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Complications - Abdominal wall reconstruction according to Ramirez

general and visceral surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative Complications

    • Intraoperative Bleeding
      Especially of the epigastric vessels or their branches at the lateral edge of the rectus sheath

      Therapy: immediate suturing/hemostasis
       
    • Bowel Injury during Adhesiolysis
      Prophylaxis: careful, layer-by-layer dissection, if necessary, start dissection in an area free of defects, from there display the fascial defect and the hernia contents. Early opening of the hernia sac.

      Deserosations must be recognized and immediately oversewn.

      In the case of transmural lesions, the location (small intestine-large intestine) and the amount of bowel content leakage are crucial, possibly postponing the mesh implantation.
       
    • Inability to Close the Anterior Rectus SheathBridging Technique: In cases where the anterior fascial layers cannot be completely united, fixation of the fascial edges on the mesh already placed in the sublay position with a continuous non-absorbable suture in the sense of partial anterior bridging is permissible. If a large hernia is treated with a dorsal fascial closure, a sublay mesh in a retromuscular position, and minimal residual bridging of the anterior fascia, and a primary skin closure is achieved over it, a satisfactory result can be expected.

  2. Postoperative Complications

    • Postoperative Hemorrhage/Hematoma
      Ultrasound monitoring, puncture if size progresses. Hemorrhages affecting hemoglobin levels and large symptomatic hematomas must be revised.

      Bleeding after removal of Redon drains: Erosion caused by Redon drainage. The suction must be removed before pulling to prevent the aspirated drain from causing bleeding in the drainage channel or muscle.
       
    • Unnoticed Secondary Bowel Perforation
      Avoid interenteric bowel adhesiolysis, preferably only prepare near the abdominal wall, possibly including the parietal peritoneum/transversalis fascia, to ensure a safe distance from tightly adherent bowel loops.

      If the expected postoperative course deviates and there is suspicion of an undetected bowel lesion (fever, peritonitis, ileus, infection parameters), surgical exploration is necessary. Reoperation with detection of the bowel lesion and suturing, possibly resection and abdominal lavage, antibiotic treatment, possibly mesh explantation. Mortality approximately 3%.
       
    • Abdominal Compartment Syndrome
      Reduced urine output, possibly bladder pressure measurement. Dissolution of the abdominal wall reconstruction, at least partially.
       
    • Postoperative Bowel Paralysis/Manifest Ileus
      Bowel paralysis after extensive adhesiolysis or bowel wall suturing is common. A slow dietary build-up is recommended, possibly with antiemetic medication to avoid retching and vomiting, which could endanger the fresh reconstruction. Prophylaxis through epidural anesthesia and early mobilization. Attempt conservative bowel stimulation, possibly administration of a prokinetic (e.g., Neostigmine). In the case of a manifest ileus, reoperation with detection and correction of the cause.
       
    • Chronic Postoperative PainChronic postoperative pain was defined as early as 1986 by the "International Association for the Study of Pain" as pain persisting for more than three months despite optimal conservative therapy. Possible causes include traumatic nerve damage from suturing during mesh fixation, especially when using non-absorbable suture material.

      Consistent postoperative analgesia. In therapy-resistant pain localized to a trans-fascial suture/knot, it should be removed through a circumscribed approach. Identification of segmental spread and attempt at segmental blockade, possibly neurectomy of the affected intercostal nerve. Mesh removal as a last resort.

      Risk factors include pre-existing or poorly controlled early postoperative pain, female gender, and defect width > 10 cm.
       
    • Seroma
      • A seroma is regularly present depending on the size of the hernia sac and without therapeutic consequence, possibly ultrasound follow-up.
      • Therapy: Wait at least 4-6 weeks, then possibly sterile puncture. For very large seromas and discomfort or suspicion of superinfection, ultrasound or CT-guided drainage with suction. In rare cases, persistent seromas with capsule formation require surgical excision.

        Prophylaxis: Insertion of Redon drains and removal only after secretion cessation.
         
    • Wound Healing Disorder/Skin Necrosis
      In extensive subcutaneous mobilizations, attention must be paid to the perforating vessels, if possible, to avoid skin necrosis.
       
    • Wound Infection/Mesh InfectionSuperficial wound infection: Conservative approach with open wound treatment
      Subfascial wound infection with mesh involvement: Open wound treatment, possibly VAC
       
    • Recurrence
      In clinically irrelevant recurrence with no symptoms, usually an incidental finding during imaging for other reasons, surgical indication should be considered very cautiously. In case of size progression or symptoms, reoperation should be considered.