Purpose
A clear definition of “complex (abdominal wall) hernia” is missing, though the term is often used. Practically all “complex hernia” literature is retrospective and lacks proper description of the population. There is need for clarification and classification to improve patient care and allow comparison of different surgical approaches. The aim of this study was to reach consensus on criteria used to define a patient with “complex” hernia.

Criteria for definition of a complex abdominal wall hernia

Combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BT) has not been previously reported in the management of large incisional hernia (LIH). Observational study of 45 consecutive patients with LIH between June 2010 and July 2014. The diameters of the hernia sac, the volumes of the incisional hernia (VIH) and the abdominal cavity (VAC), and the VIH/VAC ratio were measured before and after PPP and BT using abdominal CT scan data. We indicated the combination of both techniques when the volume of the incisional hernia (VIH)/volume of the abdominal cavity (VAC) ratio was >20%. The median insufflated volume of air for PPP was 8.600 ± 3.200 cc (4.500–13.250), over a period of 14.3 ± 1.3 days (13–16). BT administration time was 40.2 ± 3.3 days (37–44). We obtained an average value of reduction of 14% of the VIH/VAC ratio after PPP and BT (p < 0.05). Complications associated with PPP were 15.5%, and with surgical technique, 26.6%. No complications occurred during the BT administration. Reconstructive technique was anterior CST and primary fascial closure was achieved in all patients. Median follow-up was 40.5 ± 19 months (12–60) and we reported 2 cases of hernia recurrence (4.4%). Preoperative combination of PPP and BT is feasible and a useful tool in the surgical management of LIH, although at the cost of some specific complications.

Preoperative progressive pneumoperitoneum and botulinum toxin type A in patients with large incisional hernia.

Background Abdominal wall reconstruction with bioprosthetic mesh is associated with lower rates of mesh infection, fistula formation, and mesh explantation than reconstruction with synthetic mesh. The authors directly compared commonly used bioprosthetic meshes in terms of clinical outcomes and complications. Methods A database of consecutive patients who underwent abdominal wall reconstruction with porcine or bovine acellular dermal matrix and midline musculofascial closure at their institution between January of 2008 and March of 2011 was reviewed. Surgical outcomes were compared. Results One hundred twenty patients were identified who underwent a nonbridged, inlay abdominal wall reconstruction with porcine [69 patients (57.5 percent)] or bovine acellular dermal matrix (51 patients (42.5 percent)]. The mean follow-up time was 21.0 ± 9.9 months. The overall complication rate was 36.6 percent; the porcine matrix group had a significantly higher complication rate (44.9 percent) than the bovine matrix group (25.5 percent; p = 0.04) and statistically equivalent surgical complications (29.2 percent versus 21.6 percent; p = 0.34). There were no significant differences in rates of recurrent hernia (2.9 percent versus 3.9 percent; p = 0.99) or bulge (7.2 percent versus 0 percent; p = 0.07). However, the rate of intraoperative adverse events in the porcine matrix group [seven events (10.1 percent)] was significantly higher than that in the bovine matrix group (0 percent; p = 0.02). Conclusions In patients who undergo complex abdominal wall reconstruction, both bovine and porcine acellular dermal matrix are associated with similar rates of postoperative surgical complications and appear to result in similar outcomes. Porcine acellular dermal matrix may be prone to intraoperative device failure. Clinical question/level of evidence Therapeutic, III.

Bovine versus porcine acellular dermal matrix for complex abdominal wall reconstruction

Large ventral hernias are a significant surgical challenge "Loss of domain" (LOD) expresses the relationship between hernia and abdominal volume, and is used to predict operative difficulty and success This systematic review assessed whether different definitions of LOD are used in the literature The PubMed database was searched for articles reporting large hernia repairs that explicitly described LOD Two reviewers screened citations and extracted data from selected articles, focusing on the definitions used for LOD, study demographics, study design, and reporting surgical specialty One hundred and seven articles were identified, 93 full-texts examined, and 77 were included in the systematic review Sixty-seven articles were from the primary literature, and 10 articles were from the secondary literature Twenty-eight articles (36%) gave a written definition for loss of domain These varied and divided into six broad groupings; four described the loss of the right of domain, six described abdominal strap muscle contraction, five described the "second abdomen", five describing large irreducible hernias Six gave miscellaneous definitions Two articles gave multiple definitions Twenty articles (26%) gave volumetric definitions; eight used the Tanaka method [hernia sac volume (HSV)/abdominal cavity volume] and five used the Sabbagh method [(HSV)/total peritoneal volume] The definitions used for loss of domain were not dependent on the reporting specialty Our systematic review revealed that multiple definitions of loss of domain are being used These vary and are not interchangeable Expert consensus on this matter is necessary to standardise this important concept for hernia surgeons

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What Exactly is Meant by “Loss of Domain” for Ventral Hernia? Systematic Review of Definitions

Management of large incisional hernias with loss of domain: A prospective series of patients prepared by progressive preoperative pneumoperitoneum.

Introduction
The surgical treatment of large incisional hernias with loss of domain (LIHLD) carries the risk of fascia closure under tension and, thus, abdominal compartment syndrome. We investigated volume measurements as a predictive factor for tension-free fascia closure.

R. Badaoui

Papers

Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study

A critical analysis of factors leading to next-day discharge in ambulatory surgery patients.