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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 19-23

Retrospective research on initiative content reduction technique for obesity patients with huge abdominal incisional hernia


Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100043, China

Date of Submission02-May-2018
Date of Acceptance02-May-2018
Date of Web Publication16-May-2018

Correspondence Address:
Jie Chen
Beijing Chaoyang Hospital, Capital Medical University, Beijing 100043
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_2_18

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  Abstract 


OBJECTIVE: The objective of this study is to assess the prophylactic and therapeutic effects of initiative content reduction on intra-abdominal hypertension in obesity patients with huge abdominal incisional hernia.
MATERIALS AND METHODS: In this study, the retrospective cohort/descriptive research methods were applied. We collected the clinical data of a total of 62 obesity patients with single-onset huge abdominal incisional hernia who were admitted to Beijing Chaoyang Hospital of Capital Medical University for treatment between January 2011 and December 2015. In the operation, the initiative content reduction was performed. Following observation indexes were recorded as follows: (1) Surgical condition: surgical duration, length of resected intestinal tract, and length of stay (LOS) in hospital; (2) postoperative recovery: cardiac, pulmonary, hepatic and renal functions, and and intravesical pressure; (3) incidence of postoperative complications: infection of incision and intestinal fistula; and (4) patients' condition in follow-up. Return visits in outpatient service were required respectively at 1 week, 1 month, 3 months and 6 months after surgery, and 1 year after follow-up, the follow-up was carried out through telephone. Recurrences of hernia and late-onset infection were the question to be asked in follow-up, and June 2016 was set as the deadline of follow-up.
RESULTS: (1) Surgical condition: The surgeries were successfully carried out for 62 patients, in which surgical duration was (115 ± 22) min, the length of resected intestinal tract was (207 ± 64) cm, and LOS was (14.5 ± 1.9) d. (2) Postoperative recovery: the intravesical pressure of patients was decreased in comparison with the level before operation, and after surgery, no hepatic, renal and respiratory dysfunctions were observed. (3) Incidence of postoperative complications: There were four patients with infection of incision; however, no intestinal fistula was found in any patients. (4) Follow-up: follow-up was performed for 62 patients, and the average length of follow-up was 35 months, during which three patients suffered recurrence of incisional hernia.
CONCLUSION: For obesity patients with huge abdominal hernia, the application of initiative content reduction can effectively prevent the postoperative intra-abdominal hypertension, which is considered as an effective and feasible therapeutic procedure.

Keywords: Huge abdominal hernia, initiative content reduction technique, intra-abdominal hypertension, obesity


How to cite this article:
Yang S, Chen J, Shen YM, Wang MG, Cao JX, Liu YC. Retrospective research on initiative content reduction technique for obesity patients with huge abdominal incisional hernia. Int J Abdom Wall Hernia Surg 2018;1:19-23

How to cite this URL:
Yang S, Chen J, Shen YM, Wang MG, Cao JX, Liu YC. Retrospective research on initiative content reduction technique for obesity patients with huge abdominal incisional hernia. Int J Abdom Wall Hernia Surg [serial online] 2018 [cited 2022 May 18];1:19-23. Available from: http://www.herniasurgeryjournal.org/text.asp?2018/1/1/19/232493




  Introduction Top


Abdominal incisional hernia is frequently seen in clinical practice, and according to the literature, the incidence rate of it after abdominal surgeries is about 2% to 11%; retarded treatment easily leads to the huge abdominal incisional hernia, and severely affecting the life quality.[1],[2],[3] Obesity, malnutrition, and other metabolic diseases are the factors leading to susceptibility to progressive attenuation of abdominal wall.[4] As the sole method that is applicable to the treatment of huge abdominal incisional hernia, herniorrhaphy faces a quite serious problem in the operation, which is the susceptibility to increase in intra-abdominal pressure after operation due to the return of massive hernial content to the abdominal cavity,[5],[6],[7] thereby contributing the intra-abdominal hypertension, and functional damages to various organs; finally, it will evolve into the abdominal compartment syndrome (ACS), which severely affects the prognosis of patients, and the mortality rate of these patients has been as high as 60%.[8],[9] In this center that is one of the institutes where the research on prophylaxis and treatment of abdominal hypertension after the operation for huge abdominal incisional hernia was carried out in an early stage in China, the active volume reduction was applied to eliminate the hernial content, such as omentum and part of the intestinal tract. Despite of the risk of resecting the affected organs, this method can alleviate the dysfunctions of multiple organs caused by postoperative intra-abdominal hypertension to decrease the mortality rate.[10] In this study, to investigate the clinical efficacy of active volume reduction on prophylaxis and treatment of abdominal hypertension during the operation, we retrospectively analyzed the clinical data of 62 obesity patients with huge abdominal incisional hernia who were admitted to this hospital for treatment between January 2011 and December 2015.


