Preoperative progressive pneumoperitoneum for giant inguinal hernias

Preoperative Progressive Pneumoperitoneum in the Treatment of Hernias With Loss of Domain. Our Experience in 50 Cases

Introduction: Surgical planning for repair of giant hernias with loss of domain needs to consider patient comorbidities, potential risks and possible postoperative complications. Some postoperative complications are related to the increase in intra-abdominal pressure caused by the reintroduction of abdominal contents into the peritoneal space. Preoperative progressive pneumoperitoneum (PPP) increases the capacity of abdominal cavity prior to hernia repair and allows for better physiological postoperative adaptation. The aim of this study is to analyze perioperative and intraoperative characteristics as well as outcomes of a cohort of patients treated with PPP prior to giant hernia repair at a single, high volume center. Methods: Prospective, descriptive, observational single-center study including 50 patients undergoing PPP prior to hernia with loss of domain repair between January 2005 and June 2022. We analysed epidemiological, surgical and safety variables. Results: Fifty patients were included: 43 incisional hernias, 6 inguinal hernias and 1 umbilical hernia. Mean age was 66 years (36-85). Median insufflation time was 12 days (4-20) and median insufflated volume of ambient air was 10,036 cc. There were complications during PPP in nine patients: 2 decompensation of chronic respiratory disease and 7 subcutaneous emphysema. PPP was prematurely suspended in patients with respiratory decompensation. All patients with incisional and umbilical hernias underwent open repair with mesh placement. Preperitoneal repair was performed in inguinal hernias. Three cases of hernia recurrence were reported during the follow up. Conclusion: PPP is a safe and effective tool in the preoperative management of patients with giant hernias. It helps to achieve the decrease or absence of abdominal wall tension and can favour the results of complex eventroplasty techniques.

Retrospective analysis of open preperitoneal mesh repair of complex inguinal hernias

PURPOSE

The open posterior approach in the form of either a Stoppa or Wantz operation may be a good alternative technique particularly in the repair of complex inguinal hernias. The term "complex inguinal hernia" designates hernias with a combination of arduous features including large hernia defects, large to giant hernia sacs, multiple recurrences, and bilaterality. In this retrospective analysis, we investigated our results of open posterior repair in view of its feasibility in patients with complex inguinoscrotal hernias.

METHODS

From a series of 845 inguinal hernia patients, we retrospectively reviewed the records of 60 patients with complex inguinal hernias whom were directed to open preperitoneal repair by either a Stoppa or Wantz procedure.

RESULTS

More than 80% of cases were males with large to giant inguinoscrotal hernias. One half of patients had bilateral hernias, and one fourth had recurrent hernias. Early postoperative complications occurred in almost half of patients; however, most of them were minor. The most important early complication in this series was the full recurrences we encountered in the very next morning in two patients. Eighty-three percent of patients left hospital in the first 2 days averaging 1.8 days of hospital stay. The mesh:defect area ratio is < 7 in recurrent hernias while it is > 9 in nonrecurrent cases.

CONCLUSION

The open posterior approach to complex inguinal hernias facilitated both handling and repair of difficult hernias. It was very well tolerated by the patients, and yielded favorable postoperative results. We think the open posterior repair may be a method of choice in the repair of complex inguinal hernias.

Preoperative progressive pneumoperitoneum: The answer for treating giant inguinal hernias while avoiding morbidities?

PURPOSE

Preoperative progressive pneumoperitoneum (PPP) is mostly used for giant abdominal incisional hernias, and only a few isolated or paired cases that used PPP in the treatment of giant inguinal hernias (GIH) have been reported. The main objective of this study is to describe our technique in the use of PPP in the treatment of GIH in a series of patients who presented with this challenging condition.

METHODS

We retrospectively reviewed the medical records of a series of patients treated with PPP for GIH during a 6-year period (2012-2018) at a single institution. The demographics, preoperative, and surgical characteristics were analyzed.

RESULTS

In total, 7 patients were treated for GIH with PPP. The median age was 64 (range 30-89) years. The median history time with the inguinal hernia was 8 (range 2-20) years. The median time of PPP was 22 (range 15-30) days. All patients underwent the Lichtenstein technique. The median follow-up time was 12 (range 3-84) months. Three (42.8%) of the patients had preoperative complications. Two patients developed mild dyspnea during PPP, and another patient had subcutaneous emphysema during the insertion of the catheter. Two (28.5%) patients had postoperative complications. One of them developed a right scrotal abscess, and another patient developed bilateral grade III hydrocele.

CONCLUSION

With our limited experience, it is too early to tell if this should be the gold standard for the treatment of GIH. To see if there is superiority among different procedures, more studies that compare the morbidity of PPP with that of other trans operative techniques are needed. Nevertheless, the procedure we propose has provided satisfactory results.

Large inguinal bladder hernias: can a preoperative diagnosis be made?

