Complex Abdominal Wall Reconstruction

Why do people need an abdominal wall reconstruction?

13An abdominal wall needs to be put back together when there is a massive incisional hernia. This is usually due to an abdominal catastrophe of some sort involving repeated abdominal operations. Normally, muscle and skin cover the bowels entirely, but after lots of operations, the muscle deteriorated and there may be a wide gap between the muscles. The bowels may protrude, covered only by a thin layer of skin or skin grafts. In extreme cases, the bowels may sit completely outside the abdominal cavity and be exposed to the air. Their only protection might be a special dressing.

A typical massive incisional hernia patient will have spent a long time in the hospital and will have suffered many complications. There may be open wounds on the abdomen. There may be bowel or stomas coming to the surface of the skin leaking mucous or faeces. When there is a massive incisional hernia, the abdominal wall does not perform its normal functions. The bowels may be very susceptible to injury. Bowel that has no coverage is at risk to developing holes called fistulas. Faeces will flow out of these holes and onto the skin. This is a very challenging problem to fix. The other feared complication of a large incisional hernia is when a piece of bowel becomes trapped in scar tissue and causes a bowel obstruction or even worse, looses its blood supply and dies. This is a surgical emergency and can be life threatening. Symptoms of this include sudden, extreme pain in the hernia, inability to push the hernia back in, vomiting or redness over the wound. This can be a catastrophe for a patient with a massive incisional hernia because any surgery needs to be well planned.

In addition, living with a massive incisional hernia makes simple tasks like sitting up, walking and having a bowel movement very difficult. Finally, massive incisional hernias are cosmetically unappealing.

Patients with these types of hernias are very special. They have usually had life threatening surgical problems and may have been unwell for many months. They will have had multiple procedures and can be very run down.

How are massive incisional hernias treated?

14Massive incisional hernias will not go away without surgical treatment. A great deal of planning must go into repairing a hernia like this. Each case is individual and there is no “one size fits all”. Patients with massive incisional hernias must be fully rehabilitated before an attempt at surgery is made. This is sometimes several years after the event that caused the hernia. Repairing someone’s abdominal wall may require the input of many other specialists including plastic surgeons, dietitians, physiotherapists, wound nurses and psychiatrists.

Massive incisional hernias can be extremely difficult to repair because the tissues we are working with are stretched thin and have very little strength. There may not be enough muscle to cover the bowels. There may also have been previous attempts made at repairing these hernias. Massive incisional hernias are mainly repaired with an open operation i.e. a big cut often through the previous scar. Sometimes keyhole techniques will also be used to help the muscles come together. These hernia repairs involve carefully separating the small bowel from the abdominal wall. Sections of bowel may need to be removed to repair fistulas and sometimes more than one operation is required. These operations can take hours.

Most often a variety of creative techniques are required to repair these hernias.

Chronic Pneumoperitoneum

Sometimes the abdominal muscles are so far apart, that the bowels and other organs may protrude forward and sit permanently outside the abdominal cavity. This is called “loss of domain”. The bowels may be out of the abdomen for so long that there is no longer space in the abdominal cavity. For this problem, it may be possible to use a technique called “Chronic Pneumoperitoneum”. This is a labour intensive procedure that might require a lengthy hospital stay. You may require more than one operation to pull the abdominal wall closed.

Under full anaesthetic, a small tube is placed in the abdominal cavity. You are then woken up and admitted to the ward. Each day several litres of air will be injected into the tube, effectively inflating the abdomen like a balloon. This technique increases the size of the cavity where the bowels should be, making way for their eventual return. This will also stretch the muscles sufficiently to allow them to close over the top of the bowels. Typically, air is injected daily for 2-3 weeks and then elective surgery is performed. You will be asked to wear a tight elastic garment to try and keep most of the air out of the hernia sac. This is major surgery with lots of risks. You will require intensive care after the operation because closing the abdomen like this can have an effect on your ability to take a deep breath for a while.

Laparoscopic or Open Component Separation

When the abdominal muscles are separated by more than about 17cm, it will be impossible to pull the muscles back together to the midline. Something must be done to loosen the abdominal wall. The abdominal wall is made up of three layers. It is possible to release the tissue of one of the layers and this provides more “spring” in the abdominal wall. This is called component separation. This surgery can be done via the main surgical incision or with keyhole surgery via three cuts in both flanks. Most people will not notice that these muscles have been cut.

Scars and removal of excess skin or tummy tuck

After the bowels are returned to the abdominal cavity, many patients will have a significant amount of excess skin. In addition, many people undergoing abdominal wall reconstruction may have a flap of fatty tissue that hangs over their genitals. This is called the pannus. It may be possible to remove this flap of skin combined with the hernia repair. This will involve a long incision across the bikini line from one hip to the other. It will leave a long scar and may need to be combined with a vertical incision in the middle of the abdomen to repair the hernia. Sometimes it is best to remove this excess skin at another operation after the surgical wounds have settled.

Multiple or staged operations

If you have heavily infected wounds associated with your hernia or a colostomy, your abdominal wall reconstruction may need to be done with more than one operation. It is likely you will stay in hospital between operations.

Flap repairs with the help of the plastic surgeons

Some patients have had a loss of abdominal muscle so devastating that there is no hope of pulling the abdomen closed. Plastic surgeons can take a piece of skin and muscle from the thigh and rotate it up to the abdomen to fill the hole.