Conservative treatment of abdominal compartment syndrome after large ventral hernia repair
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- Bezmarevic, M., Slavkovic, D., Trifunovic, B. et al. Eur Surg (2013) 45: 31. doi:10.1007/s10353-012-0168-6
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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.
A 44-year-old man was admitted in our institution for the large ventral hernia repair. Despite large ventral hernia with thickened subcutaneous tissue above hernia sac, a relatively small primary defect that was easy to repair was found on abdominal computed tomography. Intra-operatively, the primary defect was 10 cm in diameter with preserved abdominal front wall layers around it. The hernia sac was resected and ventral hernioplasty was performed with Prolene® mesh. IAP, measured intra-operatively and after extubation of the patient, was normal. On the second postoperative day, the patient was intubated due to respiratory failure in development of abdominal compartment syndrome (ACS). This condition was treated conservatively and he was extubated on the sixth postoperative day. The subsequent course was uneventful and the patient was discharged 14 days after the surgery with significant improvement in his mobility.
Results and conclusions
Relatively small abdominal wall defect of large ventral hernia made surgery less complicated than assumed on the first presentation. The most important determinants of the postoperative complications were the mismatch of the original abdominal cavity and the mass of tissue with loss of domain. Conservative treatment of IAH/ACS should be implemented as early as possible, which can lead to the resolution of ACS as presented in our case.
KeywordsLarge, ventral, herniaRepairAbdominal, compartment, syndromeTreatment
Ventral hernia is a result of muscle and fascial layer defects of the anterior abdominal wall. It is a frequent complication of laparotomy [1–3]. In spite of the significant achievements in surgery, repair of hernias still remains problematic with the reccurence rates of 5–63 % depending on the technique used [1–8]. Treatement of large ventral hernias is possible even without usage of synthetic meshes, autologous tissue flaps, different biomaterials or implementation of various preoperative procedures to enlarge the abdominal space and expand tissue for later reconstruction, but a higher reccurence rate and postoperative complications must be expected [9–11]. A simpler surgical repair of large ventral hernia with a smaller fascial defect was reported . However, the real challenge in large hernia repair is repositioning the abdominal tissue with loss of domain and closing the defect without tension. Restoring the hernia sac contents into abdominal cavity and abdominal closing with tension may cause the abdominal compartment syndrome (ACS). It occurs when the intra-abdominal pressure (IAP) rises faster than physiological adaptations and can be fatal in some cases [13, 14]. Surgical procedures are often necessary for ACS treatment [14–16]. However, in some cases the conservative treatment may be beneficial [15–17].
We present a patient with large ventral hernia, whose treatment was rejected by the surgeons in other hospital. The patient was operated on, afterwards he developed an ACS and was conservatively treated with success.
An obese 44-year-old healthy man was admitted to our institution for surgical treatment of large ventral hernia. The patient has had a primary abdominal wall defect for more than 10 years. Nevertheless, recent enormous enlargement of hernia had greatly affected his daily activities and quality of life. Apart from obesity (BMI of 39.9), the patient had no previous history of any disease and he had not undergone surgical procedures. Hernia was presented like venter pendulus with the largest diameter of 30 cm (Fig. 1). Skin on the surface of hernia was thickened with hyperkeratosis and chronic ulcerations.
A computed tomography (CT) scan of abdomen showed a large ventral hernia with thickened subcutaneous tissue above the hernia sac, with a part of transverse colon, small bowel and great omentum as its content. The primary defect was relatively small. The largest diameter of fascial defect was 10 cm and it was approximately in the area of linea alba (Fig. 2). Laboratory findings such as blood cell count, biochemical analysis of blood and inflammatory markers were within normal ranges. It was decided to proceed with surgical intervention. Intra-operatively, the hernial ring was located in midline with 10 cm in diameter, with preserved and macroscopically normal abdominal front wall layers around the defect. The maximum width of the thickened subcutaneous tissue (panninuculus) above the hernia sac was 25 cm. The content of the hernia sac was a part of transverse colon, small bowel and great omentum. After repositioning of hernia sac contents into abdominal cavity, the dissection of abdominal front wall layers around the defect was performed. The hernia sac and the apron above it were dissected and weighed 25.7 kg. Before the peritoneum was closed, we made bilateral relaxing incisions on fascia of the external oblique muscles to approximate the straight abdominal muscles in the midline without tension. Afterwards, we set the retention loop and onlay positioning of Prolene® mesh (previously soaked in gentamicine) to ensure a 3-cm overlap from the edge of retention loop and 6 cm from the edge of defect after closing (Fig. 3). The Prolene® mesh was approximately 28 cm high and 14 cm wide.
