Loss of Domain Hernias: A Surgical Challenge

Greetings! I extend my heartfelt gratitude to the editors and readers of K-Way for allowing me the opportunity to discuss this complex and challenging condition. My aim is to raise awareness among the public and medical professionals about this difficult-to-treat disease. It is vital to understand that not all hernias are the same, and a tailored approach is essential to ensure the patient’s overall well-being, to live an uncompromised lifestyle and to achieve the best possible outcomes.

Hernia is an abnormal protrusion of a part of the body, usually presenting as a swelling that increases in size when straining or coughing. This swelling typically contains bowel or some intra-abdominal contents. Hernias are classified by their location:

– Inguinal hernia (groin region)

– Ventral hernia (umbilical/supraumbilical)

– Lateral abdominal wall hernia

– Incisional hernia (previous surgery site)

The condition can be congenital or acquired, and patients usually present with a reducible swelling that appears when straining, with or without pain. However, serious complications can arise when the hernia becomes irreducible, leading to intractable pain, bowel obstruction, or strangulation of hernia contents, which can be life-threatening.

Hernia is primarily diagnosed clinically by a surgeon or physician, often without the need for imaging. However, ultrasound (USG), CT, or MRI may be required for surgical planning or in cases of complications.

There is no medical management for hernias; surgical repair with mesh is the standard treatment. Thanks to advances in minimal access surgery, these procedures are often performed laparoscopically or robotically as day-care surgeries, allowing patients to return home on the same day. Minimal access surgery also reduces pain, blood loss, hospital stays, and the need for prolonged medications, allowing for quicker recovery and a superior cosmetic outcome. This in turn indirectly reduces the overall treatment costs too.

Loss of Domain Hernias

Loss of domain hernias is a rare subset where a significant portion of the abdominal contents resides outside the abdominal cavity in the hernia sac. Patients often present with a large abdominal or groin swelling that resembles a second abdomen. In these cases, the abdominal cavity cannot accommodate the hernia contents, and conventional surgical closure is not possible due to the risk of complications like abdominal compartment syndrome.

These hernias present significant challenges to both patients and surgeons. They carry a high risk of recurrence, and many surgeons are reluctant to undertake these cases due to the complexity and potential for complications. As a result, patients often struggle to find a solution, moving from one healthcare provider to another.

However, recent advances in medical care, including a multimodal approach, improved preoperative planning, and the availability of superior-quality meshes, have led to better treatment outcomes and higher patient satisfaction. Preoperative preparation may involve dynamic imaging of the defect, weight reduction, respiratory optimization through breathing exercises or pranayama, and lifestyle changes such as quitting smoking. Botox injections and progressive preoperative pneumoperitoneum (gradually injecting air into the abdomen) may also be employed to optimize the abdominal wall and increase intra-abdominal space.

Managing these cases requires a multidisciplinary team, including physicians, pulmonologists, intensivists, radiologists, physiotherapists, dieticians, and anesthesiologists, all working together to provide the best outcome for the patient. It is also crucial to optimize any comorbidities and educate the patient on their condition before surgery.

Surgeons should avoid rigid preoperative plans, as these hernias can present unexpected challenges during surgery. It is essential to have contingency plans (plan B or C) and to be prepared to adapt during the operation.

Postoperative care is equally important, with early identification and management of complications being key to recovery. A well-structured rehabilitation program can greatly improve the quality of life for these patients.

These complex surgeries are best performed in healthcare centers with extensive experience and expertise in managing such cases. Over the past year, our team has successfully treated more than 15 patients with loss of domain hernias, with excellent outcomes. I would like to express my gratitude to the management and team at Kauvery Main, Alwarpet, for their support in establishing the institute as a center of excellence in hernia management. I also extend my sincere thanks to my patients for their trust and cooperation throughout the treatment process.