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Preoperative progressive pneumoperitoneum in preparation for repair of large hernias of the abdominal wall
Preoperative Progressive Pneumoperitoneum in Preparation for Repair of Large Hernias of the Abdominal Wall LCDR Willard C. Johnson, MC, USNR, Chelsea, Massachusetts
Preoperative pneumoperitoneum as an adjunct to the repair of abdominal wall hernias was introduced in Buenos Aires in 1940 by Moreno [1,2] and in this country in 1954 by Koontz [3]. From 1954 to the present there have been sporadic reports [4-131 indicating only about twenty-five cases in which patients have been pretreated by pneumoperitoneum in the United States. The advent of prosthetic graft materials, particularly Marlex@ in the late 1950’s, improved the technic of repair of difficult large abdominal wall defects to such an extent that the benefits of preoperative progressive pneumoperitoneum were quickly forgotten and the technic is presently used infrequently. My experience with preoperative progressive pneumoperitoneum has been so gratifying that I believe it to be a beneficial adjunct to hernia repair, and thus would like to present several case reports and discuss the indications and benefits of this procedure. I also wish to discuss complications, with particular regard to respiratory impairment during preoperative progressive pneumoperitoneum, and to present respiratory function data which would tend to indicate that this is minimal, and indeed that postoperative respiratory performance is better than anticipated.
Case I. (Paruileal Conduit Hernia). Five years prior to admission, an obese twenty-seven year old man under-
went bilateral ureteral diversion into an ileal conduit because of bilateral hydronephrosis and pyelonephritis secondary to a neurogenic bladder. Two years prior to admission he underwent left nephrectomy for pyelonephritis, sepsis, and an obstructed left ureter causing a hydronephrotic kidney. Subsequently a progressively enlarging hernia developed in the right lower abdomen that contained his ileal conduit. Repair of this hernia was considered too formidable an undertaking by several surgeons six months prior to admission. On admission his weight was 280 pounds and his hernia measured i6 by 16 by 6 cm, and contained an estimated volume of 1,800 cc. (Figure 1.) Creatinine level had recently been elevated from 3.0 to 5.0 mg per cent and the patient was having intermittent hematuria. An ileal “loopogram” showed a distorted conduit, and because of his progressive disability, a hernia repair was considered mandatory. Preoperatively over an eighteen day period he received, in increments of 2,000 cc, a total of 15,500 cc of air. At surgery a fascial defect 12 by 8 cm was found through which the ileal conduit and other loops of bowel were herniated. As a result of preoperative progressive pneumoperitoneum there was enough relaxation to reduce the contents of the hernia and accomplish primary closure without excessive tension on the suture line. Postoperatively, he began eating and was ambulatory on the first day. He experienced no complications and was discharged home on the seventh postoperative day. (Figure 2.) No recurrence is noted at four months; and a postoperative loopogram showed marked improvement in the configuration of the ileal conduit and retrograde ureteral filling. The creatinine level has decreased from a preoperative value of 5.0 to 3.8 mg per cent.
From the Department of Surgery, Naval Hospital Boston, Chelsea, Massachusetts 02150. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at Large. Reprint requests should be addressed to Dr Johnson, Department of Surgery, Boston Veterans Hospital, Boston, Massachusetts 02130.
Case II. (Large Scrotal Hernia). A seventy-six year old man had a history of progressive enlargement of his scrotum during the past twenty years. He regularly smoked forty cigarettes a day and had chronic bronchitis and emphysema. His abdomen was scaphoid with firm
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Figure 1.
Case I. Status on admission.
musculature; the scrotal hernia extended to the mid-thigh level and its volume was estimated at about 1,800 cc. He received 8,000 cc of intraperitoneal air over an eighteen day period. Thereafter right inguinal herniorrhaphy was performed without difficulty and there is no evidence of recurrence at two years. Case III. (Large Scrotal Hernia). A fifty-three year old man was a known chronic alcoholic, having been hospitalized for pancreatitis and hepatic coma four years prior to admission. At that time he was noted to have a right scrotal hernia. For the next three years he abstained from alcohol. He has had pneumonia three times and has smoked thirty cigarettes per day for more than thirty years. His hernia had increased to the size of a small grapefruit. Routine laboratory examination including liver function tests showed no abnormalities. During a ten day preoperative evaluation period he received 6,000 cc of air intraperitoneally; thereafter, right inguinal herniorrhaphy was performed without difficulty. There is no recurrence at six months and his only complication was a Staphylococcus aureus wound infection.
(Incisional Hernia). An obese (205 pound) forty-two year old woman, who seven years previously had had an abdominal hysterectomy, noted an incisional hernia three years prior to admission that had increased until the sac was 30 by 10 by 8 cm. The contents were incarcerated, causing continuous pain. Of interest is the fact that her mother had died at the age of forty-five after an incisional hernia repair. Preoperatively over eleven days she received 8,000 cc of air intraperitoneally. At surgery, despite a fascial defect of 20 by 8 cm, there was enough relaxation to accomplish primary closure without tension on the suture line. There were no postoperative complications and no recurrence was noted at one year. Case
IV.
Case V. (Incisional Hernia). A sixty-four year old man, a retired bartender and heavy smoker, had had emergency partial gastrectomy through a midline incision six years prior to admission. A wound infection developed
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Case 1. Status at discharge seven days postFigure 2. operative/y.
