Ventral hernia repair surgery after abdominal gunshot wound

Abstract

Gunshot wounds to the abdomen frequently result in significant damage to the abdominal organs, which is accompanied by peritonitis and the further development of different complications (anastomotic leakage, formation of abscesses, repeated bleeding, etc.), which require repeated surgical interventions that contribute to the formation of postoperative ventral hernias. The surgical management of ventral hernias is challenging due to severe adhesion in the abdominal cavity (irrespective of the time period since the injury and the last surgical interventions), the difficulties in closing massive defects of the muscle‑aponeurotic component of the anterior abdominal wall, contracture of the anterior abdominal wall, and the development of the abdominal compartment syndrome in the postoperative period. As a result, there is still some debate over the best surgical treatment for postoperative ventral hernias.

Objective — to carry out a comparative analysis of open and video‑assisted laparoscopic operations for the selection of the most optimal surgical strategy for the management of ventral hernias after gunshot wounds to the abdomen.

Materials and methods. We analyzed the surgical treatment of 45 wounded patients with postoperative ventral hernias that developed after operations for abdominal gunshot wounds. The patients were treated at the Military Medical Clinical Center of the Southern Region (Odesa) from 2014 to 2021; 32 of them had penetrating gunshot wounds, and 13 patients had a closed gunshot wound to the abdomen with injuries to the abdominal organs. 66.7 % of those injured had one operation on their abdominal organs, 22.2 % had two operations, 6.7 % had three operations, and 4.4 % had five operations. The size of the hernia orifices and severity of recurrence risk were determined according to the SWE classification: W1 (width of the hernia orifices up to 4 cm) — 28.9 %, W2 (from 4 to 10 cm) — 44.4 %, and W3 (over 10 cm) — 26.7 % of patients. The patients who had laparoscopic hernia repair (LHR) (IPOM‑Plus method — 17 patients, sIPOM — 2 patients) belonged to the LHR group (n = 19). The patients who had open hernia repair (OHR) (IPOM‑Plus method — 7 patients, sublay technique — 11 patients, onlay technique — 8 patients) were added to the OHR group (n = 26). The patients of both groups did not statistically differ by age, nature of a gunshot injury, number of operations before hernia repair, or hernia parameters (all p > 0.05).

Results. Postoperative hernias after gunshot wounds are associated with pronounced adhesions in the abdominal cavity. The mean value of the peritoneal adhesion index averaged 11.7 ± 0.7 points (from 5 to 23 points) and did not statistically differ between groups: in the OHR group — 12.4 ± 0.9 points, in the LHR group — 10.8 ± 0.9 points (p = 0.339). Laparoscopic and open hernia repair in injured patients did not differ in the frequency of intraoperative complications — 19.2 % and 15.8 %, respectively (p = 0.766). There were fewer postoperative complications (10.5 % vs. 38.5 %, p = 0.036), a shorter operation duration — 79.5 ± 6.8 min vs. 105.9 ± 4.7 min, p = 0.002, a shorter bed‑day — 8.6 ± 0.4 days vs. 10.8 ± 0.5 days, p = 0.004, and fewer patients required narcotic analgesics within the first two days after surgery (p < 0.05). During the one‑year follow‑up, no hernia recurrence or adhesion signs were detected in the groups.

Conclusions. In the structure of postoperative ventral hernias after gunshot wounds to the abdomen, patients with open gunshot injuries predominate and amount to 71.1 % (р = 0.007). Among them, patients with combined and multiple wounds make up 65.6 %, while those with isolated wounds make up 34.4 % (р = 0.112); 33.3 % of patients require more than one operation before hernia repair. The laparoscopic IPOM‑Plus technique should be considered the operation of choice in the treatment of hernias after gunshot wounds to the abdomen. At the same time, for extensive cosmetic defects of the anterior abdominal wall, open operations are preferable, especially the IPOM‑Plus technique. If this is technically impossible, a sublay or onlay hernia repair using the tension‑free allohernioplasty technique should be performed.