A Preoperative Algorithm for Loss of Domain Hernia Repair: Stratified Management Using the Tanaka Index in 50 Cases

Loss of domain (LOD) in incisional hernias presents a significant challenge in abdominal wall reconstruction. Preoperative preparation of the abdominal wall is crucial to optimize surgical outcomes and prevent abdominal compartment syndrome (ACS). This study aims to develop an algorithm for selecting appropriate patients to undergo preoperative strategies based on the severity of LOD, measured by the Tanaka Index (TI).

We conducted a prospective study analyzing 50 cases of LOD hernias from a total of 558 incisional hernias treated over a 3-year period (2021-2024). Inclusion criteria were patients aged ≥18 years with a Tanaka Index (TI) > 0.25 who consented to surgery. For cases with TI between 0.25 and 0.30, we performed component separation using the Transversus Abdominis Release (TAR) technique, between 0.31 and 0.35 TAR with peritoneal flap reinforcement. In cases where TI exceeded 0.35, we implemented a structured preoperative preparation protocol involving botulinum toxin (BT) injections and progressive preoperative pneumoperitoneum (PPP) before proceeding with TAR and peritoneal flap reinforcement intraoperatively. In all groups, abdomen was reinforced with a 30 × 30 polypropylene mesh.

The efficacy of these techniques was assessed using both intraoperative and postoperative parameters. Intraoperatively, peak airway pressures (Ppeak and Pplateau) were measured immediately after intubation and after abdominal wall closure. An increase in these pressures was used as an indicator of potential ACS risk. Postoperatively, intra-abdominal pressure was vigilantly monitored using a Foley catheter with serial readings recorded. Among the 50 cases following the algorithm, only two developed elevated intra-abdominal pressures (19 cm H₂O and 18 cm H₂O or 14 mmhg and 13.2 mmhg respectively) on postoperative day 0, which normalized by day 3. 6% cases experienced surgical site infections in the immediate postoperative period, and there were no recurrences during a standard 1-year follow-up.

This feasibility study establishes a structured algorithm for managing LOD hernias, tailoring preoperative preparation based on the severity of domain loss rather than standardizing it to all cases. By incorporating intraoperative airway pressure monitoring and postoperative intra-abdominal pressure surveillance, we successfully minimized ACS risk. The proposed approach optimizes fascial closure rates, reduces postoperative morbidity, and demonstrates favorable long-term outcomes.