Loss of domain in complex ventral hernia: Volumetric assessment, prehabilitation, and algorithm-based surgical management
Manivannan Gnaneshvar, Rajendran TheakarajanAbstract
BACKGROUND:
Loss of domain (LOD) in complex ventral hernia (CVH) poses a major surgical challenge due to volumetric imbalance between the hernia sac and abdominal cavity, risking intra-abdominal hypertension and abdominal compartment syndrome. Management strategies remain heterogeneous.
MATERIALS AND METHODS:
This narrative review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews framework. A systematic search of PubMed, Embase, and Scopus identified studies published up to January 2026 using terms including “loss of domain,” “complex ventral hernia,” “Tanaka index,”“Sabbagh ratio,” “CT volumetry,” “botulinum toxin,”“progressive pneumoperitoneum,” “component separation,” “Fasciotens,” and “robotic abdominal wall reconstruction.” Two authors independently screened the titles and abstracts. The included studies comprised consensus statements, systematic reviews, meta-analyses, and cohort studies with ≥ 20 patients. Case reports, editorials, and non-English studies were excluded. Findings were synthesized descriptively.
RESULTS:
Computed tomography volumetry is the diagnostic gold standard for quantifying LOD. A Tanaka index > 25% and Sabbagh ratio > 20% identify patients at high risk for tensioned closure. Prehabilitation—including smoking cessation, glycemic control, and weight optimization—reduces surgical site morbidity. Botulinum toxin A (BTA) increases lateral abdominal wall compliance by approximately 4 cm per side, while progressive preoperative pneumoperitoneum (PPP) expands the abdominal cavity volume by up to 53%. Combined BTA and PPP achieve high primary fascial closure rates in massive defects. Transversus abdominis release provides durable retromuscular reconstruction with lower recurrence than anterior component separation. Emerging adjuncts such as Fasciotens and prolonged CO 2 insufflation offer additional muscle lengthening of up to 25%.
CONCLUSION:
CVH with LOD requires objective volumetric assessment and a tailored, algorithm-based approach integrating prehabilitation, domain-expanding techniques, and neurovascular-preserving reconstruction to improve the outcomes and reduce recurrence.