How should eventration of the rectus abdominis muscles be evaluated and managed?

Management of Rectus Abdominis Eventration

When definitive fascial closure cannot be achieved after abdominal surgery, skin-only closure is the recommended approach, with subsequent eventration managed at a later stage using delayed abdominal closure and synthetic mesh repair 1.

Initial Management Strategy

The management of rectus abdominis eventration depends critically on the clinical context in which it develops:

For Unstable Patients with Acute Eventration

• Open management is recommended to prevent abdominal compartment syndrome, particularly in patients experiencing severe sepsis or septic shock 1
• Intra-abdominal pressure should be measured intraoperatively to guide decision-making 1
• Following patient stabilization, attempt early definitive closure of the abdomen, but only when the risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1

For Progressive Closure Attempts

When early definitive fascial closure is not possible:

• Progressive closure can be gradually attempted at every surgical wound revision 1
• Cross-linked biological meshes may be considered as a delayed option for abdominal wall reconstruction 1
• Vacuum-assisted closure with mesh-mediated fascial traction (VACM) has demonstrated higher fascial closure rates and lower planned hernia rates compared to non-traction techniques 1

Definitive Repair Options

Component Separation Technique

The component separation technique is a useful and low-cost option for repair of large midline abdominal wall hernias (Grade 1B recommendation) 1. This technique:

• Enlarges the abdominal wall surface by translating muscular layers without damaging muscle innervation and blood supply 1
• Has been shown superior to bridging with prosthetic material in prospective randomized trials, though recurrence rates can reach up to 38.7% 1

Novel Autologous Tissue Techniques

For complicated eventrations with large defects (average width 16.3 cm, gap area 450 cm²), bilateral rectus muscle turning-over represents an emerging option 2. This technique:

• Involves mobilizing rectus muscles from posterior sheath and turning both muscles 180° medially
• Provides low-tension abdominal wall reconstruction without synthetic mesh
• Demonstrated significant quality of life improvement (23 ± 13 vs. 47 ± 6; p = 0.0013) with only one recurrent hernia in 22 patients 2
• Requires intact anatomical structure of rectus muscles and can be applied in acute cases 2

Critical Pitfalls to Avoid

• Avoid bridging meshes when possible, as they often result in bulging or recurrences 1
• Do not attempt primary fascial closure under excessive tension, as this increases risk of recurrent intra-abdominal hypertension 1
• In patients with poor general condition, skin-only closure is preferable initially rather than forcing definitive repair, as mortality after reoperation can reach 26.1% in high-risk patients 3

Prognostic Considerations

The patient's preoperative condition is the most important prognostic factor for eventration outcomes, more so than the underlying disease requiring surgery 3. Respiratory insufficiency occurs in 56.5% of cases, and wound infection in 60.8% of eventration cases 3, emphasizing the need for careful patient selection and timing of definitive repair.