Preoperative Progressive Pneumoperitoneum for Giant Inguinal Hernia: Useful Adjunct Prior to Surgical Management

Abstract

Giant inguinal hernias pose a significant challenge in surgical management, with the main risk of hernial sac reduction being abdominal compartment syndrome. Different therapeutic approaches have been described in literature. We present the case of a 61-year-old male patient who presented with giant inguinal hernia who was treated with preoperative progressive pneumoperitoneum followed by open tension-free mesh hernioplasty, with no postoperative complications.

Keywords

hernia - abdominal compartment syndrome - pneumatic adhesiolysis

Introduction

Reduction of large abdominal hernias at a single operative sitting, can lead to sudden rise of intra-abdominal pressure leading to abdominal compartment syndrome, which can lead to severe respiratory distress. Preoperative progressive pneumoperitoneum (PPP) uses intermittent insufflation of gas to stretch the abdominal muscles to increase abdominal capacity so that large amounts of viscera can be repositioned into the abdominal cavity without significantly raising intra-abdominal pressure.

Case Report

A 61-year-old male presented with the complaint of left inguinoscrotal swelling for 12 years. Local examination revealed a large, globular, soft left inguinoscrotal swelling of size approximately 35 × 20 cm. Expansile cough impulse was positive over the swelling. Diagnosis of left direct giant inguinal hernia was made. In view of the large size of the swelling and for surgical planning, a computed tomography (CT) scan was done, which revealed an approximately 4.6 × 4.8 cm size defect in the left inguinal region with herniation of sigmoid colon ([Fig. 1]). The volume of hernial sac and abdominal cavity were 4122 and 11,372 cm³, respectively ([Fig. 2]). Given the parameters, loss of domain was 36%. Given the loss of domain being > 20%, there was a risk of abdominal compartment syndrome, if simple operative reduction of hernial sac was done.

Fig. 1 Axial computed tomography (CT) images depict the giant left inguinal hernial sac (red arrow, A) containing sigmoid bowel as its content (yellow arrow, B).

Fig. 2 (A) Coronal computed tomography (CT) image demonstrating the calculated volume of the abdominal cavity (volume of interest [VOI]) measuring 11,372 cm³. (B) Sagittal reformatted image depicting the giant left inguinal hernial sac containing sigmoid bowel as its content (yellow arrow). (C) Volume rendering technique (VRT) image depicting the giant left inguinal hernia sac.

Botulinum toxin A (BTA) injection into the abdominal wall musculature was considered. However, in view of the high cost of the procedure, it could not be done. So, PPP was planned as a viable cost-effective adjunct. Under CT guidance, left anterolateral peritoneal lining was punctured by a 22G needle and 100 mL air was injected to create artificial pneumoperitoneum. Subsequently, under CT guidance, left anterolateral abdominal wall was punctured and an 8F pigtail was inserted into this artificially created pneumoperitoneum cavity by Seldinger's technique ([Fig. 3]). Total air injected was 400 to 500 mL. Patient vitals were stable. A graded pneumoperitoneum was created with insufflation of approximately 800 mL air per day over the course of next 15 days. Abdominal girth increased from 100 to 113 cm. Patient was posted for surgery once he could not tolerate any more insufflation of air.

Fig. 3 Axial computed tomography (CT) abdomen images show: (A) puncture of the left anterolateral abdominal wall with 22G needle (red arrow), followed by insufflation of 100 mL air to create artificial pneumoperitoneum (yellow arrow), (B) puncture of this pocket of artificial pneumoperitoneum with a 18G needle (green arrow), and (C) maximum intensity projection (MIP) image depicting the subsequently deployed 8F pigtail (orange arrow) through this 18G needle via Seldinger's technique.

Under general anesthesia, Lichtenstein open tension-free mesh hernioplasty was done. Postoperative course was eventful.

