Loss of domain in large ventral hernias.pptx

Large ventral hernias have a loss of space due to herniated bowel content. Such patients need optimization before surgery. T

1. Loss of Domain (LOD) DR PRAVIN JOHN & DR JOHN THANAKUMAR www.anurag-hospital.com

2. DEFINITION OF LOSS OF DOMAIN - LOD No clear definition Large abdominal wall ventral hernia with significant bowel content herniated through a defect which forms a second abdominal cavity Usually defect >10cm

3. Measurement of LOD Preoperative CT volumetric analysis ABBREVIATIONS: IHV – Incisional hernia volume ACV – Abdominal cavity volume (excludes IHV) PV – total Peritoneal volume (IHV +ACV) IHV/PV

4. Tanaka index … IHV/ACV >0.25 Sabbagh index … IHV/PV >20% Measurement of LOD

5. Measuring LOD radiologically

6. Effects of LOD LOCAL Size: Enlarging hernia – Increased lateral muscle traction Tension: Decrease IAP – respiratory alterations Bowels: Thickened mesentery, altered venous/ lymphatic return, dilated bowels Skin and subcutaneous –Trophic ulcers (cutaneous hypoxia); secondary bacterial / fungal infection; fistula

7. Effects of LOD SYSTEMIC Low backache: Musculoskeletal dysfunction Respiratory Failure: Discordant diaphragm, thoracic and abdominal muscle dysfunction ; chronic respiratory failure Bowel dysfunction: Altered intestinal transit – inadequate muscle contraction / chronic gut obstruction in sac Micturationg dysfunction: Detrusor dysfunction – inability to raise IAP Personal issues: aesthetic; low self esteem

8. Management - Multidisciplinary Recover anatomy/ functionality Prevent recurrence Adequate tissue cover ACS – Ramirez vs Carbonell modification vs subcutaneous endoscopic (Daes) TAR/ PCS Albanese triple incision PPP Botox Tissue expanders Pre op optimization Quit smoking Albumin >3.5g% HbA1C < 7% Respiratory rehabilitation Weight loss

9. Preoperative BTA injected into the lateral oblique muscles BTA provides temporary flaccid paralysis to the abdominal musculature and facilitates fascial closure of the defect at time of surgery BTA injected using US guidance before surgery Botulinum Toxin A (BTA)

10. Technique of Botox or BTA A 5ml injection of Dysport® (50 units/5ml) or 3ml of Botox® (30 units/5ml) are administered at each point. Commercial brand Dysport, 50U of toxin are infiltrated in each of the 5 specific points on the right side and 5 on the left, for a total of 500U.

11. Intermittent insufflation of the peritoneal cavity is used to elongate the contracted oblique muscles Increases the capacity of the peritoneal cavity to hold viscera PPP catheter insertion, with insufflation over subsequent 5 days. Preoperative ProgressivePneumoperitoneum (PPP) María Clara López Sanclemente