Progressive preoperative pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair: benefits and complications

Kristen E Elstner, MBBS1, Anita S Jacombs, MBBS, PhD2, John W Read, FRANZCR3, Michael Edye, FRACS4, Nabeel Ibrahim, FRACS5. 1Macquarie University Hospital, Sydney, Australia, 2Faculty of Medicine & Health Sciences, Macquarie University, Australia, 3Castlereagh Imaging, St Leonards, Australia, 4Professor of Surgery and Chair, University of Western Sydney, 5Hernia Insitutue Australia, Edgecliff, Australia

Introduction: Repair of complex ventral hernia, and particularly those with large defects suffering significant loss of domain, is a challenging situation for any surgeon. Closure of large defects is fraught with possible complications, such as dehiscence, impaired venous return, organ dysfunction, and impaired ventilation. First described in 1947, Progressive Preoperative Pneumoperitoneum (PPP) is a technique designed to expand the capacity of the abdominal cavity, thereby facilitating fascial closure at time of operation and reducing the risk of raised intra-abdominal pressures and its sequelae. We present a series of patients treated with PPP, along with chemical component relaxation, prior to elective laparoscopic repair of complex ventral hernia.

Methods: A series of 13 patients with loss of domain greater than 20% underwent short term PPP prior to elective repair of ventral hernia. A 6Fr peritoneal catheter was inserted into the left upper quadrant (or where feasible) 7-10 days preoperatively, with progressive insufflation of air into the peritoneal cavity. Insufflation was dictated by patient tolerance, averaging 800-1000 mls every second day. Patients were monitored clinically as well as radiologically, with serial non-contrast abdominal CT imaging. Patients then proceeded to laparoscopic or laparoscopic-assisted repair of their ventral hernia.

Results: Between 2013 and 2015, PPP was performed in 13 patients. Defect size averaged 237 cm2 (range 34 – 459) with loss of domain ranging between 20 to 41%. Mean patient age 55, and mean BMI was 32 kg/m2 (range 22 – 46). All patients had multiple previous abdominal operations and failed ventral hernia repairs.

Complications included surgical emphysema (n = 2, 15.3%), pneumothorax (n = 3, 23.1%), pneumomediastinum (n = 3, 23.1%), and metabolic acidosis (n= 1, 7.7%). No bowel perforations occurred.

All patients proceeded to successful laparoscopic or laparoscopic-assisted repair of ventral hernia. Fascial closure was feasible in all patients.

Conclusions: PPP is a rarely utilized adjunct in complex abdominal hernia surgery, despite many successful anecdotal reports in the literature. The literature states that PPP delivers pneumatic expansion of the abdominal wall, but in fact may be demonstrating the difference between unstretched versus stretched abdominal wall (without actual expansion). In our experience, the main advantage of PPP is in post- insufflation imaging, which can identify sites on the abdominal wall which are safe to use as an access point into the previously operated-on abdomen. Its benefits, however, must be weighed with its pitfalls: risk of complications such as pneumothorax, pneumomediastinum, and metabolic acidosis.

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