Preoperative Pneumoperitoneum Research Articles

Complex ventral hernia secondary to giant omphalocele managed by preoperative pneumoperitoneum and botulinum toxin: A case report

Complex ventral hernia secondary to giant omphalocele managed by preoperative pneumoperitoneum and botulinum toxin: A case report

A case of giant inguinoscrotal hernia managed by preoperative pneumoperitoneum with an unforeseen complication and outcome: a case report and review of literature

A case of giant inguinoscrotal hernia managed by preoperative pneumoperitoneum with an unforeseen complication and outcome: a case report and review of literature

Progressive preoperative pneumoperitoneum in a patient with giant inguinal hernia: report of a case

Giant hernias have chronic abdominal wall defects that slowly and progressively grow and alter the normal physiology of the abdominal wall. The clinical case we report is a 76-year-old male who began 7 years ago with protrusion in the left inguinal area with progressive increase in volume until reaching the inability to walk is presented. The protocol is followed by pneumoperitoneum insufflation with 500-1000 milliliters (ml) of carbon dioxide daily for 10 days. The treatment of large hernia defects of the abdominal wall produces a large increase in intra-abdominal pressure during visceral reduction, which entails an alteration in cardiorespiratory biomechanics by elevating the diaphragm and reducing venous return. This technique would be indicated in hernias greater than 10 centimeters (cm), as well as in large inguinal and umbilical hernias, with irreducible sacs, with "loss of domain". It is protocolized with preoperative preparation with pneumoperitoneum for 10 days, for subsequent inguinal plasty with Lichtenstein technique, during which a minimum of adhesions were found, managing to preserve the ipsilateral testicle, reducing surgical time and hospital stay, with no data on compartment syndrome in the abdomen after surgery, providing a good alternative in this type of condition.

Complications related to the prehabilitation with preoperative pneumoperitoneum in loss of domain hernias: our experience in 180 consecutive cases.

Progressive pneumoperitoneum (PPP) is useful tool in the preparation of patients with loss of domain hernias (LODH). The purpose of this observational retrospective study was to report our experience in the management of complications associated with the PPP procedure after treating 180 patients with LODH and to report preventive measures to avoid them. Of the 971 patients with a ventral incisional hernia operated on between June 2012 and July 2022, 180 consecutive patients with LODH were retrospectively analysed. Diameters of abdominal cavity, and volumes of incisional hernia and abdominal cavity were calculated from CT scan, based on the modified index of Tanaka. Complications related to the PPP procedure (catheter placement and following insufflations of air) were recorded by Clavien-Dindo classification. Complications associated to PPP were 26.6%. No complications occurred during the administration of botulinum toxin (BT). Eighteen patients (10% of 180 patients) developed subcutaneous emphysema during the last days of the insufflations; there were 2 accidental perforations of the small bowel and four punctures with liver and splenic hematomas, detected during catheter placement; a laparotomy, however, was not needed because it was solved with conservative treatment. We diagnosed it as a peritoneum-cutaneous fistula due to the cutaneous atrophy secondary to chronic eventration. PPP is a safe technique well tolerated by patients, although at the cost of some specific complications. Hernia surgeons must understand these complications to prevent them and to inform the LODH patient about their existence.

Accuracy and applicability of the novel pneumoperitoneum three-dimensional volume rendering technique in adhesive small bowel obstruction.

The accurate diagnosis of adhesive small bowel obstruction (ASBO) is challenging for surgeons. The aim of this study was to demonstrate that pneumoperitoneum 3-dimensional volume rendering (3DVR) can provide an accurate diagnosis and has applicability in ASBO. In this retrospective study, patients who underwent preoperative pneumoperitoneum 3DVR and surgery for ASBO between October 2021 and May 2022 were enrolled. The surgical findings were taken as the gold standard, and the kappa test was used to verify the consistency of the pneumoperitoneum 3DVR results and surgical findings. A total of 22 patients with ASBO were included in this study, 27 sites of obstruction adhesions were found during surgery, and 5 patients had both parietal adhesions and interintestinal adhesions. Sixteen parietal adhesions (16/16) were found using pneumoperitoneum 3DVR (κ=1.00; P<0.001), and the diagnosis of parietal adhesions on pneumoperitoneum 3DVR was perfectly consistent with the surgical findings. Eight (8/11) interintestinal adhesions were found using pneumoperitoneum 3DVR (κ=0.727; P<0.001), and the diagnosis of interintestinal adhesions on pneumoperitoneum 3DVR was substantially consistent with the surgical findings. The novel pneumoperitoneum 3DVR is accurate and applicable in ASBO. It can help personalize the treatment of patients and can be useful in planning a more effective surgical approach.