PURPOSE

Bladder hernias are asymptomatic in most cases and are found incidentally during exploration for inguinal hernia repair. The treatment of inguinal bladder hernia is either reduction or resection of the herniated bladder, followed by herniorrhaphy. We present a case series with preoperative diagnoses, along with their surgical outcomes.

METHODS

We retrospectively reviewed the medical records from a single institution over a 5-year period (2012-2017) of five patients with diagnosis of large bladder inguinal hernia. Demographics, clinical status, medical history, anatomical structure of the hernia, and surgical outcomes were all analyzed.

RESULTS

Patients' median age was 51 years (range 45-81 years). The median size of the hernial sac was 13 cm (range 8-20 cm). The diagnosis was made with computed tomography in three patients and with ultrasonography and cystography in two patients. Median length of hospital stay was 2 days (range 1-6 days), and median length of follow-up was 28 months (range 18-72 months). All patients continue to be alive and well, without hernia recurrence. The five cases are described separately along with their surgical managements.

CONCLUSION

The main objectives in treatment of inguinal bladder hernia are to preserve the voiding function and to avoid bladder injuries in a tension-free hernia repair. To our knowledge, this is the first series of cases in which all inguinal bladder hernias were diagnosed preoperatively.

Surgical treatment strategies for giant inguinoscrotal hernia - a case report with review of the literature

BACKGROUND

An inguinoscrotal hernia is defined as "giant" if descending below the midpoint of the inner thigh of a patient in upright position. In developed countries this is a rare entity. In the literature different surgical techniques have been reported so far to achieve a successful treatment.

CASE PRESENTATION

We present the case of a 63 year-old man suffering from a giant inguinoscrotal hernia, whom we treated using a combined open transabdominal and inguinal approach following an unsuccessful laparoscopic attempt. Meshes were placed in a premuscular position (Lichtenstein's procedure) and in a preperitoneal position. In addition, a reconstruction of the abdominal wall by modified components separation technique was performed. During the early postoperative period no complications were registered. Intensive care treatment was not necessary. The patient was discharged on postoperative day 8 in an excellent condition. Six months after surgery a scrotal hematocele was diagnosed and operatively removed. After a follow-up of 1.5 years neither hernia recurrence, nor chronic groin pain were recorded. The patient reported to be sexually active. His quality of life improved notably. Additionally, a Medline and PubMed database research was performed to create an overall picture of the existing surgical treatment strategies. Included were patients with diagnosis of primary giant inguinoscrotal hernia according to the given definition. Emergency interventions and cases without details of the surgical approach were excluded.

CONCLUSIONS

Firstly, this report describes a novel, successful surgical treatment of a giant inguinoscrotal hernia without administering preoperative progressive pneumoperitoneum therapy or visceral resection. Secondly, we summarize cases previously reported as a practical guide for possible surgical therapy approaches.

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.

Treatment of a half century year old giant inguinoscrotal hernia. A case report

•

Giant inguinoscrotal hernias are a rare entity in modern clinical practice mainly because of the patient’s neglect.

•

Our patient had a type II giant inguinoscrotal hernia extending below the midline between mid-inner thigh and suprapatellar bone lines.

•

We avoided preoperative or intraoperative procedures for the lengthening of the abdominal wall.

•

Despite the longevity and size of the hernia, we avoided a debulking procedure, instead we performed a lower midline incision and connected it with an extended right inguinal incision.

•

Patient’s recovery was uneventful with no complications or signs of recurrence at 6 month follow up.

Introduction

Inguinal hernias, although a common medical entity, can on rare occasions present as giant inguinoscrotal hernias, mostly because of the patient’s rejection of timely surgical management.

Presentation of case

A 77 year old patient, with a giant inguinoscrotal hernia history for more than 50 years, was advised to undergo surgical treatment due to recurrent urinary tract infections and vague abdominal pain. Physical examination showed a right sided giant inguinoscrotal hernia extending below the midpoint of the inner thigh. Preoperative CT examination confirmed a giant inguinoscrotal hernia containing the whole of the small bowel along with its mesentery.

Discussion

Giant inguinoscrotal hernias are classified into three types based on size, with each one posing a challenge to treat. There are a number of surgical options and recommendations available, depending on the type of hernia. They require close postoperative observation, because the sudden increase in the intra-abdominal pressure can account for a number of complications. Our case was classified as a type II hernia, having longevity of more than 50 years. Despite this, it was treated with forced reduction and no debulking through an extended inguinal and lower midline incision, forming a ‘V shaped’ incision. Patient recovery was uneventful and he was discharged on the 10th postoperative day.

Conclusion

Preoperative management and the correct surgical plan depending on the case are key elements in the successful treatment of this rare surgical entity.

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: a case report

Introduction

Giant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge.

Case presentation

We report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy.

Conclusions

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases.

