Complex hernias or loss of domain hernias, much like their name, is a complicated type of hernia, whose incidence is increasing throughout the world. Since they represent a significant surgical challenge but are rarely spoken about in the public domain, we hope to impart some information on the same here.
What are complex loss of domain (LoD) hernias?
To understand what a complex LoD hernia is, we first have to revisit the concept of a hernia, which is simply an abnormal bulge or an out-pouching in the body. A hernia is said to be complex when operative repair or management of the issue is not easily attainable.
A loss of domain occurs when the hernia is large enough (or the outpouching is severe enough) that it seems like there are more viscera or organs outside their boundaries than there are inside, i.e, the majority of the regional tissue/organs have out bulged from their usual area/compartment and thus their “domain” has been lost.
Surgeons sometimes define complex hernias as the hernia sac-to abdominal cavity volume ratio >30% (This is a lot! Imagine a third of your bowels not being where they are supposed to be!). In most cases, these hernias are often seen in the abdomen and can be identified by the clear appearance of the bowels or parts of it right below the abdominal surface (as opposed to the muscle or fat that is usually seen/felt).
What causes these hernias?
Complex hernias are seen in the setting of multiple previous surgeries that weaken the abdominal wall. This causes defects in the abdominal wall that is complex and multiple.
Complex loss of domain hernias is most often preceded by a chronic hernia. As the chronic hernia grew in size, it expanded its opening, drawing the abdominal muscles away from each other (much like how keeping a rubber band stretched open for extended periods leads to irreversible stretching).
Some other factors that contribute are:
Prior major surgery or multiple surgeries in the same location.
Whatever the cause, these LoD hernias are not to be taken lightly and require very experienced care.
Why is a loss of domain hernias an issue?
Apart from the various inconveniences caused by having a hernia of that size and complexity, such as disability, cosmetic disfigurement, etc, some serious complications can also arise due to the massive physiological changes caused by the loss of domain.
For example, with the outpouching of abdominal contents, the pressure inside the abdomen decreases. Now, as is normal in any decreased pressure setting, something in the vicinity moves around to fill in that gap. Unfortunately, in this case, it is the diaphragm (the main muscle helping in breathing) that lowers itself, and thus eventually causes breathing difficulty. Multiple other changes in this manner occur and some are listed below:
Bowel wall edema or mesenteric edema - can lead to diarrhea and abdominal pain.
Back pain (due to wasting/loss of core muscles and spine changes),
Furthermore, as LoD represents one of the more serious complexities, it is often used as a surgical indicator for a lot of factors, such as ease of surgery, complications, etc.
Surgery on an LoD hernia is not easy.
For starters, treating it like any other hernia (operating on the opening and closing it after pushing the contents back inside) is rife with complications. As mentioned earlier, the pressure decreases inside the actual cavity, a change that the body slowly grows accustomed to. The sudden surgical closure of the hernia can lead to an immediate rise in pressure inside the abdomen.
This rise in abdominal pressure inside is an extremely dangerous complication of repairing LoD hernias, as it can even lead to death. Furthermore, there is a chance that the repair will not “take”, and simply reopen.
I think I have a loss of domain hernia! What do I do?
The first thing to do is visit a surgeon!
As mentioned earlier, this is a complex issue best left in expert hands. Not only must a plan be made to repair the LoD hernia, oftentimes, but this also needs to be preceded by a plan to tackle the CAUSE of the hernia in the first place.
For example, if morbid obesity is the issue, strict supervised dieting and maybe even bariatric (obesity surgery) may be necessary before the operation for the hernia. Some centers may even advocate doing both bariatric and hernia surgeries together if the patient meets certain criteria. We personally don’t advocate combining surgeries.
Thus, no solution is ‘cut and dry’ or applicable to all patients. An experienced and skilled surgeon is necessary to tackle this type of hernia. Here, at Chennai Hernia Center, we specialize in treating many different kinds of hernias.
Our chief consultant, Dr. Rengan, has more than 30 years of experience in this field and is uniquely qualified to help address your concerns regarding hernias.
What operations can be done for LoD hernias? Is laparoscopy still an option?
Laparoscopic or keyhole surgery is usually not done for huge LoD hernias, due to the large field and the requirement for good visibility. However, under some conditions, it can be acceptable. The most common option for LoD hernias is open surgery, where large incisions are made to access the area requiring repair.
Good preoperative planning is crucial and includes the reduction of risk factors. Complex hernias are a classical field for the tailored approach. The more extensive and challenging the hernia repair, the fewer general rules are available. We will be training you with breathing techniques and exercises before surgery so that your lung capacity is increased. Certain strategies like preoperative botulinum are also used by hernia surgeons.
A mesh is used to keep the contents of the abdomen ‘in’. Complex problems require complex solutions. Dr. Rengan uses a number of modern and complex surgical techniques such as TAR, e-TEP, and TARM to perform LoD hernia repair.
Postoperatively, a longer stay than for other hernias may be required to observe the patient for complications. Postoperative lifestyle changes are also important to maintain freedom for the issue, for e.g, good toileting habits (no pressured defecation, reduced lifting, quit smoking, good nutrition, etc.).
Keeping all this in mind, choose a specialized and experienced hernia surgeon for tackling your loss of domain hernia problem. Dr. Rengan and his team are some of the best-trained surgeons in complex hernia repair.
Chennai Hernia Centre
Chennai Hernia Centre is an initiative by our Chief Surgeon Dr ( Major ) R S Rengan to create a hernia focussed clinic to ensure high standards of care without compromising on affordability in the field of hernia surgery.