides a more physiologic and anatomic repair. Defect closure also provides more defect overlap with mesh placement and, possibly decreases recurrence rates. We reviewed the experience of laparoscopic repair of large ventral hernia (diameter ≥5cm) at a university hospital in the Nepal with particular reference to patients with massive defects (diameter ≥15cm) and transfascial closure.Methods: A total of 32 patients underwent laparoscopic ventral (incisional or umbilical/paraumbilical) hernia repair between July 2014 and September 2015.Results: The prevalence of conversion to open surgery was 3.1%. The prevalence of postoperative complications was 15.6%. Median postoperative follow-up was 8.2 months. A total of 9.4% cases suffered late complications and 3.1% developed recurrence. Twelve patients underwent repair of defects ≥10cm in diameter with no recurrence. Three patients underwent repair of ‘massive’ incisional hernia (diameter ≥15cm) with a prevalence of recurrence of 3.1%. Ten patients with a body mass index (BMI) ≥30kg/m2 (range, 32–35kg/m2) underwent laparoscopic repair without any recurrence.Conclusions: Laparoscopic ventral hernia repair with transfascial suturing can be carried out safely with a low prevalence of recurrence. It may have advantages in obese patients in whom open repair would represent a significant undertaking. Laparoscopic ventral hernia repair may be used in cases of large and massive hernias, in which the risk of recurrence increases but is comparable with open repair and associated with low morbidity.

How to perform the endoscopically assisted components separation technique (ECST) for large ventral hernia repair.

The components separation technique (CST) is frequently used for reconstructing large ventral hernias. Unfortunately, it is associated with a high wound complication rate up to 50%, caused by large wound surface and inherent trauma to abdominal skin vascularization. An endoscopically assisted modification of the original technique (ECST) spares skin vascularization and reduces wound surface, supposedly reducing wound complications. This study accurately describes ECST step by step with detailed illustrations and report the results of a 27 patient cohort. Since September 2012 patients with midline hernias without previous subcutaneous dissection and a maximum diameter of approximately 10-15cm underwent ECST in an expert centre for abdominal wall reconstructions. Prospective data was gathered during inpatient care and 3-6 monthly follow-up. Twenty-seven patients (17 male/10 female) with median age of 60years (range 35-77), average BMI 27 (SD ±2)kg/m(2) and median ASA classification 2 (range 1-3) underwent ECST. Two patients were excluded due to bilateral conversion to conventional CST and finding of peritoneal metastases. Median defect size was 116±48cm(2). Median length of stay was 5days (range 3-15). Wound complication rate was 11%. Recurrence rate was 29% after a median follow-up of 13months. Endoscopically assisted modification of the original technique can be used for reconstructing large and complex ventral hernias up to 15cm in diameter. The results of this small sized cohort study showed that ECST is feasible in patients with a uro-, or enterostomy and suggest that ECST reduces wound complication rate when compared to CST.

Large Contaminated Ventral Hernia Repair Using Component Separation Technique with Synthetic Mesh

Large ventral hernia repair represents a major reconstructive surgical challenge, especially under contaminated conditions. Synthetic mesh is usually avoided in these circumstances because of fear of mesh infection, although evidence is outdated and does not regard new materials and techniques. The authors evaluated the safety of synthetic mesh in large contaminated ventral hernia repair. All large ventral hernias repaired with the components separation technique and polypropylene mesh were included in analysis. Primary outcomes were wound and medical complications, with a focus on surgical-site infection and mesh removal. For risk analysis, patients were stratified by surgical wound class, Ventral Hernia Working Group grade, and modified Ventral Hernia Working Group grade. One hundred thirty-seven patients were included, with a mean age of 58.6 years, mean body mass index of 26.6 cm2, and mean defect size of 235.6 cm2. Surgical-site infection and total wound complication rates were 16.1 and 48.9 percent, respectively. The surgical wound class distribution of surgical-site infections was as follows: clean, five of 56 (9.1 percent); clean-contaminated, five of 34 (14.7 percent); contaminated, three of 19 (15.8 percent); and dirty/infected, nine of 28 (32.1 percent). Seven meshes (5.1 percent) needed removal, two after clean repairs, three after clean-contaminated repairs, and two after dirty/infected repairs. Surgical wound class (OR, 1.77; 95 percent CI, 1.20 to 2.61) and Ventral Hernia Working Group grade (OR, 2.31; 95 percent CI, 1.24 to 4.28) were predictors of surgical-site infection. Rate of surgical-site infection after large contaminated ventral hernia repair with synthetic mesh is considerable but with a low mesh removal rate.

