Intra-Abdominal Hypertension and Abdominal Compartment Syndrome after Abdominal Wall Reconstruction: Quaternary Syndromes?
Reconstruction with reconstitution of the container function of the abdominal compartment is increasingly being performed in patients with massive ventral hernia previously deemed inoperable. This situation places patients at great risk of severe intra-abdominal hypertension (IAH) and the Abdominal Compartment Syndrome (ACS) if organ failure ensues. IAH and especially ACS may be devastating systemic complications with systematic and progressive organ failure and death. Surgeons should thus consider and carefully measure intraabdominal pressure (IAP) and its resultant effects on respiratory parameters and function during abdominal wall reconstruction (AWR)
The IAP post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate IAP rise after AWR including temporizing paralysis of the musculature either temporarily or semipermanently, pre-operative progressive pneumoperitoneum, permanently removing visceral contents, or surgically releasing the musculature to increase the abdominal container volume. In patients without complicating shock and inflammation, and in whom the abdominal wall anatomy has been so functionally adapted to maximize compliance, IAH may be transient and tolerable. IAH/ACS in the specific setting of AWR without other complication may be considered as a quaternary situation considering the classification nomenclature of the Abdominal Compartment Society. Greater awareness of IAP in AWR is mandatory and on-going study of these concerns is required.
The seemingly unique behaviour of “permissive IAH’ after uncomplicated AWR is a novel concept to consider especially as this is in distinction to the other classifications of primary, secondary, and recurrent IAH that have been described by the former world society of the Abdominal Compartment Syndrome . The epidemiology of post-injury ACS has dramatically changed in the last decade, largely related to dramatic changes in resuscitation and the adoption of high colloid, blood-product and low crystalloid based resuscitation strategies. With perspective, it has become apparent that any overt ACS, whether primary, secondary, or tertiary, was largely related to crystalloid resuscitation and that with more rational practices, overt ACS is becoming less common clinically . However, as quaternary IAH/ACS is not typically resuscitation related conditions there are more rationale to classify them separately.
Thus, reviewing the newly appreciated science and physiology of abdominal wall reconstruction as a distinct body of work is closely congruent with the mission of the Abdominal Compartment Society to formally appreciating the abdominal compartment as a whole within all the body’s inter-related compartments . Such combined considerations of abdominal physiology with anatomy, surgical technique, and post-operative care are what attendees at the 8th World Congress of the Abdominal Compartment Society in Banff, Alberta, Canada, in June 2017 (https://www.wcacs2017.org), will learn and discuss further.
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