Hernia with Loss of Domain

Definition

There is no standard definition for loss of domain, generally speaking it refers to the clinical situation when more of the viscera is outside the abdominal cavity than inside. Whether this should be defined when the patient is straining or lying flat for a CT scan is unclear. 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.

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 issues.

Patient management

Surgical treatment should not be offered if expertise is lacking, patient comorbidities are significant or if it is unlikely to provide an improvement in quality of life. Patient selection involves careful assessment of medical status including age, BMI, pulmonary reserve, poorly controlled diabetes mellitus, current smoking and steroid use.

The goals of the repair involve attempts at medializing the rectus, avoiding physiological compromise of the patient and reconstruction using mesh. Often, an abdominal binder with the plan for a nonoperative strategy is the best option.

Preop Planning

Some patients with loss of domain can be identified preoperatively through imaging studies, establishing the degree of eviscerated contents and the size of the abdominal cavity. Some CT programs can calculate volume of the abdominal cavity and the volume of herniated abdominal contents. Options include laparoscopic ventral hernia repair, preoperative pneumoperitoneum, preoperative tissue expanders, and open retrorectus repair. Patient risks factor modification including smoking cessation and weight loss need to be highlighted.

Preoperative Pneumoperitoneum

Preoperative pneumoperitoneum may be achieved by placing a catheter intraperitoneal with a port in the subcutaneous position. Ambient air can be injected every few days. Rather than a choose an exact 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. Following this, the patient’s hernia can be approached open or laparoscopically.

Surgical Repair

Open Hernia Repair

Open repair is frequently the appropriate option with components separation added to the repair in appropriate situations. Attempts may be made at rectus medialization and a retrorectus mesh placement. In the clean situation, synthetic mesh can be utilized and in the contaminated situation, biologic mesh may be appropriate choice.

Laparoscopic Repair

Loss of domain has traditionally been a contraindication for the laparoscopic approach. Laparoscopic repair in these situations can be technically difficult, due to the decreased working space when the viscera is reduced. Techniques that can be beneficial are addition of components separation and working above the mesh to achieve fixation. Working above the mesh can be technically challenging as well, with the needed safe guarding that tacks are not placed into bowel trying to sneak above the mesh. Outcomes from this technique highlight the complications which reflect the difficult patient population.

References

1. Loss of Domain – Definition and Management Michael Rosen, M.D. Challenging Hernias Post-Graduate Course,  World Congress of
Endoscopic Surgery Hosted by SAGES & CAGS, Thursday, April 15, 2010

2.Technique of laparoscopic ventral hernia repair can be modified to successfully repair large defects in patients with loss of domain.
Baghai, Mercedeh. Ramshaw, Bruce J. Smith, C Daniel. Fearing, Nicole. Bachman, Sharon. Ramaswamy, Archana.Surgical Innovation. 16(1):38-45, 2009 Mar