Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair

Kristen E. Elstner, John W. Read, Omar Rodriguez-Acevedo, Kevin Ho-Shon, John Magnussen, Nabeel Ibrahim

Research output: Contribution to journalArticleResearchpeer-review

Abstract

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.

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Ventral Hernia
Pneumoperitoneum
Herniorrhaphy
Abdominal Cavity
Hernia
Mediastinal Emphysema
Abdominal Muscles
Type A Botulinum Toxins
Viscera
Abdominal Wall
Pneumothorax
Intra-Abdominal Hypertension
Subcutaneous Emphysema
Insufflation
Peritoneal Cavity
Acidosis
Paralysis
Prospective Studies
Hypertension
Recurrence

Cite this

@article{60c7d3c0dd8d4bb286b0994377d90c7f,
title = "Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair",
abstract = "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.",
keywords = "preoperative progressive pneumoperitoneum, botulinum toxin A, complex ventral hernia, incisional hernia, loss of domain",
author = "Elstner, {Kristen E.} and Read, {John W.} and Omar Rodriguez-Acevedo and Kevin Ho-Shon and John Magnussen and Nabeel Ibrahim",
year = "2017",
month = "4",
doi = "10.1007/s00464-016-5194-1",
language = "English",
volume = "31",
pages = "1914--1922",
journal = "Surgical Endoscopy",
issn = "0930-2794",
publisher = "Springer, Springer Nature",
number = "4",

}

Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair. / Elstner, Kristen E.; Read, John W.; Rodriguez-Acevedo, Omar; Ho-Shon, Kevin; Magnussen, John; Ibrahim, Nabeel.

In: Surgical Endoscopy and Other Interventional Techniques, Vol. 31, No. 4, 04.2017, p. 1914-1922.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair

AU - Elstner,Kristen E.

AU - Read,John W.

AU - Rodriguez-Acevedo,Omar

AU - Ho-Shon,Kevin

AU - Magnussen,John

AU - Ibrahim,Nabeel

PY - 2017/4

Y1 - 2017/4

N2 - 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.

AB - 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.

KW - preoperative progressive pneumoperitoneum

KW - botulinum toxin A

KW - complex ventral hernia

KW - incisional hernia

KW - loss of domain

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U2 - 10.1007/s00464-016-5194-1

DO - 10.1007/s00464-016-5194-1

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SP - 1914

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JO - Surgical Endoscopy

T2 - Surgical Endoscopy

JF - Surgical Endoscopy

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