postoperatively, and two years later an incisional hernia was noted. This increased in size until a defect of 5 by 6 cm was present in the epigastrium. He also had hepatomegaly with the liver 12 cm below the right costal margin and a protuberant abdomen. He had previously had an inferior myocardial infarction. Preoperatively over eight days he received 3,600 cc of pneumoperitoneum. The surgical and postoperative courses were uneventful, and no recurrence is noted at eighteen months. Case VI. (Recurrent Incisional Hernia). A forty-three year old woman with chronic arthritis had a hysterectomy eighteen months prior to admission and repair of an incisional hernia six months thereafter; however, the hernia soon recurred. Physical examination showed a thin abdominal wall and a fascial defect 10 by 4 cm with a small hernia sac. She was treated with 2,000 cc of pneumoperitoneum and had an uneventful surgical repair and postoperative course. No recurrence is present at eight months. Case VII. (Recurrent Ventral Hernia). A fifty-two year old woman had previously had seven abdominal operations including two unsuccessful incisional hernia repairs. She smoked forty cigarettes per day and had dyspnea after climbing one flight of stairs. She was hypertensive and roentgenograms revealed mild cardiomegaly and pulmonary fibrosis. There were multiple scars on her abdomen with thin musculature and a fascial defect 4 by
The American Journal of Surgery
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8 cm above the umbilicus and another defect measuring 4 by 3 cm below the umbilicus. During the three weeks prior to surgery she received 7,500 cc of air intraperitoneally. At surgery the fascial defects were closed without tension. The postoperative course was uneventful and she was discharged on the sixth postoperative day. No recurrence was noted at one year. Case VIII. (Incarcerated Ventral Hernia). A forty-six year old obese diabetic woman had had an appendectomy at the age of five, and thereafter a “bulge” existed in the right lower quadrant. Five years prior to admission she had had cholecystectomy through a right subcostal incision. Recently the mass in the right lower quadrant had increased in size and physical examination revealed an irreducible hernia (20 by 10 by 3 cm) in the right midabdomen, midway between the cholecystectomy and appendectomy scars. She was treated over the next thirteen days with 8,000 cc of pneumoperitoneum. At surgery she had a large hernia sac that contained omentum and was incarcerated through a 5 by 8 cm fascial defect at the site of the appendectomy incision. Repair was accomplished with ease and she had no postoperative complications and no recurrence at one year.
Case IX. (Zncisional Hernia and Concomitant Carcinoma of the Colon). A sixty-two year old woman had cholecystectomy through a midline incision twelve years ago which was complicated by an incisional hernia that was repaired six months later. A recurrent hernia developed five years later and was reducible until one year prior to the patient’s admission. Physical examination revealed a 12 by 18 cm mass in the subcutaneous tissue that was irreducible. Barium enema suggested that a lesion was present in the transverse colon, incarcerated in the hernia sac. She was treated with 8,000 cc of pneumoperitoneum over a ten day period. At surgery a large carcinoma of the transverse colon was found and the patient was treated by transverse colectomy. The fascial defect measured 10 by 4 cm and was enlarged to perform the colectomy. Closure was accomplished without difficulty and the only postoperative complication was a superficial wound infection. There has been no recurrence at eight months. Case X. (Recurrent Ventral Hernia and Zncisional Hernia). Two years prior to admission an obese fortythree year old man had repair of a hiatal hernia and cholecystectomy through an upper midline incision. Six months later an incisional hernia was diagnosed and repaired; however, the hernia recurred before the patient was discharged from the hospital. Six months ago he was admitted for repair of this hernia; however, at that time he had partial obstruction of the sigmoid colon that required sigmoid colectomy to eliminate the possibility of cancer. Postoperatively a deep wound infection developed followed by an incisional hernia which has progressively enlarged. On admission his weight was 208 pounds, and theeepigastric hernia measured 12 by 6 by 3 cm and the
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left lower quadrant incisional hernia 18 by 6 by 2 cm. Each of these hernias contained a few loops of bowel and were easily reduced. Preoperatively over a twenty-two day period he received a total of 15,700 cc of air. At surgery each hernia was repaired with a “pants over vest” technic without excessive tension,’ with the suture lines measuring 15 cm in the epigastrium and 22 cm in the lower abdomen. The peritoneal cavity contained a small amount of cloudy fluid which was sterile on culture. Postoperatively the patient began to walk on the first day and was eating on the third day. He was discharged on the tenth postoperative day with no complication. No recurrence of the hernia is noted at two months. Comments Technic of Pneumoperitoneum. The technic involves the gradual distention of the abdominal wall over a five to ten day period by the injection of about 2,000 cc of air every forty-eight hours to a total of 6 to 10 L, depending on the size of the hernia sac and the size of the patient. The evening before the first injection the patient is usually given a laxative. With the patient supine, a portion of the lower abdomen, away from any scar tissue, is prepared with alcohol and Xylocainee is introduced locally into the skin and subcutaneous tissue. A 5.5 inch number 16 gauge Bardice Angiocath,@ is inserted obliquely into the peritoneal cavity. Entry into the peritoneum is ascertained by the slight painful sensation experienced by the patient and the “give” felt as the needle enters the cavity. The ease with which air is introduced verifies the correct position. One or two liters of room air is introduced over a ten minute period with a three-way stopcock and a 50 cc syringe. The instillation is terminated when the patient has discomfort and shortness of breath, or when flank tension occurs. Indications for Progressive Pneumoperitoneum. The loss of the “right of domain”: Infrequently
1.
a hernia is seen that has such a large sac that a significant portion of the abdominal viscera is residing outside the abdominal cavity. Over a period of time no space is left in the abdomen to accommodate the replacement of such viscera. The contents of the sac have lost the “right of domain” in the abdomen. Such a patient would seem to be an absolute indication for preoperative progressive pneumoperitoneum if repair cannot be performed without resection of the viscera and without causing respiratory embarrassment. To reconstruct a larger abdominal cavity by using Marlex is a major surgical undertaking and the viability of the skin overlying the Marlex of real concern. Cases I, II, III, IV, and VIII are examples of such patients.
