๐๐๐ซ๐ง๐ข๐ ๐ฐ๐ข๐ญ๐ก ๐๐จ๐ฌ๐ฌ ๐จ๐ ๐๐จ๐ฆ๐๐ข๐ง 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.
๐๐ฒ๐ฆ๐ฉ๐ญ๐จ๐ฆ๐ฌ
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.
๐๐ซ๐๐จ๐ฉ๐๐ซ๐๐ญ๐ข๐ฏ๐ ๐ฉ๐ซ๐๐ฉ๐๐ซ๐๐ญ๐ข๐จ๐ง
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.
๐๐ฒ๐ฉ๐ ๐ ๐๐จ๐ญ๐ฎ๐ฅ๐ข๐ง๐ฎ๐ฆ ๐๐จ๐ฑ๐ข๐ง
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.
๐๐๐ญ๐ก๐จ๐ ๐๐จ๐ซ ๐๐ฉ๐ฉ๐ฅ๐ฒ๐ข๐ง๐ ๐๐จ๐ญ๐ฎ๐ฅ๐ข๐ง๐ฎ๐ฆ ๐๐จ๐ฑ๐ข๐ง ๐ญ๐จ ๐๐๐๐จ๐ฆ๐ข๐ง๐๐ฅ ๐๐ฎ๐ฌ๐๐ฅ๐๐ฌ
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
๐๐ซ๐๐จ๐ฉ๐๐ซ๐๐ญ๐ข๐ฏ๐ ๐๐ซ๐จ๐ ๐ซ๐๐ฌ๐ฌ๐ข๐ฏ๐ ๐๐ง๐๐ฎ๐ฆ๐จ๐ฉ๐๐ซ๐ข๐ญ๐จ๐ง๐๐ฎ๐ฆ
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.
๐๐จ๐ฆ๐ฉ๐จ๐ง๐๐ง๐ญ ๐๐๐ฉ๐๐ซ๐๐ญ๐ข๐จ๐ง
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.
๐๐๐จ๐ฎ๐ญ ๐ญ๐ก๐ ๐๐ฎ๐ญ๐ก๐จ๐ซ
๐๐ซ. ๐๐ญ๐ฎ๐ฅ ๐๐ข๐ฌ๐ก๐ซ๐ 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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