Discussion

A large inguinal hernia, which extends below the mid-thigh level, in standing position, constitutes a “giant” inguinal hernia.[1] In long-standing hernias, there is gradual retraction of lateral abdominal musculature, relaxation of the diaphragm, which reduces effective intra-abdominal volume. The herniated bowel and mesentery also become edematous from venous and lymphatic congestion, secondary to compression at the level of the fibrotic hernial ring. The forced hernial sac reduction in an unprepared abdomen can lead to abdominal compartment syndrome, as well as the fascial closure will be under tension, leading to wound dehiscence and hernia recurrence. PPP is indicated when it is not possible to perform hernia repair due to the size of the hernia and the loss of domain. The most widely accepted definitions of hernias with loss of domain are when the hernia sac contains more than 20% of the abdominal contents.[2]

The basic principle is to gradually increase the abdominal compartment volume and reestablish the right of domain for abdominal viscera. Advantages of this procedure are that it allows a gradual and more physiological adaptation of the patient's abdominal cavity for subsequent hernia reduction, and additionally performs pneumatic adhesiolysis, which reduces the amount of dissection performed intraoperatively.[3] The median amount of insufflated air is 9.02 ± 2.7 L with a range of 3.6 to 19.5 L.[3]

The common complications are due to the local site puncture, which includes bowel perforation, solid organ injury, and intraluminal placement of the needle. Other complications include shoulder pain, gastroesophageal reflux, respiratory distress, subcutaneous emphysema, and venous stasis leading to subsequent venous thrombosis. The rate of complications with PPP (25.6%) is much higher, as compared with the alternative techniques described subsequently.[3]

PPP is being used with various modifications, throughout the world, with positive results, however, with limited uptake.[4] The most common technique used is the one which has been described in our case, with the endpoint of graded air insufflation being patient discomfort.

The various alternative techniques to PPP described in the literature include BTA injection, usage of tissue expanders, debulking surgery such as omentectomy and limited bowel resection, abdominal wall component separation, and transverse relaxing incisions.

BTA is also a commonly performed preoperative technique. BTA is a neurotoxin that works by blocking the release of acetylcholine. It leads to temporary muscle flaccid paralysis leading to decreased abdominal wall tension and facilitating tension-free abdominal wall closure. It is injected under ultrasound or CT guidance into the lateral abdominal wall muscles complex (external oblique, internal oblique, and transversus abdominis). Its maximum effects come after 2 to 4 weeks following injection; however, effect can last up to 6 months.[5] It can be used either as an addition, or in place of the currently available techniques, prior to surgical reduction.

The advantages of BTA as compared with PPP (and other alternative techniques) are that it is least invasive and has a low side effect profile. It additionally can reduce pain by inhibiting the release of substance P and calcitonin gene-related peptide that are involved in inflammation.[6]

The disadvantages of BTA are that it can cause paralysis when incorrectly injected into unintended structures and high cost of the medicine. Its use is also contraindicated in patients with neuromuscular disorders such as myasthenia gravis. In our case, it was not used in view of its cost and nonavailability as part of routine supply in our institution. When compared with BTA injection, PPP is equally efficacious, while being cost-effective especially in developing countries like India.

Postoperative complications such as surgical site infection (17.5%) and recurrence (5.9%) are much lower, when compared with other loss of domain hernia surgeries, without the use of these preoperative techniques,[3] with successful closure of the defect reported in 98.2% cases.[3]

Conclusion

Surgical repair of giant inguinal hernias requires adequate preoperative preparation of the abdominal cavity. PPP is a relatively safe and easy technique, which increases the volume of the abdominal cavity, thereby reducing the risk of abdominal compartment syndrome, as well as additionally performing pneumatic adhesiolysis.

Conflict of Interest

None declared.

• References

• 1 Gonzalo A, Navarro AC, Marín J, Pola G, Martínez B. Combination of botulinum toxin A, progressive pre-operative pneumoperitoneum for the repair of loss domain inguinal hernias. ANZ J Surg 2019; 89 (12) 1663-1664
• 2 Subirana H, Comas J, Crusellas O. et al. Preoperative progressive pneumoperitoneum in the treatment of hernias with loss of domain. Our experience in 50 cases. J Abdom Wall Surg 2023; 2: 11230
• 3 Giuffrida M, Biolchini F, Capelli P, Banchini F, Perrone G. Botulinum toxin and progressive pneumoperitoneum in loss of domain ventral hernias: a systematic review. J Abdom Wall Surg 2024; 3: 12650
• 4 Elstner KE, Read JW, Rodriguez-Acevedo O, Ho-Shon K, Magnussen J, Ibrahim N. Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair. Surg Endosc 2017; 31 (04) 1914-1922
• 5 Elstner KE, Jacombs AS, Read JW. et al. Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using botulinum toxin A. Hernia 2016; 20 (02) 209-219
• 6 Zielinski MD, Goussous N, Schiller HJ, Jenkins D. Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen. Hernia 2013; 17 (01) 101-107

Publication History

Article published online:
13 June 2025