Laparoscopic Repair of Loss of Domain Incisional Hernia Combining Endoscopic Myofascial Advancement Flaps, Medialization of the Rectus Sheath, and Mesh Reinforcement: A Case Series

OBJECTIVE: To evaluate our initial experience with combining bilateral endoscopic myofascial advancement flaps, medialization of the rectus sheath, and mesh reinforcement for laparoscopic repair of loss of domain incisional hernias.
METHODS: A retrospective chart review was performed on all patients having completed a laparoscopic incisional hernia repair combining bilateral endoscopic myofascial advancement flaps, medialization of the rectus sheath, and mesh reinforcement for loss of abdominal domain. Patients selected had loss of abdominal domain and no previous attempts at laparoscopic ventral hernia repair or component separation and no other contra-indications to laparoscopic surgery. The operation involved bilateral endoscopic myofascial separation of components and advancement flaps, adhesiolysis, primary closure of the fascial defect using a transfascial suture passer with interrupted absorbable sutures, and reinforcement with mesh – all performed using a laparoscopic approach. Peri-operative measures, outcome data, and subjective patient satisfaction were evaluated.
RESULTS: This procedure was attempted on three patients with loss of domain incisional hernias, two men and one woman. All were successfully completed. See table one for peri-operative data. There were no peri-operative complications. All patients were evaluated in clinic 4-5 weeks after surgery. The only complication seen was an asymptomatic seroma in one patient. All patients reported subjective improvement in their ability to perform daily activities and quality of life.

Table 1. Peri-operative data

Patient	Age (y)	BMI (kg/m2)	ASA Classification	Hernia Size (cm2)	Mesh Size (cm2)	Operative Time (min)	EBL (ml)	Length of Stay (d)
1	61	33	3	550	930	328	50	4
2	52	28	3	330	750	262	100	8
3	67	27	3	338	884	209	20	3

CONCLUSION: The repair of abdominal wall hernias with loss of domain can successfully and safely be performed using a completely laparoscopic approach combining bilateral myofascial advancement flaps, medialization of the rectus sheath, and mesh reinforcement. This technique may decrease the rate of post-op seromas, increase abdominal wall function, and ultimately improve patient satisfaction. Future prospective trials will be necessary to further define any benefits of this technique over standard repair.

Session: Poster

Program Number: P467