Intraoperative fascia traction (IFT): innovation for very large hernias.

Background: Incisional herniason the abdomen can become very large, especially if preceded by several complex abdominal surgeries with subsequent complications. In our hernia center in Hamburg, we have often seen scar hernias with dimensions of 25 cm and more – and operated on them successfully and gently for patients using innovative procedures.

Timely treatment is important because: With huge scar hernias, it is not uncommon for so much viscera to leak into the hernia sac that the newly created space in front of the abdominal cavity is larger than the actual abdominal cavity. With such pronounced hernias, the abdominal organs often cannot be pushed back into the abdominal cavity. In technical jargon, this means that the abdominal contents “lose their domain” in the abdominal cavity (Loss of Domain, or LOD for short).

Such a large abdominal wall hernia can have dangerous consequences:

• Due to the skin often being very taut over the large scar hernia, there is less blood supply. As a result, the skin, which is the last barrier to the outside world due to the absence of the actual inner abdominal wall, can tear in the worst case. Internal organs could prolapse unprotected to the outside.
• Similarly dramatic, adhesions between the intestinal loops can lead to intestinal entanglement (ileus) after frequent previous surgeries.
• The consequence of the permanent unnatural traction of the intestines on their blood-supplying structures can be a death of the affected intestinal parts with resulting peritonitis.

All of the clinical pictures described can be life-threatening.

To prevent this, timely intervention is needed to restore the natural conditions with viscera in a closed abdominal cavity.

Common procedures:

The complex abdominal wall interventions for very large hernias usually involve the separation of the three superimposed oblique abdominal muscles in order to “gain distance” by spreading the separated layers apart, as in an accordion or fan, to achieve a low-tension abdominal wall closure (so-called component separation). These surgical steps are technically complex and not infrequently accompanied by complications such as the tearing of individual fascia parts.

Operating more gently with IFT:

These technically very complex methods can be avoided in many cases thanks to the IFT technique from Hamburg: Without surgically spreading the three muscle layers, a standardized, defined and continuous traction is exerted on the respective entire abdominal wall via holding threads during the operation with considerably less effort. This leads to a stretching and elongation of the entire – unseparated- abdominal wall (fascia and muscles), which can usually be closed with little tension after half an hour of traction treatment.

Pretreatment of the abdominal wall with Botox can decisively support the operation.

If additionally necessary, the procedures can be combined to restore the abdominal wall/abdominal cavity with minimal tension. IFT and component separation methods are therefore not used against each other, but in certain circumstances in a specific order.

Synthetic mesh insertion outside the abdominal cavity:

The plastic mesh required for abdominal wall reinforcement after traction treatment is spread outside the abdominal cavity. In this way, the abdominal cavity, intestines and other viscera are spared and complications such as possible renewed adhesions are avoided.

Since the plastic implant lies between the peritoneum and the supporting abdominal wall (sublay position), attachment is usually not necessary. Due to the internal abdominal pressure, the synthetic mesh grows quickly and painlessly into the abdominal wall, where it safely and permanently prevents a repeated hernia.