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2. Concomitant bowel surgery: At times a patient may be seen who has both an incisional hernia and a lesion that requires partial resection of the gastrointestinal tract. Such a case is potentially contaminated, and thus Marlex cannot be used to correct the hernia. However, if difficulty with closure of the hernia is anticipated, preoperative progressive pneumoperitoneum can allow primary closure, as in case IX. 3. Paracolostomy and paraileostomy hernias: It is difficult to repair a large hernia through the fascia which involves a colostomy or ileostomy not only because of the risk of bacterial contamination but also because the defect must be approximated precisely to prevent future herniation without strangulating the bowel (case I). 4. The “recurrent” ventral hernia: If by conventional technics an attempt to repair a ventral hernia has failed, then using progressive pneumoperitoneum prior to repair should be considered. This technic can offer the patient repair where there is minimal tension on the suture line at surgery and during the immediate postoperative period as well, when he is at the highest risk for recurrence. Cases VI, VII, and X report such patients. 5. Alternative to Marlex: If a patient with a defect that would usually be repaired with Marlex is prepared preoperatively with progressive pneumoperitoneum, primary fascial repair is accomplished avoiding the Hemova@ drainage, prophylactic antibiotics, and nasogastric decompression that are usually required when Marlex is used. The associated frequent seroma and infrequent chronic draining sinuses are also eliminated (cases V, VI, VII, and Xl. 6. Infected prosthetic meshes: Rarely will one find a patient who has Marlex mesh repair, a chronic infection with draining sinus tracts, and the “spitting” of Marlex. Such a patient is condemned to a protracted course of repeated episodes of local sepsis with the little hope of relief. Before I started using preoperative progressive pneumoperitoneum I was caring for such a patient, an elderly obese woman who had undergone emergency surgery for an incarcerated ventral hernia with gangrenous colon. Marlex was used to close the fascial defect. Postoperatively a small wound infection developed and two years later was still draining purulent material even though on repeated occasions I had removed fragments of mesh. Such a patient might have been treated progressively with about 10 L of pneumoperitoneum and removal of the infected prosthesis with primary fascial closure. 7. Obesity: At times we insist that obese persons with a ventral hernia first lose 50 or 60 pounds before repair can be considered. However, the ability of the
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physician to direct the patient to follow such a weight reducing plan is frequently impossible. Even if successful, the patient may be in a negative nitrogen balance and in too poor a nutritional state to undergo major surgery and associated healing process. These obese patients, however, are not prohibitive surgical candidates when progressive pneumoperitoneum is utilized preoperatively as shown in cases I, IV, V, VII, VIII, and X. Benefits of Preoperative Progressive Pneumoperitoneum. 1. Recurrence rate: Although the follow-
up period in this small series has not been longer than two years, the recurrence rate has been zero. However, such recurrences usually do occur early and the minimal stresses on the incision during its healing phase probably account for the good early results. 2. Respiratory considerations: Patients who have chronic lung disease, that is, emphysema or chronic obstructive bronchitis, and those with purulent bronchitis are known risks for postoperative respiratory insufficiency. The elevation of the diaphragms resulting from the preoperative progressive pneumoperitoneum encourages patients to breathe with the thoracic musculature and to become accustomed to breathing with a mild reduction in vital capacity. Postoperatively, they can now breathe with both diaphragmatic and thoracic musculature. In addition, the relaxed abdominal wall allows a reduction in suture line tension that reduces incisional pain. The reduction of incisional pain contributes to respiratory well-being by decreasing immobility with associated hypostasis. The degree of impairment of vital capacity with preoperative progressive pneumoperitoneum appears to be moderate and well tolerated. Pulmonary function tests have been carried out in several patients and the results are listed in Tables I and II. In Table I it is interesting to note that even after several liters of air have been introduced and the -abdomen is quite tense, the maximal reduction in vital capacity is about 25 per cent of the initial value. That the time period involved in preoperative progressive pneumoperitoneum is enough to develop the thoracic musculature would seem to be indicated by several patients who not only failed to be distressed by the procedure but actually improved during the course (that is, in cases VIII and IX, after 6,000 cc the vital capacity was about the same as the initial volume). The pulmonary function studies that have been carried out in the immediate postoperative period showed a vital capacity of 60 to 75 per cent of initial prepneumoperitoneum value. Although a control se-
The American Journal of Surgery
Pneumoperitoneum
TABLE I
3 7 a 9
10
Diagnosis Paraileal conduit hernia Scrotal hernia Incisional hernia Ventral hernia Incisional hernia and carcinoma of colon Ventral and incisional hernias
Before Injection
Volume of Pneumoperitoneum
10
Repair
6,000
6,000
4,205 4,387 2,014 2,047
.. . ... ..
.. . ...
..
. 3,290 1,758 2,181
::: 1,523 i,aa3t
2,647
2,194
2,585
2,585
2,139
4,200
...
...
...
...
..
hours after injection
3,493 . ..
.
First Day Postoperatively
3,627 3,476
...
. ..
2,320
.
1,775
3,674
2,320
of air.
the use of pneumoperitoneum occurred in a patient who had received 8;OOOcc of air over a ten day period prior to correction of a large incisional hernia. Induction of anesthesia was with 80 per cent nitrous oxide. This lead to the rapid transfer of nitrous oxide into the peritoneal cavity, an acute increase in intraabdominal pressure, and a marked reduction in ventilatory compliance and in hypotension [16]. This situation was rapidly corrected by trocar decompression of the abdomen and can be avoided either by removing the peritoneal air prior to the induction of nitrous oxide anesthesia or by the chaice of another anesthetic agent. Minimal subcutaneous emphysema does frequently occur secondary to leakage from the peritoneal cavity back into the subcutaneous tissue after removal of the catheter. This has so far not been a problem. There are several potential complications that will be briefly discussed. Perforation of the bowel at the
Forced Expiratory Volume, (cc)*
Diagnosis
Case
3 7 a 9
15,000
4,000
ries is not available, this value is higher than one might expect from data by Finer [14], Anscombe [15], and Johnson [17]. Finer has shown that after a routine cholecystectomy the vital capacity on the first postoperative day is usually only 40 per cent of the preoperative value. 3. Pain: The reduction of incisional pain is significant and this is explained by the lack of tension on the suture lines. Although it is difficult to quantitate this pain, most patients require no narcotics and are usually complaining of such other things as intravenous catheters, warm rooms, and poor televisions. 4. Intestinal mobility: The bowel, exposed to increased extraluminal pressures preoperatively, is decompressed at surgery and thus postoperative peristaltic activity is more effective. Early ambulation and decreased narcotic requirements may also contribute to the fact that postoperative nasogastric decompression is seldom necessary. Complications. One complication associated with
1
(cc)
2,000
* Vital capacity was usually measured twenty-four t Immediately after 2,000 cc had been introduced.