PWE-230 The exaggerated inflammatory response to large incisional hernia and enterocutaneous fistula repair with biological mesh

Introduction Biological meshes are increasingly used in the repair of complex, large incisional hernias, particularly in the context of a contaminated surgical field. In our centre it was noted that patients displayed an exaggerated and prolonged inflammatory response on post-operative blood results in comparison to other similar surgical procedures. This study aims to investigate the post-operative inflammatory response in patients undergoing placement of large biological meshes for the repair of large incisional hernias or enterocutaneous fistulae. Method Post-operative white blood cell count (WCC) and complement reactive protein (CRP) levels were recorded on the first five post-operative days for a consecutive cohort of patients following repair of large ventral or incisional hernias with or without repair of enterocutaneous fistulae. The mesh size and the presence of component separation was also recorded. Post-operative WCC and CRP data was collected for a size-matched contemporaneous, consecutive control group of patients undergoing open colorectal resections for a diagnosis of colorectal cancer. Post-operative inflammatory responses were compared. Results 41 patients underwent a large ventral hernia repair using biologic mesh, of which 16 (39.0%) underwent simultaneous repair of an enterocutaneous fistula. 27 (65.9%) underwent component separation. Post-operative CRP was significantly higher in patients in the hernia group on the third (188 vs. 133) and fourth (188 vs. 117) post-operative days (p < 0.01). There was no significant difference in WCC on either day. The CRP response was not significantly different between groups by the fifth post-operative day. Repair of enterocutaneous fistulae was associated with significantly increased CRP levels on the third and fourth post-operative day when compared to hernia repair alone. There was a positive correlation between mesh area (mean area = 183cm2) and CRP level on the third post-operative day (Pearson’s r = 0.42). Conclusion Patients undergoing large ventral hernia repairs using biological mesh display an exaggerated and prolonged inflammatory response in comparison to open colorectal cancer resections. The inflammatory response is no different between groups by the fifth post-operative day. This data suggests that an exaggerated inflammatory response should be expected in such procedures and that normalisation of inflammatory markers ought to be expected by the fifth post-operative day. Disclosure of interest None Declared.

Component Separation Technique: an Effective Way of Treating Large Ventral Hernia.

Repair of large ventral hernia is a challenge for even experienced surgeons, as there are large defects with large contents, often with loss of domain. The large defects were bridged by various plastic surgical procedures like myofascial flaps or free flaps with high recurrences and complications. More often, the bridging was done with artificial prosthesis, leaving the defects open. This was accomplished by either open surgery (onlay, inlay, sublay or underlay) or laparoscopic intraperitoneal onlay meshes (IPOMs). However, non-closure of the midline had adverse effects on postural maintenance, respiration, micturition, defecation and biomechanical properties, which have a profound impact on the patients' overall physical capacity and quality of life. Component separation technique (CST) is a novel answer to the closure of midline with live, active tissues with or without the use of additional prosthesis. Though this technique was originally described in 1990, it has undergone lots of modifications like perforator preserving CST, endoscopic technique and posterior component separation. So, we present a series of 22 patients with large ventral hernia repaired using various options of component separation technique in the last 3years.

Interposition of the omentum and/or the peritoneum in the emergency repair of large ventral hernias with polypropylene mesh