Giant inguinal hernia: the challenging hug technique

PURPOSE

Giant inguinoscrotal hernia are a real challenge for every kind of surgeon. The technique that we adopt is suggested as a good option to deal with this cases. We report our experience in five cases of giant inguinoscrotal hernia with loss of domain from 2005 to 2012.

METHOD

Five patients with hernia that descended below the knees in the standing position, with an anteroposterior diameter not inferior to 30 cm and a laterolateral diameter of about 50 cm. Penis was not visible. We did the same procedure for all the five patients: single pararectus incision extended to groin region until proximal half of scrotum, isolation of the entire large sac out of the scrotal cavity, paying attention to not opening it, progressive reduction of the viscera without opening the sac with the hug technique, as shown in the video, placement of a heavyweight polypropylene meshes in the preperitoneal space, scrotal skin reductive plastic. In three of our five cases we obtained restoration of herniated viscera without resection of them. Orchiectomy was performed in all cases.

RESULTS

No general neither wound complications were recorded. Long term follow up ranges from 8 years to 18 months: we did not record recurrence or chronic groin pain and scrotal size is normal in each patient.

CONCLUSION

The technique proposed permits to treat with success giant inguinaoscrotal hernia, avoiding the use of further specific procedure such as the preoperative progressive pneumoperitoneum. All our patients were satisfied with the surgeries and their quality of daily life had definitely improved.

Giant inguinal hernia: Report of a case and reviews of surgical techniques

INTRODUCTION

Inguinal hernia is one of the most surgical common diseases. Giant inguinal hernia is more unusual and significantly challenging in terms of surgical management. It is defined as an inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position.

PRESENTATION OF CASE

A 67-year-old male presented with giant right-side inguinal hernia with symptoms of partial colonic obstruction and significant weight loss. Barium enema revealed ascending colon, cecum and ileum contained in hernia sac without significant lesions of large bowel. He underwent hernia repair with omentectomy. Hernioplasty with polypropylene mesh was performed without any complications. He recovered uneventfully.

DISCUSSION

There were several repair techniques suggested by published articles such as resection of the content and increased intraabdominal volume procedure. Many key factors for management of the giant inquinal hernia were discussed. A new classification of the giant inquinal hernia was described.

CONCLUSION

Surgical repair for the giant inquinal hernia is challenging and correlated with significant morbidity and mortality due to increased intra-abdominal pressure.

Giant inguinoscrotal hernia repaired by lichtensteins technique without loss of domain -a case report

Giant inguinal hernia is a formidable surgical problem. It is defined as inguinal hernia extending up to mid thigh or below in standing position. Giant inguinal hernia is usually associated with compromised quality of life due to sexual discomfort and constant weight bearing. It is a challenge for the operating surgeon since it is rare. It may require multistage repair with recurrence being common. A 45-year-old male patient presented with Giant inguinal hernia and compromised quality of life due to pain and sexual discomfort. Lichtenstein's polypropylene mesh repair was done after reducing the sac contents (omentum and transverse colon) with partial omentectomy. There was no loss of intra-abdominal domain. Postoperative period was uneventful. In literature many techniques are available to increase the intra-abdominal cavity (a) Creating progressive preoperative pneumoperitoneum (b) Creation of ventral wall defect (c) surgical debulking of hernia contents. Recurrence is prevented by reconstruction of the abdominal wall using Marlex mesh and a Tensor fasciae lata flap. Laparoscopic repair is associated with more recurrence. Lichtenstein's technique is one of the preferred treatments.

[Progressive preoperative pneumoperitoneum in patients with giant hernias of the abdominal wall]

INTRODUCTION

Patients with giant hernias with loss of domain require proper planning of surgical repair, because of the high associated comorbidity. The progressive preoperative pneumoperitoneum technique described by Goñi Moreno allows a more physiological adaptation of the patient and the abdominal cavity to the reinstatement of the viscera to the abdomen, enabling adequate surgical repair. The objective of this study was to analyze our experience in the treatment of this type of hernia.

MATERIALS AND METHODS

We carried out a retrospective study that included 11 patients with major abdominal wall defects and loss of domain who were treated with this technique in 2 centers between 2005 and 2010.

RESULTS

Eight patients had abdominal hernias and 3 had inguinal hernias. The average insufflation time was 2 weeks and the total amount of air was between 6.6 and 18 l. In 2 patients who showed pulmonary disease decompensation, insufflation had to be temporarily postponed. A further 2 patients had subcutaneous emphysema during the last few days of insufflation, which resolved spontaneously without sequelae. The open mesh repair technique was used in ventral hernias and the preperitoneal technique in all inguinal hernias. There was one recurrence during the 1-year follow-up.

CONCLUSIONS

Goñi Moreno's technique remains safe to prepare patients with giant hernias with loss of domain. This procedure can reduce the morbidity caused by the increase in abdominal pressure after abdominal wall repair.