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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 39-44

Quaternary abdominal compartment syndrome in complex ventral hernias

1 Department of Surgery, Pedro Hispano Hospital, Portugal
2 Colorectal and Abdominal Wall Surgery, Pedro Hispano Hospital; Department of Surgery, Lusíadas Hospital; Faculty of Medicine, Porto University, Portugal
3 Upper Gastrointestinal and Abdominal Wall Surgery, Pedro Hispano Hospital; Department of Surgery, CUF Hospital Porto; Faculty of Medicine, Porto University, Portugal

Date of Submission20-Oct-2020
Date of Decision20-Jan-2021
Date of Acceptance25-Jan-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Catarina Quintela
Department of Surgery, Hospital Pedro Hispano, Matosinhos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_43_20

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PURPOSE: Abdominal wall reconstruction (AWR) can lead to raised intra-abdominal pressure (IAP) in the postoperative setting. The term “quaternary abdominal compartment syndrome” (QACS) was recently proposed as an abdominal compartment syndrome in the particular setting of AWR that reverts with medical treatment. The aim of this report is to determine the incidence of QACS in our series, potential risk factors and the outcome of these patients.
METHODS: A retrospective study was conducted between 2010 and 2019 at our hospital, to identify patients with QACS after AWR and respective risk factors.
RESULTS: From a total of 115 patients, five were diagnosed with QACS, all being hernias with Loss of Domain (LOD) ≥20% and showing major renal and pulmonary impairment. Four patients had predictable transitory QACS, yet one patient died despite damage control surgery. A total of 19 patients had LOD ≥20%, 14 without QACS development and 5 with this entity. The most important finding between the groups was a significant variation in the Peak Respiratory Pressure (PRP) (measured before incision and intraoperatively), being higher in the QACS group (7.40 ± 1.34 vs. 3.77 ± 1.59; P < 0.001).
CONCLUSION: In this study, QACS was found to be a rare event, not always transitory. LOD ≥20% appeared as an important risk factor and PRP variations between 6 and 10 mmHg during fascial closure were a significant marker for adverse endpoints in AWR.

Keywords: Abdominal wall reconstruction, complex ventral hernia, intraabdominal hypertension, loss of domain, primary fascial closure, quaternary abdominal compartment syndrome, ventral hernia repair

How to cite this article:
Quintela C, Freire L, Marrana F, Barbosa E, Guerreiro E, Ferreira FC. Quaternary abdominal compartment syndrome in complex ventral hernias. Int J Abdom Wall Hernia Surg 2021;4:39-44

How to cite this URL:
Quintela C, Freire L, Marrana F, Barbosa E, Guerreiro E, Ferreira FC. Quaternary abdominal compartment syndrome in complex ventral hernias. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2023 Mar 24];4:39-44. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/2/39/317318

  Introduction Top

Ventral abdominal wall hernias occur in 11%–23% of all laparotomies.[1] The objective of surgical repair is to obtain a functional abdominal wall and to prevent morbidity and recurrence. Size, location, previous repairs, and patient comorbidities are factors that should be considered in hernia evaluation and require special attention during abdominal wall reconstruction (AWR). However, there is no consensus in the literature for the classification of complex hernias. Size is considered an important factor, but it is not the only one.[2],[3],[4] Slater et al.[4] described any of the following potential factors: size >10 cm, presence of enterocutaneous fistulae, multiple hernia defects, history of infected mesh, or loss of domain (LOD) >20%. The latter signifies that part of the bowel permanently resides within the hernia sac, which acts as a second abdominal cavity.[5] Restoring contents of the hernia sac to the abdominal cavity cannot easily be done without a significant risk of abdominal compartment syndrome (ACS).[6] Sabbagh et al. showed the hernia sac volume/abdominal cavity volume (HSV/ACV) <20% to be an independent factor significantly associated with tension-free fascia closure.[7]

ACS is defined as a sustained intraabdominal Pressure (IAP) >20 that is related with new organ dysfunction/failure. IAP is graded according to the World Society of ACS Grading (IAP from 12 to 15 mmHg is Grade 1, IAP from 16 to 20 mmHg is grade 2, IAP from 21 to 25 mmHg is grade 3, and IAP >25 mmHg is grade 4).[8]

Most recently,[9] intra-abdominal hypertension/ACS in the setting of AWR has been classified as a quaternary ACS (QACS). This new category is usually transitory with less pro-inflammatory mediators release and endothelial dysfunction when compared to recurrent or tertiary IAH/ACS.

