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

Intraoperative fascia traction (IFT) – what is it? Why is surgery for large abdominal wall hernias so complex? What role does the Hamburg Hernia Center play in the development of the procedure? You can find initial answers here – we will explain details in our consultation hours in Hamburg.

At a glance:

  • Intraoperative fascial traction (IFT) is used for very large abdominal wall hernias or in particular incisional hernias (here also: “scar hernias”) to the application. The innovative procedure enables gentle, low-tension closure of very large hernias. In many cases, more complex procedures involving greater risks can be bypassed in this way.
  • The procedure was first used by Dr. Dietmar Eucker under the name AWEX (“Abdominal Wall Expander System”) and then developed by Prof. Henning Niebuhr, Dr. Halil Dag and team together with Dr. Gereon Lill for specific application in hernia surgery.
  • At the Hamburg Hernia Center, the procedure for large scar hernias is now routine with the largest number of operations performed worldwide.

Very large scar hernia: gentle surgery with IFT

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.

Surgery for large abdominal wall hernias

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.

Ongoing improvement of the method - developments from Hamburg:

usually the entire existing scar is reopened during the operation of very large abdominal wall or scar hernias. Applying the MILOS Principle (Mini or Less Open Sublay) a much smaller skin incision is often sufficient.

Our chief physician Professor Niebuhr applies this principle also to very large scar hernias: The necessary “stretching” of the abdominal wall layers can also be carried out endoscopically under the intact skin and soft tissue mantle. The combination of MILOS and IFT is a Hamburg development.

Various high-ranking published studies prove the value of this gentle procedure.

Fig.: Percutaneous facial traction

Conclusion: The advantages of the IFT operation from Hamburg

  • Relatively small skin incision for huge scar hernias of the abdominal wall
  • Avoidance of the potentially complicating separation of the lateral muscle loops
  • Gentle stretching of the lateral abdominal muscles and fasciae to achieve a low-tension weder production of the abdominal cavity.
  • Leaving the lateral abdominal wall layers intact thereby also
  • no abdominal wall weakness in the long term
  • Combinability of the technique with the MILOS principles and component separation processes, if necessary
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