BackgroundVentral and incisional hernias are common surgical problems and their repairs are among the common surgeries done by a general surgeon. Repair of a large ventral hernia is still associated with high postoperative morbidity and recurrence rates. No single approach to ventral hernia repair will be the best choice for all patients. Large ventral hernias are often better approached with open surgery but may still be problematic when the defect is too wide for primary fascial closure to be achieved, as this leaves mesh exposed, bridging the gap. Techniques for incisional hernia repair have evolved over many years, and the use of mesh has reduced recurrence rates dramatically. The use of polypropylene mesh is reported to be associated with long-term complications such as severe adhesions and enterocutaneous fistula, which occur more commonly if the mesh is applied intraperitoneally with direct contact of the serosal surface of the intestine. Composite meshes containing expanded polytetrafluoroethylene (ePTFE) have been used recently; their major drawbacks lie in their high cost, inferior handling characteristics, and poor incorporation into the tissues. Although several studies have clearly demonstrated the safety and efficacy of prosthetic mesh repair in the emergency management of the incarcerated and/or strangulated inguinal and ventral hernias, however, surgeons remained reluctant to use prosthetics in such settings. PurposeThe aim of this work was to evaluate the effectiveness and safety of placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in the emergency repair of large ventral hernias using on-lay polypropylene mesh whenever complete tension-free closure of the abdominal wall was impossible. Patients and methodsThis study was carried out on all patients with large ventral hernia presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from October 2005 till October 2012. All patients were treated by placing the omentum and/or the peritoneum of the hernia sac between the viscera and the mesh whenever complete tension-free closure of the abdominal wall was impossible. Some patients necessitated removal of previous meshes and resection-anastomosis of the non-viable bowel prior to mesh repair. Those who underwent complete closure of the abdominal wall without tension prior to mesh repair were excluded from the study as there was no need for interposition of the omentum and/or peritoneum. All patients' data, surgical procedures, complications and follow-up were collected, reviewed and analyzed. After approval of local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were informed well about the operative procedure and use of prosthetic mesh and an informed written consent was obtained from every patient before carrying the procedure. ResultsBetween October 2005 and October 2012; 105 patients (13 males and 92 females) with incarcerated and/or strangulated large ventral hernias were operated upon in the Gastrointestinal Surgery Unit, Main Alexandria University Hospital using an onlay polypropylene mesh. Their age ranged from 37 to 83 years with a mean of 59.3 + 11.7 years. The hernia was para-umbilical in 5 patients (4.8%), incisional in 22 patients (21%) and recurrent in 78 patients (74.3%). The recurrent hernias were recurrent para-umbilical hernias in 56 patients and recurrent incisional hernias in 22 patients. Resection anastomosis of non-viable, devitalized or injured small intestine during removal of adherent previous meshes was performed in 19 patients (18%). Hospital stay ranged from 2 to 13 days with a mean of 3.57 + 1.6 days. There was one perioperative mortality. Complications were encountered in 28 patients (26.7%) and included wound infection with delayed wound healing in 6 patients, seroma formation in 12 patients, chest infection in 8 patients and deep vein thrombosis in 2 patients. Follow-up duration ranged from 13 to 80 months with a mean of 46.8 + 20.3 months. ConclusionPlacing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in repair of incarcerated and/or strangulated large ventral hernia using on-lay polypropylene mesh is cost-effective and safe even with resection anastomosis of small intestine.

Laparoscopic Repair of Large Ventral Hernia Following Abdominal Radical Hysterectomy for Cervical Cancer

Background: Incisional hernia is a common complication after a major abdominal gynecologic operation. Laparoscopic repair with a mesh prosthesis is a surgical modality of choice as an alternative to conventional open repair. Case: A 52-year-old woman underwent radical abdominal surgery in 2001 because she had cervical cancer. An abdominal mass had developed since 2008, measuring 8×8×4 cm. Abdominal computed tomography scanning performed at the current presentation of this patient confirmed that she had an incisional hernia at the midline of the abdominal wall. Laparoscopic hernioplasty was performed using an intraperitoneal prolene mesh and suture fixation. Results: The patient had an uneventful recovery. No recurrence has occurred as noted on outpatient follow-up. Conclusions: Laparoscopic repair of incisional hernia has been accepted as a safe and effective method. The current authors took advantage of this surgical modality to treat this patient. The desired outcome was achieved to address her large incisional hernia. (J GYNECOL SURG 30:32)

Negative Pressure Therapy for High-Risk Abdominal Wall Reconstruction Incisions

A high rate of surgical site infection (SSI) accompanies the repair of large ventral hernias in the presence of bacterial contamination. Recent clinical and laboratory studies suggest that negative-pressure therapy (NPT) applied to closed surgical incisions may reduce the risk of SSI in high-risk populations. We hypothesized that NPT would reduce the risk of SSI in patients undergoing the repair of contaminated ventral hernias. We reviewed retrospectively our prospectively collected database for patients undergoing repair of potentially contaminated and infected ventral hernias with or without NPT. All of the patients had primary wound closure. In the NPT group, a vacuum dressing was applied over the closed midline wound. The primary outcome measure was SSI at 30 d post-operatively. We evaluated 119 patients (70 with a standard wound dressing (SWD) and 49 with NPT). The groups were similar in age, gender, body mass index (BMI), the prevalence of chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and smoking; and the number of prior abdominal operations. The SWD group had a higher American Society of Anesthesiologists (ASA) score than did the NPT group (3.0 vs. 2.8; p=0.01). The two groups were similar in the sizes of their hernia defects and duration of surgery, and did not differ in their 30-d rates of SSI (25.8% SWD vs. 20.4% NPT; p=0.50) or in the distribution of major and minor SSIs (SWD: 6 major, 12 minor vs. NPT: 2 major, 8 minor; p=0.56). Factors associated with an increased risk of SSI included ASA score (p=0.02), BMI (p=0.05), defect area (p<0.01), DM (p=0.01), and duration of surgery, (p<0.01). This retrospective, non-randomized study found that NPT in the setting of a closed surgical incision after potentially contaminated or infected ventral hernia repair (VHR) did not reduce the incidence of SSI. Although prophylactic NPT has reduced wound morbidity in some surgical populations, it does not appear to offer the same reduction in wound morbidity in high-risk, contaminated, and potentially contaminated open VHR.