  Materials and Methods Top


General materials

Retrospective cohort/descriptive research methods were applied. We collected the clinical data of 62 obesity patients with huge abdominal incisional hernia, in which there were 24 males and 38 females aged 57 to 80 years old with an average of 65 years old, and the average body mass index (BMI) was (30.3 ± 2.6) kg/m2. According to the Guidelines for Incisional Hernia of Abdominal Wall,[3] these patients were diagnosed as huge abdominal incisional hernia before operation.

Inclusion criteria and exclusion criteria

Inclusion criteria as follows: (1) Obesity patients with abdominal incisional hernia with BMI > 28 kg/m2; (2) the hernial diameter >12 cm in computed tomography (CT) examination and diagnosis before operation and the volume of hernial content >20% in the supine position of the abdominal volume (the volume of hernial content was directly calculated using the ratios of length to width in multilayer of CT and magnetic resonance images); (3) patients with single-onset of incisional hernia; and (4) patients with no severe dysfunctions in major organs.

Exclusion criteria as follows: (1) Patients who had difficulties in receiving abdominal incisional hernia repair under general anesthesia; (2) patients with multionset abdominal incisional hernia; (3) patients who dropped out of initiative content reduction for subjective reasons.

Treatment methods

Preoperative preparation

At 24 h before operation, the surgical preparation was performed, in which patients were required to only take liquid food, and skin preservation was carried out (the surgical area was from the ligation between nipples along to the 1/3 part of thigh, and covered the part between bilateral midaxillary lines); at 12 h before operation, patients were required to take sulfate-free polyethylene glycol electrolyte powder for evacuating the intestinal tract.

Operation procedures

After general anesthesia, a fusiform incision was made at the site of hernial sac, and part of skin in the scar was removed; there, the hernial sac was found and separated to the neck, and resected; thereafter, the adhesions in surgical area was isolated, and the abdomen was cleaned to identify other lesions; based on the CT and other imaging results before operation, compared with the length of small intestine (about 600 cm), we calculated the proportion of content confirmed by preoperative diagnosis to the abdominal volume, and, accordingly, resected about 20% to 30% of small intestine and mesenterium; with part of the intestinal tract adhering to the hernial content, about 120 cm to 380 cm small intestine and the mesenterium were resected for initiative content reduction, while the remaining part was maximally retained in the caecum; then, the linear anastomosis stapler was used for side to side anastomosis, and the resected intestinal tract was preserved and delivered for pathologic examination; abdomen was rinsed with warm saline for more than three times to examine the active bleeding; the edge of defect was measured, and tissue separation was carried out for placing the material of hernia repair that was 5 cm longer than the length of edge of defect; absorbable suture was used to close the defect of hernial ring, and drainage tube was placed in the abdomen and under the skin to prevent the postoperative exudation and observe the condition of patients.

Postoperative treatment

Fluid therapy was provided to maintain balance of intake and output, we adjust antibiotics according to blood tests, when the WBC is lower than 10G/l, stop antibiotics. Before intestinal decompression, parateral nutrition was given.

Observation indexes

(1) Surgical condition: surgical duration, length of resected intestinal tract and length of stay (LOS) in hospital. (2) Postoperative recovery: cardiac, pulmonary, hepatic and renal functions, and intravesical pressure. (3) The incidence of postoperative complications: incisional infection, intestinal fistula, and infections secondary to the subcutaneous exudation after operation. (4) Follow-up.