The aim of this study is to determine the incidence of QACS in patients who undergo AWR, the evolution of these patients, as well as to predict potential risk factors.

  Methods Top

We performed a retrospective study that identified consecutive patients with complex ventral hernias, classified in accordance with Slater et al.,[4] undergoing advanced repair at Pedro Hispano Hospital, from January 2010 to December 2019.

Patient demographics, comorbidities, operative characteristics, including peak respiratory pressure (PRP), postoperative IAP, and complications were observed. PRP was measured after anesthetic induction (before skin incision) and after complete fascial closure (intraoperatively), with each patient deeply sedated and under neuromuscular blockade. Variation in PRP was calculated as the difference between these two measurements.

A total of 115 patients with complex ventral hernias were included in our cohort, 19 patients had LOD ≥20% and 5 were identified as developing QACS.

Loss of domain

Given that all patients that developed QACS had HSV/ACV ≥20% and since it has been reported as an important factor for ACS,[9] we chose to perform a comparative analysis in this particular patient subgroup.

LOD was estimated by the ratio of the HSV to ACV according to a formula described by Tanaka et al.[5] The formula is the product of height (a), width (b), and length (c) of a hernia sac or abdominal cavity by a constant to generate the volume of an ellipsoid ([a × b × c] ×0.52). Hernia sac and ACV were calculated preoperatively on computed tomographic scans, when available.

Surgical procedures

Anterior component separation according to Ramirez et al.,[10] posterior component separation with transverse abdominis muscle release (TAR)[1] or sandwich techniques[11] were performed. In one case, a Rives-Stoppa-Wantz approach was sufficient.

Preoperatively adjuvant use of botulinic toxin A (BTA),[12] preoperative progressive pneumoperitoneum (PPP)[13] or the combination of both were also recorded.


Intra-abdominal hypertension and ACS were identified after carefully reviewing patient files. We defined ACS according to the World Society of ACS above mentioned. Measurements of IAP during admission to the intensive care unit (ICU) and the highest values recorded were also registered. IAP was measure through a bladder catheter.

Acute kidney injury (AKI) was defined as either an increase in the serum creatinine levels by 0.3 mg/dl from above the patient's baseline or a reduction in urinary output of <0.5 ml/kg/h for in 6 h.[14]

For respiratory failure, we considered the cases, in which there was a prolonged need of mechanical ventilation, re-intubation, or non-invasive ventilation, unrelated to previous underlying lung disease.

Statistical analysis

All data were analyzed with the IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Categorical variables were expressed in the total number of individuals (percentage). Student's t-test and Fisher's exact test were used for comparison between continuous and categorical variables, respectively. All P values were considered statistically significant if < 0.05.

  Results Top

A total of 115 patients were included. The median age was 63 years (range 23–85) and the majority of the patients were male (58.3% vs. 41.7%).

We identified five patients with ACS after complex AWR, all having LOD ≥20%. In addition, 14 other patients had LOD ≥20% without QACS development.

Patient demographics and treatment characteristics

[Table 1] shows the features of both groups.
Table 1: Patient demographics and treatment characteristics

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The mean age was similar between groups (68.2 ± 8.1 and 62.9 ± 17.9). Most patients had at least one comorbidity (100% and 85.5%), hypertension being the most common. Chronic obstructive pulmonary disease, chronic kidney disease and active smoking at the time of surgery were not common in our series. There was no difference in The American Society of Anesthesiologists score. The average body mass index showed excess weight (26.9 kg/m2 ± 2.7 and 27.9 kg/m2 ± 5.1), with no differences between groups noted. The majority of these patients had previous hernia repairs, with the mean transverse size of the hernia defect of 16.8 cm ± 4.5 cm and 15.6 cm ± 4.9 cm (P = 0.634), respectively. The HSV/ACV ratio was 31.9 ± 7.8 and 39.6 ± 15.9 (P = 0.185). Posterior component separation with transverse abdominis muscle release was the most commonly performed technique. Bridging was performed in 3 patients, 1 in the QACS group (where a sandwich technique was performed), and 2 in the Non-QACS group (1 sandwich technique and 1 PCS with TAR were performed). No significant differences between groups were observed with respect to operative time, fluid administration, or urinary output. Preoperatively, an epidural catheter was placed in all patients. Although the difference failed to reach significance, the need of vasoactive drugs during surgery was higher in the ACS group (60% vs. 14.3% P = 0.084).