Re-discussion on the comprehensive treatment strategy of complex ventral hernia from the perspective of intraperitoneal pressure

Complex ventral hernia refers to a large hernia that is complicated by a series of concurrent conditions. Change in intra-abdominal pressure is one of the main pathways through which various factors exert an impact on perioperative risk and postoperative recurrence. Taking abdominal pressure reconstruction as the core, the treatment strategy for complex abdominal hernia can be formulated from three aspects: improving patients' tolerance, expanding abdominal cavity volume, and reducing the volume of abdominal contents. Improving patients' tolerance includes abdominal wall compliance training and progressive preoperative pneumoperitoneum. To expand the volume of the abdominal cavity, implanting hernia repair materials, component separation technique, autologous tissue transplantation, component expend technique, and chemical component separation can be used. Initiative content reduction surgery and temporary abdominal closure may be performed to reduce the volume of abdominal contents. For different cases of complex ventral hernia, personalized treatment measures can be safely and feasibly adopted depending on the condition of the patients and the intra-abdominal pressure situation.

Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

P-032 INCISIONAL HERNIA WITH LOSS OF DOMAIN AS A CONSEQUENCE OF BOTULINUM TOXIN A AND THE COVID-19 PANDEMIC

Abstract Introduction Abdominal wall surgery has been one of the major victims of the COVID-19 pandemic, with a large number of patients who have seen their surgery delayed and many are still waiting to be operated on today. On the other hand, botulinum toxin is one of the main protagonists in optimizing abdominal wall surgery, especially important in complex hernia, but we must not forget that it can have adverse effects. Case report We present the case of a 54-year-old man with a history of obesity, diabetes, hypertension, chronic renal failure and kidney transplant in 2000, who presented a midline incisional hernia as a result of an epigastric hernia operated on in 2006 and subsequently two onlay permanent synthetic mesh in 2010 and 2015. In February 2020 he presented an incisional hernia M2–4W3R3 with a volume of 35%, botox was infiltrated as optimization for surgery and while awaiting placement of a pneumoperitoneum catheter, the surgery was suspended due to the COVID-19 situation. He returns to our clinics in 2022 with a growth of the hernia and a volume of 95%. Weight loss, botulinum toxin and preoperative pneumoperitoneum were indicated. We performed a reconstruction of the abdominal wall with bilateral transversus abdominal release and preperitoneal 45×60cm polyvinylidene fluoride mesh and abdominoplasty. Discussion Botulinum toxin can facilitate abdominal surgery, especially in complex hernias, but we must not forget that blocking the abdominal muscles can have adverse effects. The COVID-19 pandemic has been especially hard on surgical waiting lists, delaying surgeries and aggravating pathologies.

