What is the recommended treatment for a patient with a loss of domain hernia?

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Last updated: February 5, 2026 • View editorial policy

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Management of Loss of Domain Hernia

For patients with loss of domain hernias, preoperative progressive pneumoperitoneum (PPP) followed by surgical repair with mesh reinforcement is the recommended treatment approach, achieving primary fascial closure in over 90% of cases with acceptable morbidity. 1

Preoperative Preparation Strategy

Loss of domain hernias—defined as hernias where the herniated content exceeds 20-50% of total peritoneal volume—require specialized preparation before definitive repair to avoid life-threatening complications from acute increases in intra-abdominal pressure. 1, 2

Progressive Preoperative Pneumoperitoneum (PPP)

PPP is the cornerstone of preoperative preparation and should be performed over 10-14 days before surgical repair. 1, 2

  • Technique: Ambient air is insufflated into the abdominal cavity via an indwelling catheter, with mean volumes of 7.2 liters required to achieve adequate domain expansion 2
  • Efficacy: PPP increases abdominal cavity volume by approximately 53%, allowing the peritoneal cavity to accommodate the herniated contents 1
  • Success rate: Complete reduction of herniated content with primary fascial closure is achieved in 94% of patients when PPP is used 1
  • Mortality: The procedure-related mortality is 2%, with zero postoperative mortality in properly selected patients 1

Adjunctive Botulinum Toxin Type A

Botulinum toxin type A injection into the lateral abdominal wall muscles is a complementary tool that facilitates tension-free prosthetic repair by inducing temporary muscle paralysis and relaxation. 3

Surgical Repair Approach

Definitive Repair Technique

Open anatomic reconstruction with complete fascial closure and sublay synthetic mesh reinforcement should be performed whenever possible. 1

  • Primary fascial closure: Direct approximation of the linea alba should be achieved in all cases, with normal peak airway pressures (20-21 cmH₂O) confirming tension-free closure 2
  • Mesh reinforcement: Synthetic mesh in sublay position is recommended in 84% of cases, providing superior outcomes 1
  • Mesh selection: Non-absorbable synthetic mesh has an 8% recurrence rate compared to 57% with absorbable mesh at 18-month follow-up 1

Alternative Staged Approach

For extremely massive defects where single-stage repair is not feasible, a staged approach using temporary Gore-Tex Dual mesh with serial excisions can be employed, though this requires an average of 6 operations and 36-day hospital stay. 4

Expected Outcomes and Complications

Morbidity Profile

  • Overall morbidity: 75% of patients experience some complication, though most are minor 1
  • Severe morbidity: 34% develop serious complications requiring intervention 1
  • Surgical site complications: Occur in 48% of cases directly related to the operative procedure 1
  • Wound infections: Require operative debridement in select cases 4

Long-term Results

Recurrence rates are significantly influenced by mesh type, with non-absorbable synthetic mesh providing superior durability. 1

  • Non-absorbable mesh recurrence: 8% at mean 18.6-month follow-up 1
  • Absorbable mesh recurrence: 57% at same follow-up period 1

Critical Pitfalls to Avoid

Do not attempt primary repair without adequate preoperative domain expansion, as this leads to abdominal compartment syndrome and respiratory failure. 1, 2

  • Avoid using absorbable mesh for definitive repair due to unacceptably high recurrence rates 1
  • Ensure PPP is completed over adequate time (10-14 days minimum) to allow physiologic adaptation 2
  • Monitor peak airway pressures intraoperatively; pressures exceeding 21 cmH₂O indicate excessive tension 2
  • Do not proceed with repair if herniated content cannot be reduced without tension, as this increases mortality risk 1

Quality of Life Considerations

Loss of domain hernias significantly impair quality of life through physiological modifications that affect respiratory function, mobility, and daily activities. 5 Successful repair with PPP preparation and appropriate mesh reinforcement restores abdominal wall integrity and improves functional outcomes in the vast majority of patients. 1

References

2
Research

Experience with insufflation technique in the management of incisional hernia with loss of domain.

South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie, 2021

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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