Conservative treatment of abdominal compartment syndrome after large ventral hernia repair

Background Surgical repair of large ventral hernias has become feasible after introduction of synthetic meshes and development in intensive-care treatment. In addition to operative challenges, the postoperative disorders incurred as the consequences of increased intra-abdominal pressure (IAP) still expose patients to severe risks.

Survey on Ventral Hernias: Surgeon Indications, Contraindications, and Management of Large Ventral Hernias

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons' perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons' perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: The “Pork Sandwich” herniorraphy

The repair of large ventral hernias is a challenging problem. This study investigated the use of decellularized, chemically cross-linked porcine dermal xenograft in conjunction with component separation (a.k.a. the "Pork Sandwich" Herniorraphy) in the repair of abdominal wall defects. We prospectively collected data over a 3-year period. Primary or near-total primary fascial closure was our goal in operative repair. A cross-linked porcine dermal xenograft mesh underlay and overlay were used to provide maximal reinforcement of the repair. Outcomes were compared with a case-controlled cohort of 84 patients who underwent ventral hernia repairs with alternative methods at our institution. Nineteen patients were included. Mean age was 55 years old, and mean body mass index (BMI) was 30 kg/m(2). Mean defect size was 321 cm(2). Post-operative complications were observed in ten out of 19 patients. Complications included seroma (n = 2), wound infection (n = 2), abscess (n = 1), skin necrosis (n = 6), and fistula formation (n = 3). Seven patients required re-operation. Statistically significant factors (p < 0.05) that contributed to increased post-operative complications or re-operation rates included smoking, presence of pre-operative enterocutaneous fistulae, extended post-operative hospital stay (>2 weeks), and a defect size greater than 300 cm(2). There were no hernia recurrences in our "Pork Sandwich" group, which contrasted favorably to the retrospective case-control group in which the hernia recurrence rate was 19% (p = 0.038). For the repair of abdominal hernias, primary closure, with component separation as needed, with an underlay and overlay of cross-liked porcine xenograft should be considered to minimize risk of recurrent herniation. Additional long-term prospective comparative studies are needed for further validation of the optimal method and material for repair.

Comparison of Laparoscopic Primary and Open Primary Repair of Ventral Hernias

Prosthetic materials have gained popularity for ventral hernia repair. There are situations when the use of a mesh is either unnecessary or contraindicated. This study compares 51 patients with ventral hernia who underwent laparoscopic or open primary suture repair. Results were determined by a median follow-up of 33 months. Recurrence rates and operative time were the major parameters of outcome. Mean operative time was insignificantly shorter in the laparoscopic group (14.8 ± 4.3 vs. 15.6 ± 3.7 min). There were no short-term complications in groups. One patient in each group had recurrence. Conclusively, laparoscopic primary repair of small ventral hernias is simple and can be performed as an initial approach for small defects. Compared with open repair, it has the advantages of better exposure, reduced pain, and less morbidity. It can also be performed as a component of a combined laparoscopic operation. However, this technique is not recommended for repair of large ventral hernias.

Comment to apronectomy with repair of large ventral hernia in a morbidly obese patient

This is a nice, well-written little paper. The authors will be interested and pleased to know that they have joined a unique bond. In the early 1970s, Jack Mustarde introduced a similar system at Canniesburn, and Tom Gibson and myself especially used this frequently. The apparatus was in the form of a metal “coat hanger” and this was suspended with a “block and tackle” system. It worked very well but was never published. Congratulations on joining the “belly suspension group!” Eur J Plast Surg (2006) 29:199 DOI 10.1007/s00238-006-0091-9

Apronectomy with repair of large ventral hernia in a morbidly obese patient

A 42 year old female with a body mass index of 47 presented to the general surgical outpatient clinic with a large apron of skin hanging from the anterior abdominal wall. This adversely affected her mobility and was prone to intertrigo. It was also complicated by the presence of a large ventral hernia with propensity for recurrent incarceration. Apronectomy with repair of ventral hernia was performed A novel technique to anchor the heavy apron was employed. The apron was anchored to an overhead steel bar by means of large orthopaedic Steinman’s pins and stirrups. A total of 18.5 kg of skin and soft tissue were removed. The patient had difficulty in weaning off the ventilator and spent 3 weeks in the intensive care unit. There were no other complications. There was marked improvement in her mobility and overall quality of life after the operation. Apronectomy can be safely performed in conjunction with ventral hernia repair. This method of anchoring the apron greatly facilitates an otherwise difficult operation. The number of operators as well as the operating time is reduced.