Risk and management of Abdominal Compartment Syndrome

The incidence of QACS after complex abdominal wall surgery was 4.3% (5/115), representing an incidence of 26.3%, among those patients with LOD ≥20%.

[Table 2] compares Operative characteristics, pressures and complications in ACS e Non-ACS groups. PRP was recorded after the induction of anesthesia (preoperatively) and following fascia closure (immediate postoperative). We found a significant difference in PRP variation (7.4 ± 1.3 vs. 3.7 ± 1.6 P = 0.001). ICU admission occurred in 3 (60%) in the ACS group, 2 intubated and one with need for re-intubation consequently to respiratory failure. In the non-ACS group, the 2 (14.3%) patients admitted to the ICU, both were intubated. The other patients (2 at from the ACS group and 1 at non-ACS group) who had measures of IAPs were admitted to an intermediate care unit.
Table 2: Operative characteristics, pressures and complications in ACS e Non-ACS grups

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The highest maximum IAP was 24 mmHg in the ACS group and 18 mmHg in the non-ACS group. In this last group, the higher IAP matched the IAP at admission. In the ACS group, maximum IAP occurred in the first 48 h after surgery.

Renal and respiratory failure were the most common dysfunctions associated with increase of abdominal pressure.

In the ACS group, 4 patients improved toward resolution with aggressive medical treatment according to the guidelines of WSACS.[8] Although we could not able to determine the exact time at which the IAP began to decrease, we verified that after 60 h of surgery, all these patients had normalized in terms of IAP pressure. Nonetheless, one patient presented with progressive respiratory and acute renal failure, requiring hemodialysis. Owing to exacerbation of dysfunctions despite aggressive medical treatment, a decompressive laparotomy was performed on the postoperative day 3. During procedure, segmental bowel ischemia was found and resected. Despite all efforts, the patient died a few hours later owing to disseminated intervascular coagulation (DIC).

  Discussion Top

AWR restitutes hernia content to the abdominal cavity. Compliance is defined by the capacity of the abdominal cavity to store the hernia content without tension and is closely associated with both the abdominal volume (AV) and the distensibility of the abdominal wall.[9] If compliance is not attainable, the IAP increases.

The incidence of intra-abdominal hypertension following AWR can reach 92%, while QACS tallies around of 16%.[15] In most cases, increased pressure is temporary and decreased spontaneously to baseline levels within 24 hours[15] or at postoperative day 2.[16] In this retrospective study, we cannot guarantee that we obtained the real incidence of IAH, since the measurement of IAP was not reported in every case, even in those admitted to ICU or intermediate care unit. Nonetheless, the IAP was measured in all patients presenting with associated organ dysfunction, which represents a low incidence percentage (4.3%) of QACS in all patients submitted to AWR. On the other hand, this incidence is substantially increased in those with LOD ≥ 20% (26.3%), thus reinforcing this aspect as an important risk factor for QACS.[7],[15]

In the present review, some patients with LOD ≥20% did not require postoperative ventilator support. This can be partly explained by the use of adjuvant preoperative techniques that maximize abdominal compliance. In our retrospective study, some patients had AWR before the widespread accessibility to these techniques, yet some did not develop QACS, owing to individual factors aiding to withstand these variations in pressure.

We found significant differences among groups in PRP variation and approximately 7 mmHg was observed in the ACS group. These corroborate a study that demonstrated that the measurement of plateau pressure variation of >6 mmHg was a better surrogate predictor of postoperative pulmonary complications after the abdominal wall repair than IAP.[15] These two measures of ventilation are different: plateau pressure reflects the pulmonary compliance, (being measured after end-inspiratory pause); whilst the PRP is measured in the presence of gas flow and is influenced by upper airway resistance. However, in the perioperative context, variations in PRP occurred due to raised abdominal pressure, and as long as the patient had no airway impairment, this may also be used to monitor pressure variation instead of plateau pressure.

