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Special Commentary on Kirkpatrick et al. Intra-Abdominal Hypertension and Abdominal Compartment Syndrome after Abdominal Wall Reconstruction:Quaternary Syndromes?

Kirkpatrick AW, Michael Sugrue, Michael Rosen, Chad Ball and Frederik Berrevoet

Reconstruction with reconstitution of the container function of the abdominal compartment is increasingly being performed in patients with massive ventral hernia previously deemed inoperable. This situation places patients at great risk of severe intra-abdominal hypertension (IAH) and the Abdominal Compartment Syndrome (ACS) if organ failure ensues. IAH and especially ACS may be devastating systemic complications with systematic and progressive organ failure and death. Surgeons should thus consider and carefully measure intraabdominal pressure (IAP) and its resultant effects on respiratory parameters and function during abdominal wall reconstruction (AWR). The IAP post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate IAP rise after AWR including temporizing paralysis of the musculature either temporarily or semipermanently, pre-operative progressive pneumoperitoneum, permanently removing visceral contents, or surgically releasing the musculature to increase the abdominal container volume. In patients without complicating shock and inflammation, and in whom the abdominal wall anatomy has been so functionally adapted to maximize compliance, IAH may be transient and tolerable. IAH/ACS in the specific setting of AWR without other complication may be considered as a quaternary situation considering the classification nomenclature of the Abdominal Compartment Society. Greater awareness of IAP in AWR is mandatory and on-going study of these concerns is required.