Deepithelialization of a complex ventral hernia for completely extraperitoneal Rives-Stoppa herniorrhaphy

Peritoneal incisions made during abdominal surgery are associated with numerous postoperative complications. Laparoscopic procedures are extraperitoneal, but they do not always provide adequate exposure of the defect nor room for manipulation. We suggest a de-epithelialization approach prior to mesh placement for the repair of large ventral hernias as a means of achieving a completely extraperitoneal ventral herniorrhaphy.

The use of a subfascial vicryl mesh buttress to aid in the closure of massive ventral hernias following damage-control laparotomy.

Damage control laparotomy for life-threatening abdominal conditions has gained wide acceptance in the management of exsanguinating trauma patients as well as septic patients with acute abdomen. Survivors considered too ill to undergo definitive abdominal wall closure are temporized, often with skin grafting on granulated viscera. These maneuvers compromise the integrity of the anterior abdominal wall and result in a subset of patients with loss of abdominal domain and massive, debilitating ventral hernias. A retrospective review was conducted of 21 such patients (16 men, five women) who underwent elective abdominal wall reconstruction at the Hospital of the University of Pennsylvania between November of 1998 and October of 2000. The purpose of this study was to report the authors' experience with these complex abdominal wall reconstructions. A double-layer, subfascial Vicryl mesh buttress was used in all repairs to aid in reestablishing abdominal wall integrity. The mean hernia size was 813 cm2 (range, 75 to 1836 cm2), and the average interval to definitive repair was 24.4 months (range, 3 weeks to 11 years). Mean follow-up was 13.5 months (range, 1 month to 40 months). Twenty patients (95 percent) had successful ventral hernia repair. Four patients with massive hernias (924 to 1836 cm2) required submuscular Marlex mesh implantation. Two patients (10 percent) developed abdominal compartment syndrome that required surgical decompression. One patient (5 percent) developed an incisional hernia at a prior colostomy site. Four patients (19 percent) had superficial skin dehiscence that healed secondarily with daily wound care. There were no mesh infections. In most cases, successful single-stage repair of large ventral hernias following damage control laparotomy can be achieved using a subfascial Vicryl mesh buttress in combination with other established reconstructive techniques. Massive defects exceeding 900 cm2 typically require permanent mesh implantation to achieve fascial closure and to minimize the risk of postoperative abdominal compartment syndrome and recurrent herniation. This technique represents an improved solution to a complicated problem and optimizes the aesthetic and functional outcome for these debilitated patients.

Respiratory mechanics in abdominal compartment syndrome and large incisional hernias of the abdominal wall

The abdominal compartment syndrome (ACS) is a clinical condition characterized by an increase of abdominal pressure which needs prompt abdominal decompression. The surgery of large abdominal hernias can present similar problems with an increased abdominal pressure at peritoneal closure which needs a prosthetic tension-free abdominal closure to correct the increased respiratory work-load. We undertook a study in order to compare the respiratory mechanical work-load changes during the surgery of large abdominal incisional hernias and the ACS. We measured the static compliance of the entire respiratory system (Crs), and its components-lung (CL) and chest-wall (Ccw)-during the acute phase of increased abdominal pressure and after decompressive treatment. In ACS the baseline measurements of Crs, CL, Ccw were 0.034, 0.049 and 0.115 L/cmH20 respectively; after decompression treatment we observed a great increase of Ccw (0.167 L/cmH2O) whereas Cl remained the same (0.O49L/cmH2O); Crs varied from 0.034 to 0.038 L/cmH2O. In the surgery of large laparoceles, the Crs changed from 0.048 to 0.046 and the Ccw from 0.150 to 0.180, with an unchanged Cl. We conclude that the abdominal compartment syndrome is characterized by a well-defined alteration of respiratory work-load (decrease of chest-wall compliance), and that from a mechanical point of view there is only a quantitative difference if compared to large ventral hernia repair. The decrease of chest-wall compliance in the latter is less severe and statistically different (p = 0.002).