𝐇𝐞𝐫𝐧𝐢𝐚 𝐰𝐢𝐭𝐡 𝐋𝐨𝐬𝐬 𝐨𝐟 𝐃𝐨𝐦𝐚𝐢𝐧 Loss of domain (LOD) hernia is a condition in which there is a huge, long standing neglected case of hernia where more of the viscera (Intestine and fat)) is outside the abdominal cavity than inside.
We define a loss of abdominal domain on CT scan as greater than 30% of the intestinal contents lying outside the native abdominal cavity in the hernia sac.
In patients with LOD hernias, the abdominal cavity is unable to fully accommodate the abdominal contents within its fascial boundaries. Closure of the fascia is either impossible, or can lead to high intra-abdominal pressures, fascial dehiscence, or abdominal compartment syndrome.
Patients with ventral hernia and loss of domain represent some of the most complex hernia a surgeon may face.
𝐒𝐲𝐦𝐩𝐭𝐨𝐦𝐬
Loss of domain may have significant effects on the patient’s quality of life including long term disability, loss of core muscles, changes in spine curvature with back pain, paradoxical respiratory motion, mesenteric edema, poor bowel function, and cosmetic disfigurement.
𝐏𝐫𝐞𝐨𝐩𝐞𝐫𝐚𝐭𝐢𝐯𝐞 𝐩𝐫𝐞𝐩𝐚𝐫𝐚𝐭𝐢𝐨𝐧
Patients with loss of domain can be identified before surgery through diagnostic tests, establishing the volume of hernia contents and the size of the abdominal cavity. CT scan can calculate volume of the abdominal cavity and the volume of herniated abdominal contents. Preoperative progressive pneumoperitoneum (PPP) and type A botulinum toxin (BTX) are useful tools in the preoperative preparation of patients with giant loss of domain (LOD) hernias. Both procedures are complementary to the surgical procedure and help in achieving the closure of hernia defect without causing rise in intra abdominal pressure. Patients risk factor modification by smoking cessation.
𝐓𝐲𝐩𝐞 𝐀 𝐁𝐨𝐭𝐮𝐥𝐢𝐧𝐮𝐦 𝐓𝐨𝐱𝐢𝐧
BTX injection reduces abdominal wall tension and helps in tension-free closure of the fascial defect. The neurotoxin acts as a “chemical” separation of components, which causes relaxation of the lateral abdominal wall muscles.
The benefit of the neurotoxin is based on decreased lateral tension forces on the hernia defect and the elongation of the lateral muscles of the abdomen with a subsequent increase in the volume of the abdominal cavity, which provides for abdominal reconstruction without tension. In addition, this relaxation can reduce intraabdominal pressure, improve ventilation (breathing) and thereby reduce the need of ventilatory support in postoperative period. Maximum effect of muscle paralysis is reached after 3–4 weeks.
𝐌𝐞𝐭𝐡𝐨𝐝 𝐟𝐨𝐫 𝐀𝐩𝐩𝐥𝐲𝐢𝐧𝐠 𝐁𝐨𝐭𝐮𝐥𝐢𝐧𝐮𝐦 𝐓𝐨𝐱𝐢𝐧 𝐭𝐨 𝐀𝐛𝐝𝐨𝐦𝐢𝐧𝐚𝐥 𝐌𝐮𝐬𝐜𝐥𝐞𝐬
The neurotoxin is applied in the outpatient setting 4 to 6 weeks before hernia repair surgery. The location of the points for injection is guided by ultrasound in order to visualize the 3 lateral muscle layers to be infiltrated (external oblique, internal oblique and transverse).
The patient is placed in a lateral position. Generally, 3 points on each side of the abdomen, situated on the anterior axillary line equidistant between the inferior edge of the rib and the anterior superior iliac spine .
Total 300 unit of Botox injection is used in equally divided doses
𝐏𝐫𝐞𝐨𝐩𝐞𝐫𝐚𝐭𝐢𝐯𝐞 𝐏𝐫𝐨𝐠𝐫𝐞𝐬𝐬𝐢𝐯𝐞 𝐏𝐧𝐞𝐮𝐦𝐨𝐩𝐞𝐫𝐢𝐭𝐨𝐧𝐞𝐮𝐦
Preoperative pneumoperitoneum may be achieved by placing a catheter intraperitoneal with a port in the subcutaneous position. Atmospheric air can be injected every few days. Rather than a fixed amount of air to inject, it has been suggested that insufflations be performed until the patient complains of some mild discomfort. The pneumoperitoneum does not decrease the hernia defect but can provide additional intraperitoneal space at time of definitive repair and does provides a small test of the patient’s pulmonary reserves.
𝐂𝐨𝐦𝐩𝐨𝐧𝐞𝐧𝐭 𝐒𝐞𝐩𝐚𝐫𝐚𝐭𝐢𝐨𝐧
Following adequate pre-operative preparation, the patient’s hernia can be approached by open or laparoscopic technique. During surgery we can add some form of component separation technique (preferably posterior component separation, Transversus abdominis release -TAR) to further aid in tension free closure of hernia defect.
𝐀𝐛𝐨𝐮𝐭 𝐭𝐡𝐞 𝐀𝐮𝐭𝐡𝐨𝐫
𝐃𝐫. 𝐀𝐭𝐮𝐥 𝐌𝐢𝐬𝐡𝐫𝐚 is currently working as Professor of General Surgery and Unit Head at DMC& H, Ludhiana, Punjab, India.
Dr. Mishra is skilled in all types of complicated and advanced open abdominal and laparoscopic surgeries. He is expert in laparoscopic hernia surgery, Gall bladder stone surgery, Appendectomy, Splenectomy, Rectal prolapse repair, surgery of pancreas, liver, stomach, colon and rectum. He has immense experience in operating complex fistula in ano, pilonidal sinus (limberg flap), parotid thyroid and parathyroid surgery.
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