AMT, vol. 20, no. 2 , 2015, p. 84 CAUSES OF FAILURE IN ABDOMINAL WALL DEFECTS SURGERY ELENA VIOLETA RADU1, RUXANDRA DIANA SINESCU2, OANA ILONA… [613857]

CLINICAL ASPECTS

AMT, vol. 20, no. 2 , 2015, p. 84 CAUSES OF FAILURE IN ABDOMINAL WALL DEFECTS
SURGERY

ELENA VIOLETA RADU1, RUXANDRA DIANA SINESCU2, OANA ILONA DAVID3, IONUȚ
SIMION COMAN4, DAN NICOLAE STRAJA5, MIHAI POPESCU6, IOAN PETRE FLORESCU7,
VALENTIN TITUS GRIGOREAN8

1,3,4“Bagdasar Arseni” Emergency Hospital Bucharest , 2,5,7,8“Carol Davila” University of Medicine and Pharmacy Bucharest, 6University of Pitești

Keywords:
parietal defect,
alloplastic material

Abstract: Abdominal wall defects occupy one of the leading places in the general surgery wards and
tend to grow in recent years. Parietal defects are not always a pathology easy to approach because the
abdomi nal wall reconstruction may result in total or partial failure intraoperatively or postoperatively.
Parietal defects reconstruction failure may be influenced by factors related to the patient’s biological
and general status (congenital anomalies, ascitic d ecompensation, gender etc), factors related to the
surgical act itself (septic contamination, tissue changes, failure to follow the correct sequence of the
surgical steps, alloplastic material) or a combination of the two categories which we called
“border line” failure factors (parietal hematoma, parietal suppuration, alloplastic material rejection,
etc). The probability of surgical failure in the abdominal wall defects pathology increases with the
parietal defect size, the urgency degree and the more unpre pared patient, therefore the surgical
indication is so prevalent in the chronic regimen.

2Corresponding author: Ruxandra Diana Sinescu, B-dul. Dionisie Lupu, Nr . 37, București, România, E-mail: ruxandrasinescu @gmail.com , Phone:
+40722 545830
Article received on 05.03.2015 and ac cepted for publication on 26.05.2015
ACTA MEDICA TRANSILVANICA June 2 015;20(2):84 -86
Starting from Dr. M. Rosen statement – “If 50 years
ago, Prof. Rives called hernia a breach in the abdominal wall,
today we consider hernia as the start of an abdom inal drama”,
abdominal wall defects occupy one of the leading places in
frequency in the general surgery departments, which
demonstrates the importance of this pathology for the surgeon
and especially its socio -economic implications.(1)
The failure of the surgical treatment followed by the
possible postoperative complications and/or surgical
reinterventions leads to increased hospitalization, late social
reintegration, prolonged postoperative recovery and, subsequent,
higher costs.
Abdominal wall defects are usually associated with
other comorbidities and unfavourable local factors may
subsequently lead to a failure of the parietal surgery.(2)
An important aspect of this pathology is the increased
risk of postoperative complications, initially locallz – from
seromas in the postoperative wound, thread granulomas, wound
dehiscence, etc. up to incarceration, strangulation, enteral
fistulas, adhesion syndromes and later, bowel obstructions.
Although the pathology is initially located at the abdominal
wall, it may finally lead to systemic complications, sometimes
irreversible.(3)
The probability of surgical failure in the abdominal
wall defects pathology increases with the size of parietal defect,
the urgency degree and the more unprepared patient, both in
gene ral terms (decompensated cardiac pathology, severe
metabolic disorders etc.) and also, in a digestive point of view
(filled bowel loops, in bowel obstruction). These are some of the
reasons why surgical indication in chronic regimen is wide, with
appropria te preoperative preparation of the patient. Acc ording to
Prof. Dr. Rădulescu, “no parietal defect is too small to be
operated”.(4) We classified the failure factors of parietal defects
surgery in three main categories: patient’s biological and general status related failure factors, surgical act relate d failure factors
and “borderline” failure factors.
1. Patient’s biological and general status related
failure factors
With an increased incidence, congenital anomalies
(omphalocele, gastroschisis, congenital umbilical and inguinal
hernia etc.) are primari ly parietal defects or may be
subsequently determining factors that may favour an abdominal
wall defect due to an insufficient resistance of the abdominal
wall at the exercised intraabdominal pressure.
Prenatal ultrasound has a high sensitivity in the
diagnosis of these anomalies from the first trimester of
pregnancy.(5)
Collagen diseases and changing the type I
collagen/type III (immature) collagen ratio causes the formation
of lower quality connective tissue. This favours the appearance
of hernia associ ated with another condition where the collagen
pathology is suspected (osteogenesis imperfecta, joint
hyperlaxity. etc).(4)
Consumptive diseases are also included in the risk
factors category, being able to determine the apparition of
parietal defects. Fo r example, we encounter acute or chronic
inflammatory disorders, neoplastic diseases, cardiovascular
disorders, all of them affecting the nutrition of the abdominal
wall.(6,7,8)
Ascitic decompensation of cardiac or hepatic origin
causes major electrolyte imbalances, which affects the quality of
the entire abdominal wall from the peritoneum to the skin. This
thickened, edematous abdominal wall has a poor quality (figure
no. 1).
Increased duration of the surgical interventions in
patients with multiple comor bidities seems to play an important
negative role over the reconstruction of the abdominal wall.(9)
Gender, by specific anatomical particularities in

CLINICAL ASPECTS

AMT, vol. 20, no. 2 , 2015, p. 85 women (larger pelvic transverse diameter), explains the
frequency of the femoral hernias in this genre.