Following the closure of peritoneum, the IAP was measured using a technique described by Cheatham , and it was 5 mmHg. One drain tube was placed subcutaneously. Skin closure was easily achieved primarily. The patient was extubated after the operation with a good gas exchange and IAP of 8 mmHg. IAP was measured every hour postoperatively. Six hours after the operation, IAP started rising and 24 h postoperatively it was 18 mmHg. Since the beginning of IAP growth, intra-abdominal hypertension (IAH) was treated with diuretics (furosemid, spironolactone), enemas, the nasogastric and wind tube were placed and gastrointestinal prokinetics (prostigmine, metoclopromide) were administered. On abdominal ultrasound perfomed 24 h after the operation, an increased thickness of bowel wall was found, suggesting bowel oedema. In addition to the above-mentioned conservative treatment, the patient was reintubated 36 h after the surgery due to respiratory failure (arterial pO2 on room air was 46 mmHg). On the third postoperative day, the patient developed renal failure (blood urea nitrogen of 62 mg/dL and serum creatinine of 1.5 mg/dL) in addition to respiratory failure and IAP of 24 mmHg. After the patient’s intubation, sedation and analgesia with miorelaxants were administered. All these procedures led to a decline of IAP and it was 8 mmHg on the fifth postoperative day. Renal failure was resolved 2 days after its occurrence and the patient was extubated on the sixth postoperative day. The subsequent course was uneventful. The patient was returned to oral feeding on the eighth postoperative day and drain tube was removed on the 11th postoperative day. The patient was discharged on the 17th postoperative day, and reviewed a month postoperatively (Fig. 4) with a satisfactory result. During the control examination 6 months after the surgery, patient had no signs of wound infection. He was able to move without difficulties.
Large ventral hernia and its gradual enlarging results in a relative decrease in intra-abdominal space, leading to the harmful effects on postural maintenance and normal functions of gastrointestinal tract. A significant enlargement of hernia represents a major cosmetic deformity that could affect the mental integrity of a patient [5, 10]. Reparation of these hernias remains a challenging task for both general and plastic surgeons, especially when there is a loss of domain [19, 20]. The “loss of domain” means that the hernia sac behaves like a second abdominal cavity due to herniated viscera. Restoring the herniated viscera into abdominal cavity can lead to ACS with possible catastrophic consequences. Therefore, there are many options to improve repairing of large hernias. Creation of the progressive pneumoperitoneum is an invasive procedure that requires longer time for preoperative preparation of patients with several occasional complications [21, 22]. Musculoskeletal flaps require great dissection with possibility of significant blood loss, flap necrosis and donor site-related complications . In order to decrease the bulk of the contents, parts of omentum, small bowel or colon were resected . Prosthetic meshes are widely used in ventral hernia repairing. The use of sheets of non-absorbable mesh has revolutionized the repair of abdominal wall defects and rendered most of the other older types of operations as obsolete . Other options include components’ separation technique initially described by Ramirez et al. . Despite good preoperative preparation, application of optimal surgical techniques in repairing large ventral hernias and postoperative treatment, there remains a possibility of complications. In rare cases, clinical presentation of giant ventral hernia is associated with relatively small primary defect , as shown in our case (Fig. 2). We made a decision for hernioplasty with combined techniques of Prolene mesh and the components’ separation technique with primary closure.