Changes in pulmonary and renal function were the most common findings associated with IAH. Petro et al.,[15] described that the incidence of respiratory complications was 12% and that AKI was 20%, with none requiring renal replacement. In the present review, one patient required hemofiltration, culminating in an unfortunate death a few hours after damage control surgery.

The transitory nature of QACS has been reported and conservative management has been the usual norm.[15],[16],[17],[18] However, we previously referred, we had witnessed a case that required surgical management due to maintained IAH and progressive organ failures. Despite a decompressive laparotomy, a fatality occurred, raising the question of whether this intervention was too late to reverse the onset of dysfunctions. Sustained IAH that does not resolve after up to 48 h should alert the surgeons for the presence of more severe organ dysfunctions due to less transitory ACS after AWR or tertiary ACS resulting from postoperative complications.[9],[16] In the absence of reversed IAP and maintained organ dysfunction, 24–48 h after AWR surgery, our group strongly recommends reviewing the abdomen in the operating theatre.

To prevent a pathological increase in IAP after hernia repair, we should preoperatively identify those with an increased risk of QACS, including not only those with LOD ≥20% but also account for other situations where abdominal compliance can be hindered (such as major sized hernias and myofascial fibrosis) or decreased pulmonary capacity. Two techniques have been reported to increase abdominal compliance, BTA and PPP. In our institution, we occasionally used both together. BTA induces a temporary flaccid paralysis of the abdominal wall muscles.[19] In a randomized study in rats, volume gain was approximately 20%.[18] In humans, this results in a mean hernia defect decrease[12] and higher fascial closure rate, reducing extensive dissection of component separation.[20] PPP consists of inflation of volumes of air into the abdominal cavity, leading to muscular stretching and a lower HSV/ACV ratio. PPP allows for a higher rate of tension-free fascia closure, without muscle disruption[7],[21] and improves the respiratory adaptation to AV.[22],[23]

Component separation techniques also allowed for a tension-free primary fascial closure, resulting in lower pressures and thereby avoiding end-organ damage.[23] After 2014,[1] we preferred a posterior component separation with transversus abdominis muscle release. An anterior component separation[10] was usually performed in the 1st years of this study. In one patient, PPP and BTA administration allowed for a Rives-Stoppa-Wantz technique.

Based on these results, we can hypothesize that during abdominal closure variations of PRP between 1 and 3 can be admitted to a regular surgical ward. PRP variations of 4 and 5 can be admitted at to an intermediate care unit if major comorbidities exist. PRP variations >6 require admission to an ICU, intubated, with selective analgesia, nasogastric tube decompression and regular IAP measurements. PRP variations ≥10 impede complete fascial closure bridging between fascial edges, until the PRP <10.

The review of these extreme cases of hernias had obvious limitations. First, the sample is small thus hindering the establishment of a risk factor for ACS with complete accuracy.

Secondly, due to the retrospective nature of this study, we cannot access the real incidence of intraabdominal hypertension after hernia repair. Ideally, a prospective study, including an established protocol for all measurements (PRP; plateau pressure; IAP) would allow to obtain a more reliable incidence and, a more detailed description of the risk factors for QACS.

  Conclusion Top

QACS was a rare event in our series. LOD appeared to be an important risk factor and PRP variations between 6 and 10 mmHg was a marker for worse yet limited endpoints. During AWR, these complex hernias may ultimately require bridging, on demand, until PRP is <10 mmHg to avoid a highly lethal ACS during the postoperative period.

To the best of our opinion, these are the key points to retain:

  • PRP variations between 6 and 10 mmHg may signal a worse prognosis. Higher values appear prohibitive for primary ventral hernia closure and in these cases, bridging is proposed
  • Intensive postoperative surveillance and monitoring of these risk patients should be mandatory
  • IAP and dysfunctions that do not resolve within the first 24–48 h after AWR should alert surgeons and intensivists for severe complications that may require a lifesaving decompressive laparotomy.

Ethical approval

This study was approved by the local ethical committee (IRB#: 95/20/RS, 2020/07/01, The Department of Knowledge).

Consent for publication

Written informed consent for the publication was obtained from all study participants. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Petro CC, O'Rourke CP, Posielski NM, Criss CN, Raigani S, Prabhu AS, et al. Designing a ventral hernia staging system. Hernia 2016;20:111-7.  Back to cited text no. 3
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  [Table 1], [Table 2]


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