TABLE II
Hernia
Vital Capacity (cc)*
Case 1
for Abdominal
Paraileal conduit hernia Scrotal hernia Incisional hernia Ventral hernia Incisional hernia and carcinoma of colon Ventral and incisional hernia
Before Injection
Volume of Pneumoperitoneum 4,000
4,025 3,203 i ,598 i ,728
...
...
...
.. ...
..
..
1,856
2,369 1,474 ...
::: 1,294 1,654.f
2.139
1,702
1,605
i ,827
1,694
3,521
...
.
..
...
* FEV, was usually measured twenty-four hours after injection t Immediately after 2,000 cc had been introduced.
Volume124, July 1972
(cc)
2,000
6.000
8,000
15,000
First Day Postoperatively
3,493 . ..
3,135 2.179
... .. .
... ...
..
i ,287
2,985
1,800
of air
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time the catheter is introduced may conceivably occur. However, in the absence of bowel obstruction, the sequelae of such a perforation are assumed to be clinically insignificant. In case X, the peritoneal cavity contained a small amount of cloudy fluid which was sterile on culture. This may have been secondary to a puncture of the bowel wall; however, clinical sepsis was not apparent during administration of pneumoperitoneum. Preferential distention of the hernia sac, that is, Laplace’s Law, does not seem to occur. Clinically, this may be because of fibrosis in the overlying skin and subcutaneous tissue. The abdominal cavity exposed to room air during surgery appears capable of resisting infection from this source, so that bacterial contamination from pneumoperitoneum is most likely only a theoretical possibility. Air emboli associated with pneumoperitoneum have occurred in the treatment of tuberculosis and in peritoneoscopy. However, these cases were always associated with direct intrahepatic, intrasplenic, or intravenous injection [I&19]. This potential complication is completely preventable by proper technic. Venous stasis and associated risk for thrombosis may possibly be considered a potential hazard associated with the increase in intra-abdominal pressure. Clinically, no evidence of impaired venous return from the legs has been detected. This may be because the maximal intra-abdominal pressure usually is only 8 to 10 cm of water. Normal variation of the venous volume with respiration is found in the presence of pneumoperitoneum as evidenced by several patients who had measurements of venous patency with an impedence meter using the technic of Wheeler [20]. Summary
A series is presented of ten patients who had complex hernias that were treated with preoperative progressive pneumoperitoneum. The benefits of this method are indicated in the dramatic clinical picture of these patients in the postoperative period, when they are breathing without difficulty, have minor incisional pain, are ambulating with ease, voidilig well, and usually hungry. The indications for preoperative progressive pneumoperitoneum are in massive hernias where the “right of domain” is lost, large scrotal hernias, with concomitant bowel surgery, in recurrent ventral hernias, in obese patients,
as an alternative to using Marlex mesh, and in correcting hernias in which the prosthesis is infected. Respiratory function data are presented indicating that not only is ventilatory performance not significantly impaired during preoperative progressive pneumoperitoneum but also that it is improved in the postoperative period when this technic is used.
References 1. Moreno IG: Chronic eventration and large hernias: preoperative treatment by progressive pneumoperitoneum. Surgery 22: 945, 1947. 2. Moreno IG: The rational treatment of hernias and voluminous chronic eventration, p 668. Hernia (Nyhus LM. and Harkins HH, ed). Philadelphia, JB Lippincott Co, 1964. 3. Koontz AR, Graves JW: Preoperative pneumoperitoneum as an aid in the handling of gigantic hernias. Ann Surg 140: 759,1954. 4. Mason EE: Pneumoperitoneum in the management of giant hernia. Surgery 39: 143, 1956. 5. Koontz AR: Hernias that have forfeited the right of domicile: use of pneumoperitoneum as an aid in their operative care. Southern Med J 51: 165, 1958. 6. Mansuy MM, Hager HG: Pneumoperitoneum in preparation for correction of giant hernias. New Eng J Med 258: 33, 1956. 7. Moyer CA, Butcher HR: Experiences with pneumoperitoneum for massive ventral hernias, p 703. Hernia (Nyhus LM, and Harkins HH, ed). Philadelphia, JB Lippincott Co, 1964. 8. Pingree JH. Clark JH: Pneumoperitoneum: a neglected procedure for the repair of large abdominal hernias. Arch Surg 96: 252, 1968. 9. Connolly DP. Perri RF: Giant hernias managed by pneumoperitoneum. JA MA 209: 71.1969. 10. Pines B: Pneumoperitoneum in the preparation for correction of a large abdominal hernia in an infant. Pediatrics 26: 276, 1969. 11. Moore RP: Giant ventral hernia and pneumoperitoneum. Northwest Med 60: 51,1961. 12. Martin RE: Successful repair of the seventh recurrence of a massive incisional hernia. Amer J Surg 111: 565, 1966. 13. Ziffrin SE, Womach NA: An operative approach to the treatment of gigantic hernias. Surg Gynec Obsfet 91: 709, 1950. 14. Finer B: Studies on the variability in expiratory efforts before and after cholecystectomy. Acta Anesfh Stand (suppl38): 1, 1970. 15. Anscombe AR: Pulmonary Complications of Abdominal Surg&y. Chicago, Year Book Medical Publishers, 1957. 18. Johnson WC: Pulmonary function data in the pre and postoperative period. (Submitted for publication.) 17. Johnson WC: Pneumoperitoneum for ventral hernia repair: anesthesia complication. JA MA 217: 968, 1971. 18. Dasher WA, Black JPM, et al: Air emboli complicating pneumoperitoneum; a review. Amer Rev Tuberc 69: 396, 1954. 19. Jernstrom P: Air emboli during peritoneoscopy. Amer J C/in Path 21: 573,195l. 20. Wheeler HG et al: Diagnosis of occult deep vein thrombosis by a non invasive bedside technique. Surgery 70: 20. 1971.
