Fatal abdominal compartment syndrome following reduction of long-standing diaphragmatic hernia: Expanding the concept of loss of domain beyond ventral hernias—A case report

Abstract

Loss of domain (LOD) is a recognized concept in complex ventral hernia surgery but has received limited attention in the context of diaphragmatic hernia repair. Failure to recognize this physiology may precipitate catastrophic intra-abdominal hypertension and abdominal compartment syndrome (ACS). Here, we report a case of a 21-year-old male with a long-standing left-sided diaphragmatic hernia who presented for elective surgical repair. Diagnostic laparoscopy revealed a left diaphragmatic hernia containing the stomach, transverse colon, and omentum. Notable abdominal wall rigidity noted during insufflation suggested reduced abdominal compliance and possible functional LOD. Due to technical difficulties, the procedure was converted to an open bilateral subcostal approach. Following the reduction of herniated contents, the diaphragmatic defect was repaired primarily and reinforced with prosthetic mesh. However, primary abdominal closure was not feasible because of a markedly contracted and noncompliant abdominal cavity. Temporary abdominal closure using a Bogota bag was performed. Following postoperative failure of the Bogota bag, re-exploration and negative pressure-assisted abdominal closure were attempted. The patient developed progressive bowel edema and persistent abdominal compartment physiology despite intensive care support and repeated closure attempts. The condition remained refractory to intervention, and the patient expired on postoperative day 21. This case represents an extreme form of functional LOD in diaphragmatic hernia, where reintegration of chronically displaced viscera exceeds abdominal cavity compliance. Preoperative volumetric assessment, progressive pneumoperitoneum, botulinum toxin A, and staged reconstruction may be valuable in selected cases. Recognition of LOD physiology and adoption of a physiology-based rather than purely anatomical approach may help prevent fatal ACS following diaphragmatic hernia repair.