Follow-up

Return visits in outpatient service were required respectively at 1 week, 1 month, 3 months, and 6 months after surgery, and at 1 year after follow-up, the follow up was carried out through telephone. June 2016 was set as the deadline of follow-up. Followings are the items of follow-up:

  1. After the operation, dynamic observation was performed to identify the recovery of the abdominal incision and to examine the infections, intestinal fistula, postoperative infections secondary to incisional exudation
  2. Before operation and at 1 to 3 days after the operation, we consecutively monitored and recorded the intravesical pressure twice a day, and the maximum was served as the result
  3. At 1 to 3 days after the operation, we examined and recorded the cardiac, pulmonary, hepatic, and renal functions every day, and indicators that exceeded 20% of the upper limit of normal value were defined as the adverse events.


    1. Cardiac function: Every day, noninvasive cardiac function tester was used to detect the indicators, such as cardiac output and ejection fraction
    2. Pulmonary function: Every day, the pulmonary functions were evaluated according to the results of pulmonary function tester and blood gas analysis
    3. Renal and hepatic functions: Every day, the levels of indicators, including aminotransferase, bilirubin, albumin, ions, uric acid, creatinine and urea nitrogen, were recorded to monitor the level of lactic acid which was served as an indicator for ischemia in the intestinal tract.


  4. After the operation, the recovery of gastrointestinal tract was observed, and air exhausting, defecation and adverse events, such as constipation and diarrhea, were also recorded.


Statistical analysis

Ranked sum test for data in non-normal distribution was performed to compare the intravesical pressures of enrolled patients before and after operations (the maximum detected at the 3rd day after the operation), and Statistical Product and Service Solutions 15.0 (International Business Machines Corporation, Armonk, New York, United States) was used to perform statistical analysis.


  Results Top


(1) Surgical condition: The surgeries were successfully carried out for 62 patients, in which surgical duration was (115 ± 22) min, the length of resected intestinal tract was (207 ± 64) cm, and LOS was (14.5 ± 1.9) d. (2) Postoperative recovery: Before the operation, the intravesical pressure of patients after operation was (18.3 ± 1.9) cmH2O, and the maximum of intravesical pressure after operation was (8.6 ± 1.3) cmH2O; the difference between two groups had statistical significance (P = 0.0000), and after surgery, no hepatic, renal and respiratory dysfunctions were observed.(3) The incidence of postoperative complications: There were four patients (4/62, 6.5%) with infection of incision, but no intestinal fistula was found in any patients.(4) Follow-up: Follow-up was performed for 62 patients, and the average length of follow-up was 35 months ([35.5 ± 18.5] months), during which three patients (3/62, 4.8%) suffered recurrence of incisional hernia.


  Discussion Top


Limitations of conventional hernia repair surgery in treatment of huge abdominal incisional hernia and the pathogenesis

With the improvement of medical conditions and increasing attention to the abdominal diseases of people in China, the number of patients who receive abdominal operations is increasing on a year-by-year basis, which, however, augments the number of cases with incisional hernia and parastomal hernia after abdominal operations; in addition, obesity,[11] malnutrition and ascites [12] are the factors more easily inducing the poor recovery of incisions.[4] Without timely treatment, abdominal incisional hernia usually evolves into the huge type.[13]

As the sole method that is applicable to the treatment of huge abdominal incisional hernia, herniorrhaphy is a tremendous challenge for surgeons; moreover, the recurrence rate of herniorrhaphy for huge abdominal incisional hernia is 10% to 30%, and the incidence rate of postoperative complications is as high as 50%.[14] In addition to the frequent complications of herniorrhaphy, including recurrence, infection and chronic abdominal pains, treatment of huge abdominal incisional hernia faces a serious problem, which is how to deal with the huge hernial ring and hernial content. To guarantee the reconstruction effect of abdomen, we must rationally process the second abdomen and content. Besides, other than the adhesion and edema, malignant lesions, such as tumors, are scarcely found in hernial content, and clinically, herniorrhaphy is required to return the content, which is in accordance with the regular operation standard and ethic principal. However, in clinical practice, the return of content in the second abdomen after surgical resection of huge hernial sac usually leads to an increase in intra-abdominal pressure after the operation, evolving into abdominal hypertension or even ACS.[4] Thus, in herniorrhaphy for huge abdominal incisional hernia, forced return of hernial content frequently results in the postoperative abdominal hypertension, which, thus, has been proved to be a dangerous surgical method severely affecting the prognosis of patients.[10],[15]

