Some of the most serious repairs of the abdominal wall are called “complex abdominal wall reconstructions” rather than hernia surgeries. They occur after surgeries by other physicians (such as general surgeons, trauma surgeons, gynecologists, and urologists) where the rectus muscles either could not be reapproximated, or where a wound developed soon after surgery. Fistulas, or leaking of bowel contents, can be present. Complex abdominal wall wounds occur commonly after traumatic conditions. Papers written by Dr. Dumanian on this topic go back to one of the earliest reports of closing abdominal wounds with skin grafts (1996), and a paper entitled “Challenging abdominal wall defects (2001). The principle established by Dr. Dumanian is to close the wound in as simple a manner as possible, and to perform a delayed hernia reconstruction when the patient is better nourished. His most recent papers and book chapters have echoed these concepts. See the CV area to see a list of topics dedicated to complex abdominal wall reconstruction.
The first step in an abdominal wall reconstruction is for the surgeon to attempt to heal any open wounds that remain after the last abdominal surgery. Often, local wound care with dressings is all that is needed to achieve wound closure. Some small and deep wounds are due to retained stitches previously used to suture the abdominal wall muscles. Getting rid of the sutures often allows the wound to close by itself. This is often done in the office, and sometimes in the operating room. The risk to this procedure is creating a hole in the intestines while looking for the suture. To decrease the chance of this happening, Dr. Dumanian will often get a CT scan to see if the bowel is near the open wound. The topic of abdominal wall wounds is covered by a book chapter of the same title, written in 2012.
Some patients with large open wounds require skin grafts to heal. The skin grafts are taken from the leg, and placed on the surface of the open wound. The procedure is typically successful. Dressings and protection of the newly skin grafted area is needed for a few weeks after surgery. With time, the scar tissue holding in the bowel begins to thin and stretch. It is at this time that the hernia becomes more visible. An enlarging hernia also means that the scar holding individual bowel loops has softened enough to undergo a subsequent procedure, making the hernia repair much easier and prone to fewer complications.
People with massive hernias more often require the use of either permanent or biologic mesh to help close the abdominal wall. The surgeries take longer, and require longer hospital stays. The hernia recurrence rate is higher than for standard hernias. The postoperative complication and recurrence rates are difficult to predict, but most patients do very well. One problem with fixing the most massive hernias is with the lungs. Putting the intestines back within the abdominal wall may put pressure on the diaphragm and the lungs, making breathing difficult after surgery. Patients with long smoking histories, emphysema, or a previous tracheostomy may have the greatest problems after surgery. Your doctor may conclude that the hernia is too risky for your lungs to tolerate the repair.
Some patients with massive hernias have associated problems with the intestines. These patients may need bowel removed at the time of the abdominal wall reconstruction. When this is necessary, Dr. Dumanian will work with a general surgeon to perform the reconstruction.