Loss Of Domain (Complex Hernia)

Decoding Loss of Domain in Complex Hernia Cases: The Most Important Measurement in Modern-Day Hernia Surgery

Loss of domain (LOD) is a term used in hernia literature to describe the ratio of peritoneal content located in the hernia sac. The LOD ratio expresses the relationship between the hernia and the residual abdominopelvic cavity and it is used by surgeons to predict the risk of pre, post, and perioperative complications in hernia operations.

Here is a simplified breakdown of the Loss of domain (LOD) ratio:

  • When a hernia occurs, the lining of the abdominal cavity (the peritoneum) forms a hernia sac.
  • This sac gets exposed through weak areas in the belly wall.
  • The hernia sac can contain various types of abdominal contents, depending on the type of hernia.

The type and amount of abdominal contents found in a hernia sack will vary from patient to patient. Regardless of the contents, low loss of domain means that the hernia sac contains a relatively small proportion of the abdominal contents. Such hernia sacs are easier to operate on.

Conversely, if the loss of domain is higher than 20%, there’s a major risk of surgical complications. In other words, if surgeons do not calculate a hernia patient’s loss of domain (LOD) ratio, they expose themselves to high risks of surgical complications.

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So, how do surgeons calculate the LOD ratio? By dividing the Hernia Sac Volume (HSV) by the Total Peritoneal Volume (TPV):

  • Hernia Sac Volume (HSV) is a measure of the total space taken by the hernia sac. HSV is measured via CT and ultrasound scans. A ‘healthy’ HSV is 200 mL. Patients with significant LOD typically have higher HSV scores than that.
  • Total Peritoneal Volume (TPV) is a measure of the total space in the abdominal cavity. A high TPV indicates that the LOD will be low and the abdominal cavity is large enough to accommodate all abdominal contents. A ‘healthy’ TPV is 2,000 mL. Patients with high LOD have lower TPV scores than that.


The Importance of Calculating the LOD Ratio

Performing surgery on hernia patients with high LOD is not easy. Before operating on such patients, surgeons have to account for countless technical difficulties and risks of post-operative complications. Calculating the LOD ratio is the only way surgeons can accurately plan for these risks. The LOD ratio also helps surgeons:

  • Understand the extent to which the patient’s abdominal cavity has lost volume and space to the hernia sack. This understanding prepares them for the challenges they’re set to encounter during the surgery.
  • Evaluating the LOD ratio helps surgeons determine the most suitable surgical approach for patients with complex ventral hernias. For e.g., patients with complex incisional hernias and high LOD require open surgery: no other methods work.
  • By evaluating the LOD ratio, surgeons can also plan in advance for the potential physiological impediments that may occur during/after the hernia repair.

In summary, evaluating the loss of domain (LOD) ratio in patients with complex ventral hernias is the most effective way for hernia surgeons to guarantee better outcomes for their patients. Hopefully, this guide has been helpful in simplifying this critical yet confusing concept in modern-day hernia care!

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