Figure no. 1. CT examination of a cirrhotic patient with an
abdominal wall defect

2. Surgical act related failure factors
Septic contamination is a major failure factor in the
abdominal wall surgery. The rehabilitation measures of the
abdominal wall sep tic foci represent a priority. However, there
is a possibility of accidental intraoperative discovery of
microabscesses, thread granulomas, especially in case of
reinterventions.
The operative wound becomes contaminated, scarring
will be difficult and the use of alloplastic material is not
recommended in the reconstruction of the abdominal wall. Local
infections of the abdominal wall after laparotomy have a
percentage of 5 -10% and if not evacuated in short time and are
not responding to appropriate antibio tic treatment, they can
create real problems in the integrity of the abdominal wall.(10)
Tissue changes occurred after repeated surgical
interventions in the abdominal area, especially in case of large
eventrations which require alloplastic material (11), give rise to
a modified, fibrous, retractable tissue, with multiple adhesions.
(figure no. 2). Extending the resection of these tissues is difficult
to assess and the scaring process is sometimes questionable.
Failure to follow the correct sequence of the surgical steps can
cause visceral lesions, especially in case of eventrations and
eviscerations, where the adherence process is more intense and
the possibility of iatrogenic damage is higher. The surgical
technique itself may be a cause of failure, somet imes too large
anatomical incisions can cause an iatrogenic parietal defect.
Median and transverse incisions lead to similar occurrence rates
of parietal defects.(12)

Figure no. 2. Fibrosis after insertion of alloplastic material

Inadequately used allop lastic material can be a major
cause of surgical failure. Parietal alloplasty as a principle of
surgical treatment of the inguinal hernia was first introduced by
Prof. Dr. Rives in 1966 and represents the “gold standard”
procedure.(13)
A microporous prost hesis (shrinkage) of small dimensions can suffer a disinsertion from the muscle –
aponevrotic layer due to increased parietal pressure and can
migrate from the original site, causing a decreased abdominal
wall resistance and a place for possible recurrence o f the parietal
defect.
Closing the abdominal wall in multiple layers favours
the occurrence of eventrations more than the closure in one
single layer, especially if inadequate suture materials in structure
and size are used. Sutures are responsible for th e first months of
postoperative wound integrity. Using a continuous thread is
useful for uniform distribution of tension in the wound, but its
failure can lead to the whole wound dehiscence. Successively
failed surgical techniques require finding new surgi cal solutions
tailored to the patient. The abdominal wall should not be closed
in excessive tension (figure no. 3).(14)

Figure no. 3. Tension in the graft material

3. “Borderline” failure factors
We take into consideration such factors when the
etiolog y of the surgical failure in case of a parietal defect is a
bad combination between the surgical act and the diseases of the
patient. One such example is the parietal hematoma occurred
due to inefficient intraoperative hemostasis and/or preexisting
vascula r pathology – antiplatelet or anticoagulant treatment.
Postoperative hematomas can be treated conservatively in small
dimensions but with prolonged hospitalization days (15), or may
require surgical reintervention for the completion of hemostasis.
Superfic ial or deep parietal suppuration is a feared
complication and can completely compromise the outcome of
the surgical intervention, especially in immunocompromised
patients. The suppuration is more serious when it appears in a
presence of a wall prosthesis a nd can ultimately determine the
surgical removal of the alloplastic material. One advantageous
solution could be the component separation technique, with the
advantage of the recovering of the white line for superior
functional outcome (figure no. 4).(16)

Figure no. 4. Abdominal wall abscess after rejection of the
alloplastic material

CLINICAL ASPECTS

AMT, vol. 20, no. 2 , 2015, p. 86 Rejection of the alloplastic material is a rare cause of
failure, but it can occur after an improper insertion of the
prosthesis or because of an allergy to one of the com ponents of
the prosthetic material. Graft rejection requires removal of the
graft, remediation of the septic local focus and rethinking the
parietal reconstruction.(17)
Postoperative intestinal fistula occurred, either due to
improper placement of the all oplastic material directly on the
visceral mass, or due to neoplastic background of the patient
with severe electrolyte imbalances , who underwent
radiotherapy, is an extremely serious complication which
predisposes to the destruction of the abdominal wall. Surgical
intervention focuses primarily on the digestive fistula, only
afterwards we consider the reconstruction of the abdominal wall.
Conclusions:
1. Parietal defects surgery tends to become an important
branch of general surgery, due to this increasingly complex
pathology, often associated with intraoperative or
postoperative complications.
2. Failure of the parietal defects reconstruction surgery
depends on the patient’s associated pathology and also on
the surgical act itself. One cannot always determine a limit
between these two causes of failure, sometimes there is a
combination of risk factors that subsequently leads to an
imperfect reconstruction of the abdominal wall parietal
defect.
3. The development of alloplastic materials with high
biocompatibility c reated the notion of “gold standard” and
reduced the risk of parietal defects recurrence.
Acknowledgement:
This article is sustained by the “Doctoral and
postdoctoral research – priority of the Romanian superior
education system (Doc -Postdoc)” project –
POSDRU/159/1.5/S/137390 .

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