P-031 TREATMENT OF A VOLUMINOUS INGUINOSCROTAL HERNIA AFTER A PREOPERATIVE PNEUMOPERITONEUM PREPARATION

Abstract Voluminous inguinoscrotal hernias that have lost their “right of domain”, are usually hard to repair, and need preoperative preparations to reduce the risk of complications after the treatment, such as compartment syndrome, intestinal ischemia, and respiratory problems. In this e-poster, we present a case report of a patient who had a voluminous inguinoscrotal hernia containing most of the small intestine and the entire right colon, which we treated after a preoperative pneumoperitoneum preparation (PPP). The preparation was conducted 20 days before the surgery and the pneumoperitoneum was created through a percutaneous catheter that we inserted in the epigastric region after a radiologic control. We injected 1000 ml of air per day, and the dose was adapted to the clinical tolerance of the patient. We performed a reintegration of the hernia's volume, a resection of the hernial sac, and a reduction of the size othe profound inguinal ring via a Raphia, no intestinal resections were made, and the postoperative course was uneventful. We plan a second intervention that consists of a hernia repair by a mesh insertion and a resection of the extra skin developed as a result of the voluminous hernia. PPP is an interesting way to prepare the abdominal cavity to receive the component of a voluminous hernia after its reduction. The patient should be closely monitored during the preparation and after the surgery in order. Sometimes a second operation is necessary for definitive cure or aesthetic needs.

P-049 DAMAGE CONTROL SURGERY FOR AN INCARCERATED GIANT UMBILICAL HERNIA IN A SUPEROBESE PATIENT

Abstract Aim To report the case of the emergency management of an incarcerated giant umbilical hernia in a superobese patient with a damage control surgery as the first step for its treatment. Material &amp; Methods We present the case of a 47-year-old man with a BMI of 62 kg/m2 who arrived to the emergency department for abdominal pain. Examination and CT scan revealed a giant umbilical incarcerated hernia with loss of domain, with an 8 cm hernia neck and containing the entire bowel except for the rectosigmoid and duodenum. Results The emergency managment was a laparotomy with a subcutaneous right lateral approach, opening first the hernia sac to verify bowel viability. Then, we performed a tranverse chelotomy on the right side of the defect, leaving the defect open and wider to prevent hernia strangulation. We left two drains in the subcutaneuos space and the wound was covered with vacuum therapy dressing. The patient recovery was uneventful and he was discharged in the sixth postoperative day. After this episode the patient started a very strict weight loss treatment, so we coul plan the final wall reconstruction surgery, which hasn't already been performed, but which will include botulinum toxin and progressive preoperative pneumoperitoneum. Conclusions We belive that damage control surgery was the most appropiate option as the first step for the management of an incarcerated complex hernia, so in a second time an elective complex wall reconstruction surgery could be performed.

USE OF TANAKA INDEX IN PLANNING OF PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM (PPP) FOR THE REPAIR OF GIANT INCISIONAL HERNIAS WITH LOSS OF DOMAIN IN A TERTIARY CARE HOSPITAL

BACKGROUND AND OBJECTIVES :Incisional hernia is the most common iatrogenic malady. Not only does it lead to complications, aesthetic problems and a prolonged disability, there is also the problem of recurrences. Incisional hernias occur in 2–15% of patients who undergo laparotomy, with recurrence rates after treatment of 0–46%. In this study, we have used the Tanaka index in planning of preoperative pneumoperitoneum for the repair of large incisional hernias with loss of domain. METHODS: In this study, all patients with large incisional hernias with loss of domain who were admitted to surgical wards of McGann District Teaching Hospital, attached to Shimoga Institute of Medical Sciences during the study period of 18 months (01/01/2021 to 30/06/2022) are included. After satisfying inclusion and exclusion criteria, these patients have been thoroughly examined, investigated and evaluated preoperatively and subjected to pre operative progressive pneumoperitoneum (PPP) and subsequently to various surgical repairs. Follow up post operatively has been done for a maximum of 6 months after discharge. RESULTS: Incidence of Incisional hernias was more in females with male to female ratio of 1.7:1. On an average, 10 PPP sessions were needed and the volume of air inated was 4000ml (average) .Rives stoppas repair with left Transverse abdominis release repair was performed in maximum cases. We received good results with healthy wound status post 6 months of surgery. CONCLUSION For large incisional hernias with LOD, PPP and the use of TANAKA Index has been found to be useful with excellent results

Role of progressive preoperative pneumoperitoneum in the management of giant inguinoscrotal hernia-case report

Managing a giant inguinal hernia/ incisional/ ventral hernia had its own complications. The overtime adaptation of peritoneal cavity to a lower abdominal pressure was one of the most important factors responsible for these complications. Surgical repair is also quite a challenge because of the massive contents in sac, adhesions and concomitant fibrosis. In order to reduce the complications like intra-abdominal hypertension, cardiorespiratory problems and to increase the abdominal wall compliance, many techniques were described. Progressive preoperative pneumoperitoneum is a well described technique for the repair of giant inguinal hernia/ incisional/ ventral hernia with loss of domain which helps in conditioning the abdominal wall in the preoperative period, increasing the likelihood of primary closure and decreasing the incidence of compartment syndrome.

