| Summary: | BACKGROUND: Incisional hernia (IH) is the most frequent complication of laparotomy with an increasing incidence over time. A large amount of them present in complex forms with large defects or even loss of domain. There is still no consensus regarding the optimal surgical approach for this IHs. The posterior component separation with transversus abdominis release (TAR) alone or in combination with augmentation of the abdominal wall became the standard of repair in large IHs (LIH). No clear evidence that TAR alone can recreate the normal volume of the peritoneal cavity is available. We assessed if it is possible to reconstruct normal peritoneal volume (PV) by TAR.
MATERIALS AND METHODS: In this retrospective study, data from LIH patients with midline defects equal or larger than 10 cm width, and computed tomography scans available before and 1-week after TAR with complete fascial closure were analyzed. Hernia sac volume (HSV), abdominal cavity volume (ACV), and (PV = HSV + ACV) were evaluated before surgery. Peritoneal index (PI) was calculated as HSV/PV ratio. PV was measured at 7 days post-TAR (PVTAR). The compliance of the abdominal wall (Cab) was calculated as the ratio between the difference of the PV before surgery and after TAR and the difference between preoperative intra-abdominal pressure (IAP) and postoperative IAP.
RESULTS: 23 consecutive patients with a mean age of 64 years were included in the study. The mean value of the HSV was 3,775 cm3 and of the ACV 8377 cm3. PI varied between 0.22 and 0.4. A statistically insignificant difference was recorded between PV and PVTAR(P = 0.7). Patients with PI ≥0.3 had the volume of the peritoneal cavity lesser than patients with PI <0.3. The compliance of the abdominal wall was decreased for the patients with defects larger than 15 cm width and PI larger than 0.33. Urine output in the first postoperative day was smaller in the patients with PI larger than 0.3 with a statistically significant (P = 0.0002) difference and was highly correlated with the abdominal perfusion pressure (APP) and PI.
CONCLUSIONS: TAR is able to recreate normal PV in LIH patients with PI <0.3. When PI is larger than 0.33, a permissive intraabdominal hypertension develops for 24 h with the reduction of the APP and of the urine output. In this condition, the augmentation of the abdominal wall could be considered as an option by preoperative administration of pneumoperitoneum and/or Botulin toxin.
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