# Case Report: Intraoperative Fascial Traction for Increasing Intra-Abdominal Volume in Loss-of-Domain Incisional Hernias: A Report of Two Cases

## TL;DR

This case report describes using intraoperative fascial traction to safely repair complex hernias with reduced abdominal space, offering a promising new surgical technique.

## Contribution

The paper introduces intraoperative fascial traction as a novel technique for managing incisional hernias with loss of domain.

## Key findings

- Intraoperative fascial traction successfully increased intra-abdominal volume in two patients with loss of domain.
- The technique facilitated primary fascial closure without serious complications in both cases.
- IFT shows potential to reduce risks of intra-abdominal hypertension and compartment syndrome.

## Abstract

The primary goal in incisional hernia repair is achieving primary fascial closure and reinforcing the area with a synthetic mesh. However, when Loss of Domain (LoD) is present, serious complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may arise. Various strategies have been employed to overcome these challenges and increase the reduced intra-abdominal volume, including preoperative botulinum toxin (BTA) injection, progressive pneumoperitoneum (PPP), various component separation techniques, and their combinations. Intraoperative fascial traction (IFT) has recently been added to this armamentarium. The two cases presented here aim to demonstrate the potential benefits of this innovative technique and offer a different perspective to surgeons dealing with such challenging cases.

The two patients presented here had previously undergone open umbilical hernia repair with mesh—one 17 years ago and the other 5 years ago—both of whom experienced recurrence and developed LoD over time. In both cases, IFT was successfully performed, resulting in an uneventful recovery.

The repair of incisional hernias accompanied by LoD presents significant challenges. In managing these cases, it is essential not only to optimise the patient preoperatively but also to employ interventions aimed at increasing intra-abdominal volume. In recent years, the intraoperative fascial traction (IFT) technique has emerged as a valuable tool in complex incisional hernia repairs. This technique not only facilitates primary fascial closure but also significantly increases intra-abdominal volume, potentially reducing the risks associated with intra-abdominal hypertension and compartment syndrome.

IFT offers promising advantages in the repair of incisional hernias with LoD, as it addresses the dual challenge of achieving primary fascial closure and restoring intra-abdominal volume. The two cases presented highlight the potential of this innovative technique in achieving successful outcomes. However, further research and larger studies are needed to fully establish its efficacy and long-term benefits in this challenging patient population.