State-of-the-art abdominal wall reconstruction and closure.

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

DECOMP Report: Answers surgeons expect from an abdominal wall imaging exam.

Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Preoperative pneumoperitoneum in the surgical preparation of complex eventrations

Preoperative pneumoperitoneum in the surgical preparation of complex eventrations

Botulinum toxin abdominal wall injection and post-omphalocele ventral hernia repair: database and proposal of a protocol

BackgroundPost-omphalocele ventral hernias (POVH) are common after giant omphaloceles. Abdominal wall botulinum toxin injections (BTI) are useful to treat complex incisional hernias (CIH) in adults, which may also apply to POVH. We review BTI data in the treatment of CIH and POVH and propose an algorithm applicable to POVH.ResultsSixteen papers which described the treatment of CIH on the treatment of POVH in adults (n = 15) and children (n = 1) were reviewed. BTI elongates the lateral abdominal wall and reduces the hernia defect, with a lower incidence of compartment syndrome and respiratory complications. Doses and injection volumes vary. Effects start after 3 days, peak after 10–15 days, stabilize for 2–3 months, and decline after 4–6 months, disappearing after 6–9 months. Patients should be operated on 3–4 weeks after injection. Post-operative complications are uncommon. BTI may be associated with pre-operative pneumoperitoneum (PPP). Children presenting POVH differ from adults presenting CIH. Associated congenital cardiac malformations, genetically determined syndromes, pulmonary hypoplasia, abdominal wall hypoplasia, and thoracic dysmorphism, are common; children need sedation for any procedures; non-absorbable reinforcing meshes are not indicated; and POVH limits are frequently near to the costal margin.ConclusionBTI to induce preoperative muscular relaxation in preparation of CIH repair in adults is effective and safe. Experience with the method in children with POVH is limited, but the proposal is logical and probably safe. POVH differs from CIH in some aspects, especially abdominal wall hypoplasia, proximity to the rib cage, and diaphragmatic biomechanics.

Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre.

Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30days and 1year post-operatively. Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool. Mean gestational age was 28+4weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed. Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32weeks), mortality is uncommon.

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

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

Right Colectomy with Absorbable Mesh Repair as a Salvage Solution for the Management of Giant Incisional Hernia with Loss of Domain: Results of a Bicentric Study.

Incisional hernia (IH) may occur in 20% of patients after laparotomy. The hernia sac volume may be of significance, with reintegration of visceral contents potentially leading to repair failure or abdominal compartment syndrome. The present study aimed to evaluate a two-step surgical strategy comprising right colectomy for hernia reduction with synchronous absorbable mesh repair followed by definitive non-absorbable mesh repair in recurrence. Patients operated between 2012 and 2017 at two university centers were retrospectively included. Volumetric evaluation of the IH was performed by CT imaging. Eleven patients were included. The mean BMI was 43kg/m2 (23-52kg/m2). Progressive preoperative pneumoperitoneum was performed in 82% of patients, with complications in 22%. The mean volumetric ratio of the volume of the hernia to the volume of the abdominal cavity was 70% (48-100%). The first parietal repair was performed using an synthetic absorbable mesh (36%), a biologic mesh (27%), or a slowly absorbable mesh (36%). No patients died as a result of the procedure. Seven (64%) patients developed grade III-IV complications, including one case of an anastomotic fistula. Recurrence occurred in eight (73%) patients after the first repair. Of these, four (50%) patients were reoperated using a non-absorbable mesh, leading to solid repair in 75% of cases. After 27 ± 18months of follow-up, the residual IH rate was 46%. Right colectomy for volume reduction in IH with loss of domain potentially represents an appropriate salvage option, supporting bowel reintegration and temporary hernia repair with absorbable material.