Progressive Pneumoperitoneum for the Repair of Massive Inguinal ...

www.downstatesurgery.orgProgressivePneumoperitoneum for theRepair of Massive InguinalHerniasLixana Vega Vg Vega, Vg,MDSUNY Downstate Medical CenterMarch h20 th , 2009

www.downstatesurgery.orgACGME Core Competencies• Patient Care• Medical knowledge• Practice Based dLearning &Improvement• Interpersonal & Communication Skills• Professionalism• Systems based practice

Case presentation• 74 y/o male presented to surgery clinic with a massiveright inguinal hernia, that became progressively largerover the past 20 years.• Intermittent right groin pain.• Urinary incontinence.i• Progressive impairment of activities of daily living(ambulation).• PMH- Alzheimer's disease recently diagnosed• Meds- AA ASA• PSH- denies• Allergies-NKDAwww.downstatesurgery.org

• Abdomen• Scaphoid, soft, nontender,nondistended.• Right groinwww.downstatesurgery.orgPhysical Exam• Massive right inguinal hernia withscrotum extending to knee caps.• Hernia nontender.• Scrotum does not translluminate.• Left groin- no palpable hernias.• Labs – WNL

www.downstatesurgery.orgAbdomen and Pelvis CT Scan

www.downstatesurgery.orgAbdomen and Pelvis CT Scan

www.downstatesurgery.orgAbdomen and Pelvis CT Scan

www.downstatesurgery.orgCase Presentation• 74 y/o male with massive right inguinal hernia withloss of intraabdominal domain, affecting ADL.• Standard reduction and primary repair• Abdominal compartment t syndrome.• Respiratory distress.• Hernia recurrence.• Progressive Preoperative Pneumoperitoneum• Insufflation of ambient air into peritoneal cavity inorder to accommodate herniated viscera at time ofhernia repair.

www.downstatesurgery.orgProgressive PreoperativePneumoperitoneum• Peritoneal dialysis catheter placed and oneliter of air was insufflated into the abdomen.• During each clinic visit (every 2 – 3 days for a20 day period) approximately one liter ofambient air was introduced to the abdominalcavity via the dialysis catheter.• Pt tolerated procedure well. Denied abdominalpain, n/v or dyspnea.• Pt admitted for bowel prep prior to RIH repair.

www.downstatesurgery.orgRight inguinal hernia repair• Long right inguinal incision.• Massive inguinal herniaextending to right scrotum.• Right colon and loops of smallbowel within sac• Contents of spermatic cord wereidentified and isolated.• Contents of the hernia werereduced to the abdomen afterincision on the anteriorabdominal wall, lateral tointernal ring.• Residual hernia sac was resected.

www.downstatesurgery.orgRight inguinal hernia repair• Vas deferens and testicle wereplaced in the scrotum.• The hernia defect extended fromthe pubic tubercle, towards theinternal ring including the entireinguinal floor.• Proced mesh 4 x 5.5cm (withkeyhole for spermatic cord) wassecured with 0 Tevdek suture topubic tubercle, inguinal ligamentand superior edge of internaloblique muscle aponeurosis.

www.downstatesurgery.orgRight inguinal hernia repair• Aponeurosis of external obliquemuscle was closed with 2-0 vicrylrunning sutures.• Peak airway pressures increasedslightly from low 20s to upper20s. No respiratory distress uponfull reduction of herniatedviscera.• Peritoneal dialysis catheterremoved via infraumbilicallincision .• Pt was extubated in OR andtransferred to SICU.

• POD #2• Pt started on clears.Post-op op course• Abdomen became mildly distended.• AXR showed large stomach air bubble.• Pt placed NPO. NGT placed.• Bladder pressures WNL• POD#5• Abdominal distention improved. Pt started on clears.• POD #8• Tolerating clears, +flatus, +BM, transferred to floor.• POD #9www.downstatesurgery.org• Advanced to regular diet

• POD#10www.downstatesurgery.org• Mild respiratory distress• Chest CT positive for PEPost-op op course• Pt transferred to SICU and started on heparin drip.• AXR showed gastric distention.• POD #14- Abdominal distention persisted• CT scan positive i for intraabdominal i lh hematoma and d151.5cmpseudoaneurysm of pancreaticoduodenal artery (PDA)• POD#15- angiogram and coil embolization of inferior PDA.• POD #16- Pt started on clears, transferred to floor.• POD #17- Advanced to regular diet.• POD #24- discharged to rehab facility.

www.downstatesurgery.orgProgressivePneumoperitoneum for theRepair of Massive InguinalHernias

www.downstatesurgery.orgMegahernia• Hernia that exceeds20cm in diameter andhas lost its right ofdomicile in the peritonealcavity for a period of oneyear.¹

www.downstatesurgery.orgLoss of domain induces• Impaired venous and lymphatic return fromviscera due to compression from the herniadefect. ¹• Dilation of mesentery and bowel wall edema.• Impairs reduction• Decrease in intraabdominal pressure• Decrease capacity of the abdominal cavity• Hemidiaphragm lowers altering ventilatorymechanism.