The American Journal of Surgery
Preoperative pneumoperitoneum as an adjunct to the repair of abdominal wall hernias was introduced in Buenos Aires in 1940 by Moreno [1,2] and in this country in 1954 by Koontz [3]. From 1954 to the present there have been sporadic reports [4-131 indicating only about twenty-five cases in which patients have been pretreated by pneumoperitoneum in the United States. The advent of prosthetic graft materials, particularly Marlex@ in the late 1950’s, improved the technic of repair of difficult large abdominal wall defects to such an extent that the benefits of preoperative progressive pneumoperitoneum were quickly forgotten and the technic is presently used infrequently. My experience with preoperative progressive pneumoperitoneum has been so gratifying that I believe it to be a beneficial adjunct to hernia repair, and thus would like to present several case reports and discuss the indications and benefits of this procedure. I also wish to discuss complications, with particular regard to respiratory impairment during preoperative progressive pneumoperitoneum, and to present respiratory function data which would tend to indicate that this is minimal, and indeed that postoperative respiratory performance is better than anticipated.
Case I. (Paruileal Conduit Hernia). Five years prior to admission, an obese twenty-seven year old man under-
went bilateral ureteral diversion into an ileal conduit because of bilateral hydronephrosis and pyelonephritis secondary to a neurogenic bladder. Two years prior to admission he underwent left nephrectomy for pyelonephritis, sepsis, and an obstructed left ureter causing a hydronephrotic kidney. Subsequently a progressively enlarging hernia developed in the right lower abdomen that contained his ileal conduit. Repair of this hernia was considered too formidable an undertaking by several surgeons six months prior to admission. On admission his weight was 280 pounds and his hernia measured i6 by 16 by 6 cm, and contained an estimated volume of 1,800 cc. (Figure 1.) Creatinine level had recently been elevated from 3.0 to 5.0 mg per cent and the patient was having intermittent hematuria. An ileal “loopogram” showed a distorted conduit, and because of his progressive disability, a hernia repair was considered mandatory. Preoperatively over an eighteen day period he received, in increments of 2,000 cc, a total of 15,500 cc of air. At surgery a fascial defect 12 by 8 cm was found through which the ileal conduit and other loops of bowel were herniated. As a result of preoperative progressive pneumoperitoneum there was enough relaxation to reduce the contents of the hernia and accomplish primary closure without excessive tension on the suture line. Postoperatively, he began eating and was ambulatory on the first day. He experienced no complications and was discharged home on the seventh postoperative day. (Figure 2.) No recurrence is noted at four months; and a postoperative loopogram showed marked improvement in the configuration of the ileal conduit and retrograde ureteral filling. The creatinine level has decreased from a preoperative value of 5.0 to 3.8 mg per cent.
From the Department of Surgery, Naval Hospital Boston, Chelsea, Massachusetts 02150. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at Large. Reprint requests should be addressed to Dr Johnson, Department of Surgery, Boston Veterans Hospital, Boston, Massachusetts 02130.
Case II. (Large Scrotal Hernia). A seventy-six year old man had a history of progressive enlargement of his scrotum during the past twenty years. He regularly smoked forty cigarettes a day and had chronic bronchitis and emphysema. His abdomen was scaphoid with firm
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Figure 1.
Case I. Status on admission.
musculature; the scrotal hernia extended to the mid-thigh level and its volume was estimated at about 1,800 cc. He received 8,000 cc of intraperitoneal air over an eighteen day period. Thereafter right inguinal herniorrhaphy was performed without difficulty and there is no evidence of recurrence at two years. Case III. (Large Scrotal Hernia). A fifty-three year old man was a known chronic alcoholic, having been hospitalized for pancreatitis and hepatic coma four years prior to admission. At that time he was noted to have a right scrotal hernia. For the next three years he abstained from alcohol. He has had pneumonia three times and has smoked thirty cigarettes per day for more than thirty years. His hernia had increased to the size of a small grapefruit. Routine laboratory examination including liver function tests showed no abnormalities. During a ten day preoperative evaluation period he received 6,000 cc of air intraperitoneally; thereafter, right inguinal herniorrhaphy was performed without difficulty. There is no recurrence at six months and his only complication was a Staphylococcus aureus wound infection.
(Incisional Hernia). An obese (205 pound) forty-two year old woman, who seven years previously had had an abdominal hysterectomy, noted an incisional hernia three years prior to admission that had increased until the sac was 30 by 10 by 8 cm. The contents were incarcerated, causing continuous pain. Of interest is the fact that her mother had died at the age of forty-five after an incisional hernia repair. Preoperatively over eleven days she received 8,000 cc of air intraperitoneally. At surgery, despite a fascial defect of 20 by 8 cm, there was enough relaxation to accomplish primary closure without tension on the suture line. There were no postoperative complications and no recurrence was noted at one year. Case
IV.
Case V. (Incisional Hernia). A sixty-four year old man, a retired bartender and heavy smoker, had had emergency partial gastrectomy through a midline incision six years prior to admission. A wound infection developed
64
Case 1. Status at discharge seven days postFigure 2. operative/y.