Many clinical physicians have paid attention to the increase in abdominal pressure after herniorrhaphy of huge abdominal incisional hernia, which is usually caused by following factors: (1) massive accumulation in second abdomen – the tissues and organs included in the hernial sac are returned to the abdomen in the operation, contributing to the sudden increase in abdominal pressure; (2) after herniorrhaphy of abdominal incisional hernia, patients were usually required to wear an abdominal bandage for 3 to 6 months to prevent the postoperative complications, such as the shift of patch and loosened sutures caused by the moves leading to an increase in abdominal pressure such a cough, hiccup and defecation straining, but wearing the bandage also increases the passive increase of abdominal [16] (3) during separating the intestinal tract and tissues in adhesion, the operations with instruments such as electrome result in the tissue edema, and the enlarged tissues also increases the postoperative abdominal pressure; (4) after abdominal operations, especially the laparoscopic surgeries, intestinal activities usually recover after several days due to the artificial pneumoperitoneum, anesthesia and trauma, which usually contributes to the accumulation of intestinal content and, thus, the increase of abdominal pressure; (5) in the surgical treatment of abdominal incisional hernia, the placement of artificial patch for hernia repair limits the compliance of abdominal wall to the movement,[17],[18] thus increasing the exudation and abdominal pressure.[9],[10]

Clinical efficacy of initiative content reduction (passive volume reduction)

For treatment of abdominal pressure after the surgery of huge abdominal incisional hernia, incarceration usually appears in some patients with huge abdominal incisional hernia, resulting in the ischemia and necrosis of content; after intraoperative resection of necrotic omentum and intestinal tract initiative content reduction (passive volume reduction), the abdominal pressure remains normal after operation, and, accordingly, we inferred that active volume reduction can reduce the abdominal pressure after operation. Through statistical analysis, we found that the resection and anastomosis of intestinal tract initiative content reduction would not increase the incidence rate of postoperative infection and intestinal fistula, and we believed that initiative content reduction, intestinal tract with adhesion and edema was resected, and the parts that might be susceptible to the intestinal fistula were also removed from the abdomen;[19],[20] thus, after operation, patients only dealt with the risk of anastomotic fistula. Nevertheless, in patients who did not receive volume reduction therapy, the intestinal tract that was separated from adhesion was completely returned to the abdomen, and, under the abdominal hypertension, the intestinal tract with edema and dilation after operation suffered the poor blood supply,[21] and the edema and injuries to the surface of serosa caused by isolating the intestinal tract from adhesion easily induced the infection and intestinal fistula in abdomen due to the intestinal inflation, which greatly extended the LOS of patients, and brought tremendous loss for patients.


  Conclusion Top


To prevent the abdominal hypertension in obesity patients with huge abdominal incisional hernia after operation, my colleagues in this center have been exploring the prophylaxis and treatment measures.[11],[12] Although active volume reduction faces various ethic problems like medical risk of resecting the organs and normal tissues, various studies have confirmed that it is indeed an effective method for prophylaxis and treatment of abdominal hypertension and even ACS;[20] in addition, with better perioperative management and sufficient preoperative evaluation, the complications can be effectively controlled. For ACS with a relatively high mortality rate, we require more in-depth studies on active volume reduction to search for the safer and more effective treatment method.

Financial support and sponsorship

Fund Project (No.): Yangfan Program of Beijing Municipal Administration of Hospital (XMLX201602). Fund resource: Jie C, the director.

Conflicts of interest

There are no conflicts of interest.



 
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