Zusammenfassung
Die erfolgreiche Therapie komplexer Bauchwandhernien erfordert ein integratives, individualisiertes und ggf. interdisziplinäres Behandlungskonzept. Aufgrund des hohen abdominellen sowie kardiopulmonalen Komplikationspotenzials sollte die Betreuung an spezialisierten Zentren mit entsprechender Erfahrung und Expertise erfolgen. Neben der Prähabilitation und Optimierung hernienspezifischer Risikofaktoren und beeinflussbarer Komorbiditäten spielt die präoperative Konditionierung vor komplexen Bauchwandchirurgischen Eingriffen eine zunehmend wichtige Rolle. Die Bariatrische Chirurgie zur Gewichtsreduktion ist ebenso Teil dieser Strategien wie die Applikation von Botulinumtoxin A in die laterale Bauchwand zur Dehnung der Muskulatur und Vergrößerung des Rumpfdurchmessers. Das präoperative progressive Pneumoperitoneum hat seine Indikation bei massiven Eviszerationen, erleichtert die Reposition der Eingeweide und bewirkt über Tage präoperativ die langsame Adaptation des Patienten an die postoperativ geänderten Druckverhältnisse. In operativ-technischer Hinsicht sollte der Grundsatz gelten: „Netzverstärkung kommt vor Defektüberbrückung“. Das heißt, der morphologiegerechten und funktionellen Restauration der myofaszikulären Bauchwand mit Netzaugmentation ist gegenüber Verfahren, bei denen ein Bauchwanddefekt lediglich netzbasiert überbrückt wird, der Vorzug zu geben. Die retromuskuläre/präperitoneale Netzverstärkung im Sinne der „Sublay-Technik“ ist Goldstandard. Selbige kann zu anterioren oder posterioren Komponentenseparationen erweitert werden, um eine Spannungsreduktion zur Mittellinie und/oder eine Erweiterung des Implantatlagers zu erreichen
Abstract
The successful treatment of complex abdominal wall hernias requires individualized and if necessary interdisciplinary treatment concepts. Due to the high potential for abdominal and cardiopulmonary complications, specialized centers with a high level of expertise and experience should undertake the care of patients. Prehabilitation and optimization of hernia-specific risk factors and comorbidities play an essential role in the treatment algorithm. Preoperative conditioning prior to surgery can be crucial for success. Bariatric surgery for weight loss and administration of botulinum toxin A in the lateral abdominal wall for stretching the musculature to provide myofascial advancement and enlargement of the torso diameter are parts of such strategies. The preoperative progressive pneumoperitoneum has its justification in massive evisceration, facilitates repositioning of the viscera and helps the patient to slowly adapt to the postoperatively changed abdominal pressure conditions. From a surgical technical point of view, the following principle should apply: “mesh augmentation comes before defect bridging”. This means preference should be given to a morphological functional restoration of the myofascicular abdominal wall compared to procedures that merely bridge abdominal wall defects based on meshing. The retromuscular preperitoneal mesh strengthening in the sense of a sublay technique is the gold standard. This can be extended to anterior or posterior component separation techniques in order to achieve a reduction of tension to the midline and/or to achieve enlargement of the space for mesh placement.
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G. Köhler bezieht Einkünfte für Schulungs- und Beratungstätigkeit der Firmen Medtronic, Dahlhausen, AFS und Bard. Es besteht kein Ineressenkonflikt bezüglich dieser vorgelegten Publikation.
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Köhler, G. Präoperative Konditionierung und operative Strategien zur Therapie komplexer Bauchwandhernien. Chirurg 91, 134–142 (2020). https://doi.org/10.1007/s00104-019-01027-3
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DOI: https://doi.org/10.1007/s00104-019-01027-3