Intra-Abdominal Hypertension and Abdominal Compartment Syndrome after Abdominal Wall Reconstruction: Quaternary Syndromes?

BACKGROUND AND AIMS: 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 and abdominal compartment syndrome if organ failure ensues. Intra-abdominal hypertension and especially abdominal compartment syndrome may be devastating systemic complications with systematic and progressive organ failure and death. We thus reviewed the pathophysiology and reported clinical experiences with abnormalities of intra-abdominal pressure in the context of abdominal wall reconstruction. MATERIAL AND METHODS: Bibliographic databases (1950-2015), websites, textbooks, and the bibliographies of previously recovered articles for reports or data relating to intra-abdominal pressure, intra-abdominal hypertension, and the abdominal compartment syndrome in relation to ventral, incisional, or abdominal hernia repair or abdominal wall reconstruction. RESULTS: Surgeons should thus consider and carefully measure intra-abdominal pressure and its resultant effects on respiratory parameters and function during abdominal wall reconstruction. The intra-abdominal pressure post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate intra-abdominal pressure rise after abdominal wall reconstruction including temporizing paralysis of the musculature either temporarily or semi-permanently, 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, intra-abdominal hypertension may be transient and tolerable. CONCLUSIONS: Intra-abdominal hypertension/abdominal compartment syndrome in the specific setting of abdominal wall reconstruction without other complication may be considered as a quaternary situation considering the classification nomenclature of the Abdominal Compartment Society. Greater awareness of intra-abdominal pressure in abdominal wall reconstruction is required and ongoing study of these concerns is required.

Comparison of intermittent and continuous intra-abdominal pressure monitoring using an in vitro model.

INTRODUCTION: Intra-abdominal pressure (IAP) is increasingly being considered as an important physiologic parameter to be measured in critically ill patients. Traditional methods of monitoring IAP rely on intermittent IAP (IIAP) measurements using indwelling bladder catheters. Recently, a method of continuous IAP (CIAP) monitoring has been developed using a three-way bladder catheter. This study evaluates the reliability of IIAP and CIAP measurement techniques using an in vitro model. METHODS: An in vitro model of the abdomen was constructed using a 50 l container with a 100 ml infusion bag at the base to simulate a bladder. A three-way catheter tip was centered within the infusion bag filled with 50 ml saline. To simulate IAP the container was filled with water at 5 cm H(2)O increments from 10 to 25 cm H(2)O. Pressures were recorded by observers from a bedside monitor interfaced with a three-way Foley catheter using alternating intermittent and continuous techniques. Each subject was blinded to the known pressure values. Descriptive statistics and a generalised estimating equation (GEE) was used to describe the relationship of IIAP and CIAP to known pressures. RESULTS: One hundred and thirty-two (132) observations were made by 20 subjects for both IIAP and CIAP estimates. In 45.5% of IIAP measures, the estimate was correct, and it was never more than 1 cm H(2)O different from the actual. Similarly, in 38.6% of CIAP measures, the estimate was correct, and was never more than 2 cm H(2)O from the actual. The GEE regression coefficients comparing known pressures with IIAP and CIAP were 1.007 and 0.976 respectively. The minimum and maximum pressure deviations never exceeded more than 1.3 cm H(2)O from the actual. CONCLUSION: Intermittent IAP and CIAP are both reliable and reproducible methods to measure IAP in an in vitro model. There exists a direct and significant association between both measurements and the actual value. Neither measure was shown to be superior.