Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair.
BACKGROUND
A rarely used technique for enabling closure of large ventral hernias with loss of domain is preoperative progressive pneumoperitoneum (PPP), which uses intermittent insufflation to gradually stretch the contracted abdominal wall muscles, increasing the capacity of the abdominal cavity. This allows the re-introduction of herniated viscera into the abdominal cavity and assists in closure of giant hernias which may otherwise be considered inoperable.


METHODS
This was a prospective study assessing 16 patients between 2013 and 2015 with multi-recurrent ventral hernia. All patients were treated preoperatively with both Botulinum Toxin A (BTA) injections to the lateral abdominal wall muscles to confer flaccid paralysis, and short-term PPP to passively expand the abdominal cavity. All patients underwent serial abdominal CT imaging, with pre- and post-treatment circumference measurements of the peritoneal cavity and hernia sac, prior to undergoing operative mesh repair of their hernia.


RESULTS
The mean hernia defect size was 236 cm2, with mean 28 % loss of domain. The mean overall duration of PPP was 6.2 days. The mean gain in abdominal circumference was 4.9 cm (5.6 %) (p 0.002) after BTA and PPP. Fascial closure and mesh hernia repair were performed in all 16 patients, with no patients suffering from postoperative abdominal hypertension, ventilatory impairment, or wound dehiscence. There are no hernia recurrences to date. Eight patients (50 %) experienced PPP-related complications, consisting of subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumocardium, and metabolic acidosis. No complication required intervention.


CONCLUSIONS
PPP is a useful adjunct in the repair of complex ventral hernia. It passively expands the abdominal cavity, allowing viscera to re-establish right of domain. At the same time, it helps to minimize the risks of postoperative abdominal compartment syndrome and the sequelae of fascial closure under tension. However, its benefits must be carefully weighed with the risk of serious complications, such as infection, perforation, pneumothorax, and pneumomediastinum.
['Elstner|Kristen E|KE|', 'Read|John W|JW|', 'Rodriguez-Acevedo|Omar|O|', 'Ho-Shon|Kevin|K|', 'Magnussen|John|J|', 'Ibrahim|Nabeel|N|']
D034841:Abdominal Cavity D000009:Abdominal Muscles D034861:Abdominal Wall D000138:Acidosis D000328:Adult D000368:Aged D019274:Botulinum Toxins, Type A D005260:Female D006555:Hernia, Ventral D059685:Herniorrhaphy D006801:Humans D007273:Injections, Intramuscular D007327:Insufflation D008297:Male D008478:Mediastinal Emphysema D008875:Middle Aged D009465:Neuromuscular Agents D010529:Peritoneal Cavity D011026:Pneumopericardium D011028:Pneumoperitoneum, Artificial D011030:Pneumothorax D011183:Postoperative Complications D011446:Prospective Studies D012008:Recurrence D013352:Subcutaneous Emphysema D013526:Surgical Mesh D014781:Viscera
Preoperative progressive pneumoperitoneum Complex ventral hernia Loss of domain Botulinum toxin A Incisional hernia