Although there is no exact data on the incidence of ACS after surgical management of large ventral hernias, it is clear that this was one of the major problems before non-tension techniques were used. ACS can arise after repair of large ventral hernias with the “loss of domain”, or when meshes are placed with a great tension [12, 27]. If it occurs, the treatment of ACS usually ends up with decompressive laparotomy or laparostomy [14, 16, 28]. The increase in IAP directly determines the alterations in respiratory mechanics, so normal IAP during ventral hernioplasty indicates that the closing of the defect is not under tension [28, 29]. In our patient, we noted normal IAP after peritoneum closure and patient extubation, which indicated that the hernioplasty was performed without tension, suggesting low probability for postoperative appearance of ACS. The cause of ACS in our case was the bowel oedema, as the result of intestinal paresis [13, 14, 17]. A non-operative medical management strategies play an important role in both the prevention and treatment of ACS. Also, conservative treatment should be implemented whenever IAH is present . There are several therapeutic non-operative interventions for the management of IAH/ACS (Table 1).
We started with the conservative treatment as soon as IAP began to rise. Following the applied procedures there was a withdrawal of ACS and improvement of the patient’s condition.
Regardless of the applied technique, complications of surgical repair such as hernia recurrence, postoperative fluid collections, and complications related to prosthetic material occur in about 20 % of cases [31–33]. Obese patients face an increased risk of primary and incisional ventral hernias development, as well as high recurrence rates, systemic and wound complications after ventral hernioplasty [32, 34, 35]. Also, IAP is greater in obese individuals, contributing to obesity-related comorbidity . Although our patient had no comorbidities nor elevated IAP in the immediate postoperative period, he developed serious complications. However, wound infection and hernia recurrence were not observed during the follow-up. There is no uniform consensus on the indications and timing for surgical decompression in ACS. It was suggested that the first line of ACS treatment should be non-operative . Our patient responded well to diuretics, sedation, analgesia and miorelaxants, which led to the decreasing of IAP and resolving of the organ dysfunctions. If non-operative interventions fail to relive ACS, surgical decompression should be considered. Continuous hemodiafiltration and percutaneous drainage  would probably not result in decreasing of IAP due to bowel oedema as a cause of ACS in our patient. The midline or transverse laparostomy with the abdomen left open and later reconstruction would result in prolonged and complicated treatment of our patient with the uncertain solving of his hernia. If surgical decompression would be required in our patient, we would prefer the subcutaneous abdominal fasciotomy , but high incidence rate of subsequent hernia should be expected.
There are cases with respiratory complications and organ dysfunctions after ventral hernioplasty [27–29], but they are not mentioned in literature presenting methods to optimize large hernia repair. Although a small fascial defect was found intra-opertively as well as normal IAP after the extubation, the mass of tissue with loss of domain is the most important objective for complication risk determination. Our previous experience in ACS and timely application of the approved principles and guidelines in its treatment helped us to make adequate decisions in order to preserve the patient’s life and ensure his normal daily functioning.
Relatively small abdominal wall defect of large ventral hernia made surgery less complicated than assumed on the first presentation. The most important determinants of the postoperative complications were the mismatch of the original abdominal cavity and the mass of tissue with loss of domain. In cases where there is no IAH in the immediate postoperative period, there is still a possibility for ACS development. Conservative treatment of IAH/ACS should be implemented as early as possible and can lead to resolution of ACS as presented in our case.
The operation was performed by N. Stankovic, D. Slavkovic and M. Bezmarevic, whereas B. Neskovic was responsible for taking the photos. M. Bezmarevic, N. Stankovic and B. Neskovic were engaged in the postoperative treatment. M. Bezmarevic and J. Beloica did the research of the reference sources. In addition, D. Slavkovic, M. Bezmarevic and J. Beloica helped draft the final version of the manuscript. B Trifunovic helped in critical revision of the manuscript for important intellectual content. All authors have read and approved the final manuscript.
Conflicts of interest
The authors did not report any relationships and declare no conflict of interest.