Loss of Domain in Ventral Hernias: Definition and Repair Challenges
Definition of Loss of Domain
Loss of domain occurs when a significant portion of abdominal contents has chronically herniated outside the abdominal cavity, resulting in loss of the "right of domain" to reside within the peritoneal cavity. This is quantitatively defined as a hernia defect greater than 300 cm² or when the hernia sac-to-abdominal cavity volume ratio exceeds 30% 1. The abdominal cavity essentially "forgets" how to accommodate these displaced organs, creating a contracted peritoneal space that cannot safely house the herniated contents upon reduction 2.
Primary Challenges in Repairing Loss of Domain Hernias
Physiologic Challenges
The fundamental challenge is preventing abdominal compartment syndrome when returning chronically herniated contents to a contracted abdominal cavity 2. Key physiologic concerns include:
- Intra-abdominal hypertension develops when the reduced peritoneal volume cannot accommodate the herniated viscera, potentially causing respiratory compromise, impaired venous return, and organ dysfunction 2
- Respiratory mechanics are severely compromised as the diaphragm is pushed cephalad, reducing functional residual capacity and increasing work of breathing 3
- Cardiovascular instability may occur from increased intra-abdominal pressure compressing the inferior vena cava and reducing cardiac preload 2
Technical Surgical Challenges
Achieving tension-free primary fascial closure is the central technical challenge, as simply bridging large defects with mesh leaves the midline open and compromises abdominal wall function 3. Specific technical obstacles include:
- Massive fascial defects averaging 300-884 cm² that cannot be primarily approximated without advanced techniques 4, 1
- Multiple prior operations (average 4.3 prior laparotomies) create hostile surgical fields with dense adhesions and compromised tissue quality 4
- Inadequate tissue mobility to achieve midline closure without component separation or tissue expansion techniques 3, 2
Postoperative Complications
Surgical site occurrences affect approximately 48% of patients with loss of domain, representing a major burden 1. Common complications include:
- Wound infections are the most frequent complication, particularly problematic when mesh is present 5, 4
- Prolonged hospital stays averaging 17-36 days depending on hernia size, with giant hernias (>30% volume ratio) requiring significantly longer hospitalization (31 vs 17 days, p=0.03) 1
- Recurrence rates vary dramatically by technique and mesh type: 8% with non-absorbable mesh versus 57% with absorbable mesh at 18-month follow-up 2
Patient-Specific Risk Factors
Obesity, previous abdominal surgeries, and conditions causing chronically elevated intra-abdominal pressure compound all the above challenges 3. These factors:
- Increase fascial tension required for closure, raising compartment syndrome risk 2
- Compromise tissue quality and healing capacity, increasing infection and recurrence rates 4
- Limit surgical options as laparoscopic approaches may be contraindicated in multiply-operated abdomens 3
Quality of Life Impact
Non-closure of the midline has profound adverse effects on postural maintenance, respiration, micturition, defecation, and biomechanical properties, severely impacting patients' physical capacity and quality of life 3. This underscores why bridging techniques that leave the fascia unrepaired are suboptimal despite being technically easier.
Critical Pitfalls to Avoid
- Do not attempt primary closure without adequate preoperative preparation in hernias with >30% volume ratio, as this risks life-threatening abdominal compartment syndrome 2
- Do not bridge large defects with mesh alone without attempting fascial closure, as this compromises long-term functional outcomes and biomechanics 3
- Do not underestimate the complexity of multiply-recurrent hernias—these require staged procedures or advanced techniques like component separation, not simple mesh repairs 4, 1