www.downstatesurgery.orgPossible complications ofreduction• Increased abdominal pressure• Decreased venous return.• Abdominal compartment syndrome.• Elevation of diaphragm• Increased thoracic pressure causing respiratorydistress. 2• Dhi Dehiscence with ihh hernia recurrence. 1

www.downstatesurgery.orgAlternatives of repair• Resection omentum and bowel.• Increase morbidity/mortality associated with bowelresection.• Short gut syndrome - nutritional problems• Requires a separate incision. 1• Phrenectomy (Tournoff-1950s)• Respiratory complications.3

www.downstatesurgery.orgAlternatives of repair• Creation of ventral hernia(Ziffrinand Womack-1950)4• Long transverse abdominal incision.• Division of abdominal wall except the peritoneum.• Reduction and repair of inguinal hernia.• Peritoneum protrudes through unsutured fascia (ventralherniation).• Closure of fascia (ventral hernia repair) 12 days later.• Useful when size of hernia was misjudged pre-op, andwhen pt develops circulatory or repiratory distress intra-op.• Requires a second surgical procedure.

www.downstatesurgery.orgAlternatives of repair• Preoperative Progressive Pneumoperitoneum• Ivan Goni Moreno (1940s)•Intraperitoneal injection of oxygen to expand theabdominal cavity before hernia repair, making room toaccommodate herniated viscera.•First case reported was repair of incarcerated epigastrichernia.5•Reported 3% recurrance rate in a series of 487 gianthernia repairs.

www.downstatesurgery.orgAlternatives of repair• Preoperative Progressive Pneumoperitoneum• Koontz and Graves (1954)•Reported successfull repair abdominal wallhernias with loss of domicile with this technique. 4• This technique was then applied to inguinal herniarepairs and for repair of omphaloceles. 3

• Indicationwww.downstatesurgery.orgPreoperative ProgressivePneumoperitoneum• Repair massive abdominal wall hernias with loss ofintraabdominal domain.6• Contraindications• Advanced d age and poor general condition.• Cardiac decompensation. 1

www.downstatesurgery.orgAdvantages of PreoperativeProgressive Pneumoperitoneum• Stretches the abdominal wall, creating a larger cavityfor operative reduction of herniated viscera.• Stretches the hernia sac causing elongation ofadhesions, for an easier dissection.• Induces preoperative respiratory and circulatoryadjustments to the elevation of the diaphragm. 5• Increases tone of fddiaphragm.

www.downstatesurgery.orgTechnique for EstablishingPneumoperitoneum• Intermittent percutaneous puncture of abdominal wall• Spinal needle or a 16-gaugeangiocath.• Increased risk of bowel perforation.• Abdominal indwelling catheter• Started by Steichen in 1965. 3• Modified Seldinger technique.• Catheter connected to a 3-way stop-cock attached to asyringe.

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Technique for EstablishingPneumoperitoneum• Injection of 500 to 1500ml of ambient air uponthe first treatment.• Injection of air isstopped ifwww.downstatesurgery.org• Diffuse abdominal pain• lumbar or shoulder pain,• dyspnea or palpitations. 2• Air is withdrawn ifdiscomfort persists.

www.downstatesurgery.orgTechnique for EstablishingPneumoperitoneum• Total amount of air injecteddepends on• size of hernia and abdominal cavity• presence of adhesions• individual patient tolerance. 7• Air injections every 2 - 5daysforten days to three weeks prior tosurgery.• Insufflations done as outpatient,bed rest not necessary.• Spirometry pre-op.8

www.downstatesurgery.orgResults of Progressive PreoperativePneumoperitoneumHernia repairsPeriod ofpneumoperitoneumType ofrepairResults and complications1 inguinal 19 days via McVay Successful hernia reductionpuncture w. aand primary repairspinal needleAli et al(1975-Washington DC) 1Coopwood et al 1 inguinal 5-6 days via(1987- 1 incsicional puncture w. 16GTennessee) 8 angiocatherLichtensteinNo recurrance at 2 yr f/uNo complicationsiMayagoitia et al 1 inguinal, 9.3 days via Lichtenstein Failed pneumoperitoneum 2(2005-Mexico) 6 11 ventral indwelling cath Wound dinfx 1SQ emphysema 1Abdominal discomfortRodriguez Ortega 2 inguinal,1-3 weeks viaLichtensteinNo recurrences in 10mo-et al(2005-Spain) 21 umbilical,1 incisionalJP drain11yrs f/u

