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Permissible Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction

Petro, Clayton C. M.D.; Raigani, Siavash B.S.; Fayezizadeh, Mojtaba M.D.; Rowbottom, James R. M.D.; Klick, John C. M.D.; Prabhu, Ajita S. M.D.; Novitsky, Yuri W. M.D.; Rosen, Michael J. M.D.

Plastic and Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 868–881
doi: 10.1097/PRS.0000000000001621
Reconstructive: Trunk: Original Article
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Background: Repair of hernias with loss of domain can lead to elevated intraabdominal pressure. The authors aimed to characterize the effects of elective hernia repair on intraabdominal pressure, as well as its predictors and association with negative outcomes.

Methods: Patients undergoing elective hernia repair requiring myofascial release had intraabdominal and pulmonary plateau pressures measured preoperatively, postoperatively, and on the morning of the first postoperative day. Loss of domain was measured by preoperative computed tomography. Outcome measures included predictors of an increase in plateau pressure, respiratory complications, and acute kidney injury.

Results: Following 50 consecutive cases, diagnoses of intraabdominal hypertension (92 percent), abdominal compartment syndrome (16 percent), and abdominal perfusion pressure less than 60 mmHg (24 percent) were determined. Changes in intraabdominal pressure (preoperative, 12.7 ± 4.0 mmHg; postoperative, 18.2 ± 5.4 mmHg; postoperative day 1, 12.9 ± 5.2 mmHg) and abdominal perfusion pressure (preoperative, 74.7 ± 15.7; postoperative, 70.0 ± 14.4; postoperative day 1, 74.9 ± 11.6 mmHg) consistently resolved by postoperative day 1, and were not associated with respiratory complications or acute kidney injury. Patients who remained intubated postoperatively for an elevation in pulmonary plateau pressure (≥6 mmHg) all demonstrated an improvement in plateau pressure by postoperative day 1 (preoperative, 18.9 ± 4.5 mmHg; postoperative, 27.4 ± 4.0 mmHg; postoperative day 1, 20.1 ± 3.7 mmHg), and could be identified preoperatively as having a hernia volume of greater than 20 percent of the abdominal cavity (p < 0.001), but were still more likely to have postoperative respiratory events (p = 0.01).

Conclusions: Elevated intraabdominal pressure following elective hernia repair requiring myofascial releases is common but transient. Change in plateau pressure by 6 mmHg or more following repair can be expected with a loss of domain greater than 20 percent and is a more useful surrogate than intraabdominal pressure measurements with regard to predicting postoperative pulmonary complications. The perception and management of elevated intraabdominal pressure should be considered distinct and “permissible” in this context.

Cleveland, Ohio

From the Case Comprehensive Hernia Center and the Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center.

Received for publication November 6, 2014; accepted March 26, 2015.

Presented at the 16th American Hernia Society Annual Hernia Repair Meeting, in Las Vegas, Nevada, March 12 through 15, 2014, Fruchaud Award for Best Poster Presentation.

Disclosure: None of the authors has financial disclosures or commercial associations that would potentially create a conflict of interest with information presented in this article.

Clayton C. Petro, M.D., Department of General Surgery, 11100 Euclid Avenue, 7th Floor Lakeside, Cleveland, Ohio 44106, clayton.petro@uhhospitals.org

©2015American Society of Plastic Surgeons