Pre-operative progressive pneumoperitoneum for repair of a large incisional hernia

Use of botulinum toxin type A in the prehabilitation of abdominal wall musculature for hernia repair: a consensus proposal

The prehabilitation of the abdominal wall through the infiltration of botulinum toxin type A, which induces temporary chemical denervation ("chemical component separation") in the lateral abdominal musculature, is a common practice in units specialized in abdominal wall surgery. However, its use for this indication is currently off-label. The main objective of this article is to describe a consensus proposal regarding indications, contraindications, dosages employed, potential side effects, administration method, and measurement of possible outcomes. Additionally, a proposal for an informed consent document endorsed by the Abdominal Wall Section of the Spanish Association of Surgeons is attached.

Preoperative Abdominal Muscle Elongation Facilitated Laparoscopic Intraperitoneal Onlay Mesh Repair of Complex Ventral Hernia

Background: Complex ventral hernia remains a challenging situation for any surgeon. In this study, our aim was to analyze the effect of laparoscopic intraperitoneal onlay mesh (IPOM) repair in the treatment of complex abdominal wall hernia, with the assistance of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA). Methods: In this retrospective study, we included 13 patients with complex ventral hernia between May 2021 and December 2022. All patients undergoing PPP and BTA protocol before hernia repair. The length of abdominal wall muscles and abdominal circumference were measured from CT scan. All hernias were repaired with laparoscopic or laparoscopic-assisted IPOM. Results: Thirteen patients received PPP and BTA injections. PPP and BTA administration time was over 8.8 ± 2.5 days. Before and after PPP and BTA, imaging showed that the length of lateral muscle on each side increased from 14.3 to 17.4 cm (P < .05). The abdominal circumference increased from 81.8 to 87.9 cm (P < .05). Complete fascial closure was obtained in 13 patients (100%), and no patient experienced postoperative abdominal hypertension and ventilatory support. No patient suffered from recurrent hernia to date. Conclusions: Preoperative PPP combined with BTA injection plays a role similar to component separation technique, avoids the abdominal hypertension after laparoscopic IPOM repair of complex ventral hernia.

A systematic review of the use of progressive preoperative pneumoperitoneum since its inception

INTRODUCTION

Preoperative progressive pneumoperitoneum (PPP) is a technique that has been used since 1947 to expand the abdominal cavity volume, for presurgical preparation of patients with large hernias. This systematic review attempts to answer some unresolved questions about PPP, while using the evidence to clarify the different forms that the procedure has taken over time.

PURPOSE

The purpose of the paper was to analyze the literature about PPP and gather information about the procedure and its indications, advantages, and disadvantages.

METHODS

A systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The database searches, in English and Spanish, were made using the terms "preoperative pneumoperitoneum," "progressive pneumoperitoneum," "preoperative pneumoperitoneum," and "progressive pneumoperitoneum," for the period between 1 January 1940 and 31 May 2019. Indications, techniques, results, and complications were registered. The statistical analysis was based on means, standard deviations, medians, mode, and interquartile ranges for quantitative variables, and frequencies and percentages for categories.

RESULTS

The qualitative synthesis was made on the basis of 53 articles that reported the treatment of a total of 1216 patients. The most frequent indication for PPP was a large incisional hernia with loss of domain. The most common technique employed a spinal needle or multipurpose catheter by the anatomical method in the left hypochondrium. In spite of the heterogeneity of the data and the management of different volumes of air and daily insufflations, 99.6% of visceral reintroduction and 86% of primary fascial closure was achieved. Complications had an incidence of 12%, mostly minor, and there were five mortalities.

CONCLUSION

Preoperative progressive pneumoperitoneum (PPP) is a beneficial and safe technique to use in preparing patients with large hernias, but the procedure is not free of complications. The technique has evolved through the years and, although many variations exist, it is possible to establish an algorithm for its application.

Preoperative combination of progressive pneumoperitoneum and botulinum toxin type A in patients with loss of domain hernia

INTRODUCTION

Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BT) are tools in the surgical preparation of patients with loss of domain hernias (LODH). The aim of this paper is to report our experience with these preoperative techniques in 70 patients with LODH.

METHODS

Observational study of 70 consecutive patients with LODH was conducted between May 2010 and May 2016. Diameters of the hernia sac, incisional hernia (VIH), and abdominal cavity (VAC) volumes, and VIH/VAC ratio were measured before and after PPP and BT, using abdominal CT scan data. Combination of both techniques was performed when the VIH/VAC ratio was > 20%.

RESULTS

Median insufflated volume of air for PPP was 8450 ± 3400 cc (4500-13,450), over a period of 11.3 ± 2.3 days (9-16). BT administration time was 38.1 ± 3.7 days (35-44). An average reduction of 16.6% of the VIH/VAC ratio after PPP and BT was obtained (p < 0.05). Complications associated with PPP were 20%, and with surgical technique 29.6%. No complications occurred during the BT administration. Reconstructive technique was anterior CST in 54 patients, TAR in 14 cases and Rives-Stoppa technique in two patients. Median follow-up was 34.5 ± 22.3 months (12-60) and four cases of hernia recurrence (5.7%) were reported.

CONCLUSIONS

Using a CT volumetric protocol, combination of PPP and BT decreases the VIH/VAC ratio and hernia defect diameters, which constitutes a key factor in the treatment of LODH.

A new technique for tension-free reconstruction in large incisional hernia

In the surgical management of large incisional hernias, the main target is the closure of the abdominal wall defect on the midline without a dangerous increase in the intraabdominal pressure. In this setting, new intraperitoneal prosthesis and components separation techniques were proposed to solve this problem. Both solutions present some critical issues. A new surgical approach with a free lateral double layer prosthesis totally in polypropylene both sides (FLaPp®) is proposed to overcome this problem. This is a retrospective cohort analysis study with a prospectively collected database from two different Italian hospitals. Twenty-nine patients operated from April 2010 to December 2015 were treated using the new prosthesis. Four patients developed postoperative complications: one (3.4%) presented wound infection, two (6.9%) experienced seroma, and one had a hematoma (3.4%). No deaths were recorded. At a median follow-up of 28.5 months (IQR 22-36), no hernia relapse occurred. The application of FLaPp® mesh is a safe and feasible option that can be employed to manage Rives repair in cases of abdominal wall defects with difficult closure of the posterior plan when the conventional prosthetic meshes could be unsuitable.

Preoperative preparation of «loss of domain» hernia. Progressive pneumoperitoneum and botulinum toxin type A

Preoperative progressive pneumoperitoneum and botulinum toxin type A are useful tools in the preparation of patients with loss of domain hernias. Both procedures are complementary in the surgical repair, especially with the use of prosthetic techniques without tension, that allow a integral management of these patients. The aim of this paper is to update concepts related to both procedures, emphasizing the advantages that take place in the preoperative management of loss of domain hernias.

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.