Abdominal Wall Reconstruction after Acute and Chronic Loss of Domain with Peritoneal Cavity Expansion and Component Separation
John P. Tutela, MD1, Adam R. Kolker, MD2, Jamie P. Levine, MD3, Daniel Kovacs, MD1.
1St. Vincent's Hospital, New York, NY, USA, 2Mount Sinai School of Medicine, New York, NY, USA, 3New York University Medical Center, New York, NY, USA.
Background: The management of abdominal defects in acute and chronic loss of domain presents a complex array of challenges. Abdominal hypertension and compartment syndrome preclude primary fascial closure, and classical reconstructive maneuvers often result in hernia recurrence. In this study, a new technique of peritoneal cavity expansion and reduction of hernia defect dimensions followed immediately by definitive reconstruction of complex abdominal wall defects with components separation in cases of acute and chronic loss of domain is evaluated.
Methods: Four cases of complex abdominal wall hernias with abdominal hypertension and compartment syndrome with loss of abdominal domain were treated. In all cases, peritoneal cavity expansion was achieved with fascial-interposition of two adhering adjustable sheets of biocompatible polymeric material (Whitmann Patch, Star Surgical, Burlington, WI). The two sheets adhere to each other when compressed together, and can be slowly and serially adjusted to reduce herniated viscera, decrease the dimensions of the hernia defect, and expand the peritoneal cavity volume, conceptually akin to the treatment of an omphalocele. In acute loss of domain (two patients), treatment was initiated immediately upon the identification of abdominal compartment syndrome (ACS). In chronic loss of domain (two patients), hemodynamic instability and sepsis associated with ACS necessitated initial coverage of evisceration with split skin grafts. After stabilization and nutritional optimization (5 and 8 months, respectively), peritoneal cavity expansion and abdominal wall reconstruction were performed (Figure). Transurethral bladder manometry was used in all cases to monitor abdominal compartment pressure (ACP), maintaining pressures below 20 mmHg during the expansion process. The when fascial apposition was brought within 3 cm, and ACP to below 15 mmHg, the polymeric sheets were removed completely, and definitive closure was performed with musculofascial components separation. In three cases, acellular dermal allograft (AlloDerm; LifeCell, Branchburg, NJ) was used to further support the fascial closure. Primary skin closure was achieved over all repairs. Data were reviewed retrospectively.
Results: Mean follow-up was 21 months, range 8 to 35 months. Mean peritoneal cavity expansion and hernia defect reduction time was 13 days, range 8 to 23 days. Mean pre-expansion maximal fascial defect width was 14 cm, range 9 to 20 cm, and mean post-expansion fascial width was 2 cm, range 2 to 3 cm. There were no hernia recurrences or wound complications.
Conclusions: Peritoneal cavity expansion with sequential abdominal wall defect reduction using a temporary implantable reducible patch allows for the steady and safe increase of abdominal compartment volume and approximation of the abdominal fascia. Abdominal compartment expansion followed by definitive musculofascial components separation repair should be considered in the treatment of abdominal hernia defects with both acute and chronic loss of domain.