Complications of PreoperativeProgressive Pneumoperitoneum• Organ perforation.www.downstatesurgery.org• Subcutaneous emphysema.• Epigastric i pain, sensation of gastric fullness.• Hematoma formation.• Spontaneous dissection of the gallbladder from thehepatic bed.• Air emboli.• Failure to establish pneumoperitoneum(intraabdominaladhesions from previous surgery) 6

www.downstatesurgery.orgConclusion• Progressive preoperative pneumoperitoneum is auseful fl adjunct ti in the repair rpir of fm massive inguinal i lhriherniaswith loss of domain.• It gradually expands the abdominal cavity andincreases in intraabdominal and thoracic pressures,that may prevent abdominal compartment syndromeand acute respiratory distress upon hernia reduction.• Complications similar to those of pneumoperitoneumfor laparoscopic surgery.

References1. Ali SD, Calhoun T, Kurtz LH (1975) The Use of Pneumoperitoneum in the Treatment t of Megaherniae. JNMA 67:16-18.18.2. Rodriguez M, Garaulet P, Rios R, Jimenez V, Limones E (2006) Pneumoperitoneum in the Treatment ofGiant Hernias. Cir Esp 80: 220-223.223.3. Winfield R, Del Guercio L (1989) The Place for Pneumoperitoneum in the Repair of Massive Hernia.World J Surg 13: 581-585. 585.4. Koontz AR, Graves JW (1954) Preoperative Pneumoperitoneum as an Aid in the Handling of GiganticHernias. Annals Surg 140: 759-762. 762.5. Moreno IG (1947) Chronic Eventrations and Large Hernias: Preoperative Treatments by ProgressivePneumoperitoneum: Original Procedure. Surgery 22: 945-953. 953.6. Mayagoitia JC, Suarez D, Arenas JC, Diaz de Leon V (2005) Preoperative Progressive Pneumoperitoneumin Patients with Abdominal Wall Hernias. World J Hernia Abd Wall SrgOct Surg 20057. Connolly DP, Perri FR Giant Hernias Managed by Pneumoperitoneum (1969) JAMA 209: 71-74748. Coopwood RW, Smith RJ (1988) Treatment of Large Ventral and Scrotal Hernias Using PreoperativePneumoperitoneum. J NMA 81: 402-404. 404.9. Valliattu AJ, Kingsnorth (2008) Single-stage repair of giant inguinoscrotal hernias using the abdominal wallcomponent separation technique. Hernia 12: 329-330. 330.10. Beitler JC, Gomes SM, Coelho ACJ, Manso JEF (2009) Complex inguinal hernia repairs.Hernia 2009:13-6161-666611. Ekwww.downstatesurgery.orgEk EW, Ek ET, Bingham R, Wilson J, Mooney B, Banting SW, Burt J (2006) Component Separation in theRepair of a Giant Inguinoscrotal Hernia. ANZ J Surg 76: 950-952. 952.

www.downstatesurgery.orgQuestions1. Indications for preoperative progressivepneumoperitoneum include:a) Patient with giant inguinal hernia and poor generalmedical condition.b) Massive abdominal wall hernias with loss ofintraabdominal domain.c) Strangulated inguinal hernia with evidence ofischemic bowel.d) Small reducible inguinal hernias.

www.downstatesurgery.orgQuestions2. Loss of intraabdominal domain induces all ofthe following except:a) Impaired venous and lymphatic return fromviscera due to compression from the hernia defectcausing dilation of mesentery and bowel walledema.b) Decrease in intraabdominal pressure.c) Decrease capacity of the abdominal cavity.d) Elevation of the diaphragm.

www.downstatesurgery.orgQuestions3. Possible complications of reduction of massiveinguinal hernias include:a) Increased abdominal pressure and decreasedvenous return leading abdominal compartmentsyndrome.b) Elevation of diaphragm leading to increasedthoracic pressure causing respiratory distress.c) Dehiscence with hernia recurrence.d) All of the above.

www.downstatesurgery.orgQuestions4. Regarding establishment of pneumoperitoneumall are correct except:a) Injection of air is done via indwelling catheter.b) Injection of air is stopped when patient complaintsof diffuse abdominal pain, lumbar or shoulderpain, dyspnea or palpitations.ic) Injection of air is done on an in-patient basis.d) Pneumoperitoneum can be effectivelyinstituted from ten days to three weeks prior tosurgery.

www.downstatesurgery.orgQuestions5. The advantages of Preoperative ProgressivePneumoperitoneum include:a) Stretching of the abdominal wall, creating a larger cavityfor operative reduction of herniated viscera.b) Stretching of the hernia sac causing elongation ofadhesions, for an easier dissection or reduction.c) Increased tone of diaphragm.d) Preoperative respiratory and circulatory adjustments tothe elevation of the diaphragm.d)e) All of the above.

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