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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

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

INTRODUCTION: 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. PURPOSE: The purpose of the paper was to analyze the literature about PPP and gather information about the procedure and its indications, advantages, and disadvantages. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Abdominal wall reconstruction with biosynthetic absorbable mesh after infected prosthesis explantation: single stage is better than two-stage approach of chronic mesh infection.

PURPOSE: To assess the efficacy of surgical management of chronic mesh infection (CMI) after abdominal wall hernia repair (AWHR) in single-stage approach (complete removal of infected prosthesis and simultaneous replacement with poly-4-hydroxybutyrate mesh or BAM group), comparing results with two-stage treatment (complete mesh excision and abdominal wall repair with synthetic mesh after several months or SPM group). METHODS: Retrospective comparative study of all patients who underwent surgery for CMI between January 2006 and January 2019 at a tertiary center. We compared results in terms of epidemiological data, hernia and prosthesis characteristics, surgical and postoperative variables of both two groups. RESULTS: Over the 13-year study period, 2791 AWHR was performed at our hospital; the overall CMI rate was 2.5%. Of 71 patients, 30 (42.2%) were in BAM group and 41 (57.8%) in SPM group. The median cumulative operative time (252 min versus 132 min) and length of stay (16.6 days versus 6.2 days) were significatively longer in SPM group compared with BAM group, due to the need of two surgical procedures. There were a higher number of postoperative complications in SPM group (p = 0.002), some of them grade III. With mean follow-up of 36.5 months (range 21-59), there were no significant differences in terms of overall hernia recurrence and mesh reinfection in both groups. CONCLUSION: The use of a poly-4-hydroxybutyrate resorbable mesh in single-stage management of CMI may be a safe and better option than two-stage approach, although more studies are needed to confirm our results.