postoperatively, and two years later an incisional hernia was noted. This increased in size until a defect of 5 by 6 cm was present in the epigastrium. He also had hepatomegaly with the liver 12 cm below the right costal margin and a protuberant abdomen. He had previously had an inferior myocardial infarction. Preoperatively over eight days he received 3,600 cc of pneumoperitoneum. The surgical and postoperative courses were uneventful, and no recurrence is noted at eighteen months. Case VI. (Recurrent Incisional Hernia). A forty-three year old woman with chronic arthritis had a hysterectomy eighteen months prior to admission and repair of an incisional hernia six months thereafter; however, the hernia soon recurred. Physical examination showed a thin abdominal wall and a fascial defect 10 by 4 cm with a small hernia sac. She was treated with 2,000 cc of pneumoperitoneum and had an uneventful surgical repair and postoperative course. No recurrence is present at eight months. Case VII. (Recurrent Ventral Hernia). A fifty-two year old woman had previously had seven abdominal operations including two unsuccessful incisional hernia repairs. She smoked forty cigarettes per day and had dyspnea after climbing one flight of stairs. She was hypertensive and roentgenograms revealed mild cardiomegaly and pulmonary fibrosis. There were multiple scars on her abdomen with thin musculature and a fascial defect 4 by
The American Journal of Surgery
Pneumoperitoneum
8 cm above the umbilicus and another defect measuring 4 by 3 cm below the umbilicus. During the three weeks prior to surgery she received 7,500 cc of air intraperitoneally. At surgery the fascial defects were closed without tension. The postoperative course was uneventful and she was discharged on the sixth postoperative day. No recurrence was noted at one year. Case VIII. (Incarcerated Ventral Hernia). A forty-six year old obese diabetic woman had had an appendectomy at the age of five, and thereafter a “bulge” existed in the right lower quadrant. Five years prior to admission she had had cholecystectomy through a right subcostal incision. Recently the mass in the right lower quadrant had increased in size and physical examination revealed an irreducible hernia (20 by 10 by 3 cm) in the right midabdomen, midway between the cholecystectomy and appendectomy scars. She was treated over the next thirteen days with 8,000 cc of pneumoperitoneum. At surgery she had a large hernia sac that contained omentum and was incarcerated through a 5 by 8 cm fascial defect at the site of the appendectomy incision. Repair was accomplished with ease and she had no postoperative complications and no recurrence at one year.
Case IX. (Zncisional Hernia and Concomitant Carcinoma of the Colon). A sixty-two year old woman had cholecystectomy through a midline incision twelve years ago which was complicated by an incisional hernia that was repaired six months later. A recurrent hernia developed five years later and was reducible until one year prior to the patient’s admission. Physical examination revealed a 12 by 18 cm mass in the subcutaneous tissue that was irreducible. Barium enema suggested that a lesion was present in the transverse colon, incarcerated in the hernia sac. She was treated with 8,000 cc of pneumoperitoneum over a ten day period. At surgery a large carcinoma of the transverse colon was found and the patient was treated by transverse colectomy. The fascial defect measured 10 by 4 cm and was enlarged to perform the colectomy. Closure was accomplished without difficulty and the only postoperative complication was a superficial wound infection. There has been no recurrence at eight months. Case X. (Recurrent Ventral Hernia and Zncisional Hernia). Two years prior to admission an obese fortythree year old man had repair of a hiatal hernia and cholecystectomy through an upper midline incision. Six months later an incisional hernia was diagnosed and repaired; however, the hernia recurred before the patient was discharged from the hospital. Six months ago he was admitted for repair of this hernia; however, at that time he had partial obstruction of the sigmoid colon that required sigmoid colectomy to eliminate the possibility of cancer. Postoperatively a deep wound infection developed followed by an incisional hernia which has progressively enlarged. On admission his weight was 208 pounds, and theeepigastric hernia measured 12 by 6 by 3 cm and the
Volume
124,July1972
for Abdominal
Hernia Repair
left lower quadrant incisional hernia 18 by 6 by 2 cm. Each of these hernias contained a few loops of bowel and were easily reduced. Preoperatively over a twenty-two day period he received a total of 15,700 cc of air. At surgery each hernia was repaired with a “pants over vest” technic without excessive tension,’ with the suture lines measuring 15 cm in the epigastrium and 22 cm in the lower abdomen. The peritoneal cavity contained a small amount of cloudy fluid which was sterile on culture. Postoperatively the patient began to walk on the first day and was eating on the third day. He was discharged on the tenth postoperative day with no complication. No recurrence of the hernia is noted at two months. Comments Technic of Pneumoperitoneum. The technic involves the gradual distention of the abdominal wall over a five to ten day period by the injection of about 2,000 cc of air every forty-eight hours to a total of 6 to 10 L, depending on the size of the hernia sac and the size of the patient. The evening before the first injection the patient is usually given a laxative. With the patient supine, a portion of the lower abdomen, away from any scar tissue, is prepared with alcohol and Xylocainee is introduced locally into the skin and subcutaneous tissue. A 5.5 inch number 16 gauge Bardice Angiocath,@ is inserted obliquely into the peritoneal cavity. Entry into the peritoneum is ascertained by the slight painful sensation experienced by the patient and the “give” felt as the needle enters the cavity. The ease with which air is introduced verifies the correct position. One or two liters of room air is introduced over a ten minute period with a three-way stopcock and a 50 cc syringe. The instillation is terminated when the patient has discomfort and shortness of breath, or when flank tension occurs. Indications for Progressive Pneumoperitoneum. The loss of the “right of domain”: Infrequently
1.
a hernia is seen that has such a large sac that a significant portion of the abdominal viscera is residing outside the abdominal cavity. Over a period of time no space is left in the abdomen to accommodate the replacement of such viscera. The contents of the sac have lost the “right of domain” in the abdomen. Such a patient would seem to be an absolute indication for preoperative progressive pneumoperitoneum if repair cannot be performed without resection of the viscera and without causing respiratory embarrassment. To reconstruct a larger abdominal cavity by using Marlex is a major surgical undertaking and the viability of the skin overlying the Marlex of real concern. Cases I, II, III, IV, and VIII are examples of such patients.
65
Johnson
2. Concomitant bowel surgery: At times a patient may be seen who has both an incisional hernia and a lesion that requires partial resection of the gastrointestinal tract. Such a case is potentially contaminated, and thus Marlex cannot be used to correct the hernia. However, if difficulty with closure of the hernia is anticipated, preoperative progressive pneumoperitoneum can allow primary closure, as in case IX. 3. Paracolostomy and paraileostomy hernias: It is difficult to repair a large hernia through the fascia which involves a colostomy or ileostomy not only because of the risk of bacterial contamination but also because the defect must be approximated precisely to prevent future herniation without strangulating the bowel (case I). 4. The “recurrent” ventral hernia: If by conventional technics an attempt to repair a ventral hernia has failed, then using progressive pneumoperitoneum prior to repair should be considered. This technic can offer the patient repair where there is minimal tension on the suture line at surgery and during the immediate postoperative period as well, when he is at the highest risk for recurrence. Cases VI, VII, and X report such patients. 5. Alternative to Marlex: If a patient with a defect that would usually be repaired with Marlex is prepared preoperatively with progressive pneumoperitoneum, primary fascial repair is accomplished avoiding the Hemova@ drainage, prophylactic antibiotics, and nasogastric decompression that are usually required when Marlex is used. The associated frequent seroma and infrequent chronic draining sinuses are also eliminated (cases V, VI, VII, and Xl. 6. Infected prosthetic meshes: Rarely will one find a patient who has Marlex mesh repair, a chronic infection with draining sinus tracts, and the “spitting” of Marlex. Such a patient is condemned to a protracted course of repeated episodes of local sepsis with the little hope of relief. Before I started using preoperative progressive pneumoperitoneum I was caring for such a patient, an elderly obese woman who had undergone emergency surgery for an incarcerated ventral hernia with gangrenous colon. Marlex was used to close the fascial defect. Postoperatively a small wound infection developed and two years later was still draining purulent material even though on repeated occasions I had removed fragments of mesh. Such a patient might have been treated progressively with about 10 L of pneumoperitoneum and removal of the infected prosthesis with primary fascial closure. 7. Obesity: At times we insist that obese persons with a ventral hernia first lose 50 or 60 pounds before repair can be considered. However, the ability of the
66
physician to direct the patient to follow such a weight reducing plan is frequently impossible. Even if successful, the patient may be in a negative nitrogen balance and in too poor a nutritional state to undergo major surgery and associated healing process. These obese patients, however, are not prohibitive surgical candidates when progressive pneumoperitoneum is utilized preoperatively as shown in cases I, IV, V, VII, VIII, and X. Benefits of Preoperative Progressive Pneumoperitoneum. 1. Recurrence rate: Although the follow-
up period in this small series has not been longer than two years, the recurrence rate has been zero. However, such recurrences usually do occur early and the minimal stresses on the incision during its healing phase probably account for the good early results. 2. Respiratory considerations: Patients who have chronic lung disease, that is, emphysema or chronic obstructive bronchitis, and those with purulent bronchitis are known risks for postoperative respiratory insufficiency. The elevation of the diaphragms resulting from the preoperative progressive pneumoperitoneum encourages patients to breathe with the thoracic musculature and to become accustomed to breathing with a mild reduction in vital capacity. Postoperatively, they can now breathe with both diaphragmatic and thoracic musculature. In addition, the relaxed abdominal wall allows a reduction in suture line tension that reduces incisional pain. The reduction of incisional pain contributes to respiratory well-being by decreasing immobility with associated hypostasis. The degree of impairment of vital capacity with preoperative progressive pneumoperitoneum appears to be moderate and well tolerated. Pulmonary function tests have been carried out in several patients and the results are listed in Tables I and II. In Table I it is interesting to note that even after several liters of air have been introduced and the -abdomen is quite tense, the maximal reduction in vital capacity is about 25 per cent of the initial value. That the time period involved in preoperative progressive pneumoperitoneum is enough to develop the thoracic musculature would seem to be indicated by several patients who not only failed to be distressed by the procedure but actually improved during the course (that is, in cases VIII and IX, after 6,000 cc the vital capacity was about the same as the initial volume). The pulmonary function studies that have been carried out in the immediate postoperative period showed a vital capacity of 60 to 75 per cent of initial prepneumoperitoneum value. Although a control se-
The American Journal of Surgery
Pneumoperitoneum
TABLE I
3 7 a 9
10
Diagnosis Paraileal conduit hernia Scrotal hernia Incisional hernia Ventral hernia Incisional hernia and carcinoma of colon Ventral and incisional hernias
Before Injection
Volume of Pneumoperitoneum
10
Repair
6,000
6,000
4,205 4,387 2,014 2,047
.. . ... ..
.. . ...
..
. 3,290 1,758 2,181
::: 1,523 i,aa3t
2,647
2,194
2,585
2,585
2,139
4,200
...
...
...
...
..
hours after injection
3,493 . ..
.
First Day Postoperatively
3,627 3,476
...
. ..
2,320
.
1,775
3,674
2,320
of air.
the use of pneumoperitoneum occurred in a patient who had received 8;OOOcc of air over a ten day period prior to correction of a large incisional hernia. Induction of anesthesia was with 80 per cent nitrous oxide. This lead to the rapid transfer of nitrous oxide into the peritoneal cavity, an acute increase in intraabdominal pressure, and a marked reduction in ventilatory compliance and in hypotension [16]. This situation was rapidly corrected by trocar decompression of the abdomen and can be avoided either by removing the peritoneal air prior to the induction of nitrous oxide anesthesia or by the chaice of another anesthetic agent. Minimal subcutaneous emphysema does frequently occur secondary to leakage from the peritoneal cavity back into the subcutaneous tissue after removal of the catheter. This has so far not been a problem. There are several potential complications that will be briefly discussed. Perforation of the bowel at the
Forced Expiratory Volume, (cc)*
Diagnosis
Case
3 7 a 9
15,000
4,000
ries is not available, this value is higher than one might expect from data by Finer [14], Anscombe [15], and Johnson [17]. Finer has shown that after a routine cholecystectomy the vital capacity on the first postoperative day is usually only 40 per cent of the preoperative value. 3. Pain: The reduction of incisional pain is significant and this is explained by the lack of tension on the suture lines. Although it is difficult to quantitate this pain, most patients require no narcotics and are usually complaining of such other things as intravenous catheters, warm rooms, and poor televisions. 4. Intestinal mobility: The bowel, exposed to increased extraluminal pressures preoperatively, is decompressed at surgery and thus postoperative peristaltic activity is more effective. Early ambulation and decreased narcotic requirements may also contribute to the fact that postoperative nasogastric decompression is seldom necessary. Complications. One complication associated with
1
(cc)
2,000
* Vital capacity was usually measured twenty-four t Immediately after 2,000 cc had been introduced.
TABLE II
Hernia
Vital Capacity (cc)*
Case 1
for Abdominal
Paraileal conduit hernia Scrotal hernia Incisional hernia Ventral hernia Incisional hernia and carcinoma of colon Ventral and incisional hernia
Before Injection
Volume of Pneumoperitoneum 4,000
4,025 3,203 i ,598 i ,728
...
...
...
.. ...
..
..
1,856
2,369 1,474 ...
::: 1,294 1,654.f
2.139
1,702
1,605
i ,827
1,694
3,521
...
.
..
...
* FEV, was usually measured twenty-four hours after injection t Immediately after 2,000 cc had been introduced.
Volume124, July 1972
(cc)
2,000
6.000
8,000
15,000
First Day Postoperatively
3,493 . ..
3,135 2.179
... .. .
... ...
..
i ,287
2,985
1,800
of air
67
Johnson
time the catheter is introduced may conceivably occur. However, in the absence of bowel obstruction, the sequelae of such a perforation are assumed to be clinically insignificant. In case X, the peritoneal cavity contained a small amount of cloudy fluid which was sterile on culture. This may have been secondary to a puncture of the bowel wall; however, clinical sepsis was not apparent during administration of pneumoperitoneum. Preferential distention of the hernia sac, that is, Laplace’s Law, does not seem to occur. Clinically, this may be because of fibrosis in the overlying skin and subcutaneous tissue. The abdominal cavity exposed to room air during surgery appears capable of resisting infection from this source, so that bacterial contamination from pneumoperitoneum is most likely only a theoretical possibility. Air emboli associated with pneumoperitoneum have occurred in the treatment of tuberculosis and in peritoneoscopy. However, these cases were always associated with direct intrahepatic, intrasplenic, or intravenous injection [I&19]. This potential complication is completely preventable by proper technic. Venous stasis and associated risk for thrombosis may possibly be considered a potential hazard associated with the increase in intra-abdominal pressure. Clinically, no evidence of impaired venous return from the legs has been detected. This may be because the maximal intra-abdominal pressure usually is only 8 to 10 cm of water. Normal variation of the venous volume with respiration is found in the presence of pneumoperitoneum as evidenced by several patients who had measurements of venous patency with an impedence meter using the technic of Wheeler [20]. Summary
A series is presented of ten patients who had complex hernias that were treated with preoperative progressive pneumoperitoneum. The benefits of this method are indicated in the dramatic clinical picture of these patients in the postoperative period, when they are breathing without difficulty, have minor incisional pain, are ambulating with ease, voidilig well, and usually hungry. The indications for preoperative progressive pneumoperitoneum are in massive hernias where the “right of domain” is lost, large scrotal hernias, with concomitant bowel surgery, in recurrent ventral hernias, in obese patients,
as an alternative to using Marlex mesh, and in correcting hernias in which the prosthesis is infected. Respiratory function data are presented indicating that not only is ventilatory performance not significantly impaired during preoperative progressive pneumoperitoneum but also that it is improved in the postoperative period when this technic is used.
References 1. Moreno IG: Chronic eventration and large hernias: preoperative treatment by progressive pneumoperitoneum. Surgery 22: 945, 1947. 2. Moreno IG: The rational treatment of hernias and voluminous chronic eventration, p 668. Hernia (Nyhus LM. and Harkins HH, ed). Philadelphia, JB Lippincott Co, 1964. 3. Koontz AR, Graves JW: Preoperative pneumoperitoneum as an aid in the handling of gigantic hernias. Ann Surg 140: 759,1954. 4. Mason EE: Pneumoperitoneum in the management of giant hernia. Surgery 39: 143, 1956. 5. Koontz AR: Hernias that have forfeited the right of domicile: use of pneumoperitoneum as an aid in their operative care. Southern Med J 51: 165, 1958. 6. Mansuy MM, Hager HG: Pneumoperitoneum in preparation for correction of giant hernias. New Eng J Med 258: 33, 1956. 7. Moyer CA, Butcher HR: Experiences with pneumoperitoneum for massive ventral hernias, p 703. Hernia (Nyhus LM, and Harkins HH, ed). Philadelphia, JB Lippincott Co, 1964. 8. Pingree JH. Clark JH: Pneumoperitoneum: a neglected procedure for the repair of large abdominal hernias. Arch Surg 96: 252, 1968. 9. Connolly DP. Perri RF: Giant hernias managed by pneumoperitoneum. JA MA 209: 71.1969. 10. Pines B: Pneumoperitoneum in the preparation for correction of a large abdominal hernia in an infant. Pediatrics 26: 276, 1969. 11. Moore RP: Giant ventral hernia and pneumoperitoneum. Northwest Med 60: 51,1961. 12. Martin RE: Successful repair of the seventh recurrence of a massive incisional hernia. Amer J Surg 111: 565, 1966. 13. Ziffrin SE, Womach NA: An operative approach to the treatment of gigantic hernias. Surg Gynec Obsfet 91: 709, 1950. 14. Finer B: Studies on the variability in expiratory efforts before and after cholecystectomy. Acta Anesfh Stand (suppl38): 1, 1970. 15. Anscombe AR: Pulmonary Complications of Abdominal Surg&y. Chicago, Year Book Medical Publishers, 1957. 18. Johnson WC: Pulmonary function data in the pre and postoperative period. (Submitted for publication.) 17. Johnson WC: Pneumoperitoneum for ventral hernia repair: anesthesia complication. JA MA 217: 968, 1971. 18. Dasher WA, Black JPM, et al: Air emboli complicating pneumoperitoneum; a review. Amer Rev Tuberc 69: 396, 1954. 19. Jernstrom P: Air emboli during peritoneoscopy. Amer J C/in Path 21: 573,195l. 20. Wheeler HG et al: Diagnosis of occult deep vein thrombosis by a non invasive bedside technique. Surgery 70: 20. 1971.
The American Journal of Surgery