Repair of massive abdominal wall defects. Combined use of pneumoperitoneum and Marlex mesh

Progressive preoperative pneumoperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: volumetric, respiratory and clinical impacts. A prospective study

INTRODUCTION

Progressive preoperative pneumoperitoneum (PPP) is used to prepare incisional hernias with loss of domain (IHLD) operations. The aim of the present study was to analyze the effect of PPP on peritoneal volume [measured using a new computed tomography (CT)-based method] and respiratory function.

METHODS

From July 2004 to July 2008, 19 patients were included in a prospective, observational study. The volumes of the incisional hernia (VIH), the abdominal cavity (VAC), the total peritoneal content (VP) and the VIH/VP ratio were measured before and after PPP using abdominal CT scan data. Spirometric parameters were measured before and after PPP, and postoperative clinical data were evaluated.

RESULTS

Before and after PPP, the mean VIH was 1,420 cc and 2,110 cc (P  < 0.01), and the mean VAC was 9,083 cc and 11,104 cc (P < 0.01). The VAC increased by 2,021 cc (P < 0.01) and was greater than the mean VIH before PPP. After PPP, the spirometric measurements revealed a restrictive syndrome. The overall postoperative morbidity rate was 37%.

CONCLUSIONS

PPP increased the hernia and abdominal volumes. PPP induced a progressive, restrictive syndrome.

Progressive pneumoperitoneum increases the length of abdominal muscles

The aim of this prospective observational study was to determine the effects of progressive preoperative pneumoperitoneum (PPP) on the size of large incisional hernia (IH) and abdominal muscles by abdominal computed tomography (CT) scan. PPP was performed in 18 patients. All IH were large. A mean volume of 12.8 l was insufflated over a mean period of 14.8 days. Respectively, before and after PPP, the mean IH height and width was 117 and 130 mm (P < 0.05) and 101 and 115 mm (P < 0.05), the mean width of the right and left rectus abdominis was 99 and 109 mm (P < 0.05) and 100 and 113 mm (P < 0.05), and the length of the right and left anterolateral muscles was 198 and 233 mm (P < 0.05) and 185 and 210 mm (P < 0.01). In conclusion, PPP increases the abdominal wall muscle length and has the same impact on the IH orifice. PPP would facilitate the fascial repair of otherwise untreatable large IH.

[Use of pneumoperitoneum in the repair of giant abdominal hernias]

The preoperative use of progressive pneumoperitoneum has been demonstrated to be safe and effective in the treatment of large hernias. The indications for this technique include massive hernias, hernias in patients with high surgical risk, and large recurrent hernias. We describe four patients in whom progressive pneumoperitoneum was carried out under local anesthesia and sedation between 1 and 3 weeks before surgery. All four hernias were closed with a preperitoneal mesh. Insufflation was performed on an inpatient basis in two patients and in the ambulatory setting in one. No postoperative complications were detected. No evidence of recurrence was found during follow-up (10 months-11 years).

Preoperative pneumoperitoneum used for tissue expansion before abdominal wall reconstruction

The use of preoperative pneumoperitoneum was described initially for the repair of large ventral hernias. Large volumes of air are injected into the peritoneal cavity, which distends the abdominal wall progressively. This method is usually used to facilitate the reinstatement of the viscera into the abdominal cavity and improves postoperative diaphragmatic function. The authors use this method for preoperative tissue expansion of the abdominal wall before full-thickness resection of the abdominal wall for dermatofibrosarcoma protuberans in a 12-year-old girl. In total, 6.8 L air was injected over 3 weeks without problem. The subsequent laxity of the abdominal wall permitted the primary closure of a 14- x 16-cm resection. The postoperative course was uncomplicated. Preoperative pneumoperitoneum can be used when reconstruction can be delayed. This is so in cases of slow tumor growth and in cases of infectious or posttraumatic full-thickness abdominal defects. The parietal laxity obtained with the pneumoperitoneum not only increases the possibilities of direct closure but also increases the possibilities of pedicled flap reconstructions.

Repair of a giant inguinoscrotal hernia

We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper.

A preliminary report on the use of relon mesh in the repair of eventrations with large parietal defects. An experimental study in rats

This experimental study in rats was designed to investigate the tolerability and the mode of healing when commercial relon mesh is used in the repair of large abdominal-wall defects. A defect was created to simulate anatomical derangement of the abdominal wall and a surgical correction was performed using relon mesh. The mesh was implanted intraperitoneally in 18 Wistar albino rats. The animals were killed under anaesthesia 4, 6, 8, 12, 15 or 30 days later and the intra-abdominal viscera were examined macroscopically for adhesions and other evidence of inflammatory reactions. Skin healing usually occurred within 7-8 days of surgery. Microscopic studies were used to confirm the gross findings and showed that maturation of granulation tissue, fibrocyte invasion with encapsulation of the mesh and the appearance of newly formed vessels occurred 2 weeks after surgery. Within 4 weeks a strong layer of connective tissue was present. The relon mesh was tolerated well. These results indicate that the use of relon mesh may provide a cheap alternative means of repairing large abdominal-wall defects.

[Progressive pneumoperitoneum in treatment of inguinal and scar hernias. Results of animal experiments and clinical applications]

Preoperative progressive pneumoperitoneum is a well-known, but sporadically used procedure in preparing patients with giant inguinal or incisional hernias for the operation. The technique requires frequent insufflation of air into the abdominal cavity in order to create space to accommodate herniated viscera and facilitate fascial repair with minimal tension. This article demonstrates the histological findings, technique, complications, advantages and long-term results of the preoperative progressive pneumoperitoneum in hernia repair.

Abdominal Wall Reconstruction with a Vascular External Abdominal Oblique Myofascial Flap

A myofascial island flap for abdominal wall reconstruction was based on the lumbar component of the external abdominal oblique muscle and supplied by a major neurovascular pedicle consisting of branches of the cranial abdominal artery, cranial hypogastric nerve, and a satellite vein. The flap was elevated and sutured into a 10 cm x 10 cm body wall defect in five dogs. The dogs were observed for 26 to 28 days. Abdominal wall contour and function were preserved. All dogs developed seromas, two of which became infected. One dog developed a hernia at the dorsal margin of the flap, which was repaired. At necropsy, there was no evidence of dehiscence in any of the dogs. Loose adhesions of omentum to the inner surface of the flap occurred in four dogs. Results of histologic examination confirmed the clinical impression of flap viability. The myofascial island flap has a wide range of mobility over the ventral and caudal areas of the abdomen and lateral thoracic wall. It has potential clinical use for reconstruction of defects within its arc of rotation.

Progressive pneumoperitoneum in the management of giant incisional hernias: a study of 41 patients

Forty-one patients (17 men and 24 women) were treated with progressive pneumoperitoneum before repair of giant incisional hernias. The pneumoperitoneum was induced using nitrous oxide gas and a laparoscopic insufflator, and was topped up every other day for a mean of 5.5 days with a total injection of 23.2 litres of nitrous oxide. The pneumoperitoneum was well tolerated in 30 patients, caused a mild temporary pain in 10 patients and a sharp pain in one patient; no serious side-effects occurred. All the patients underwent surgery to repair their hernias, 40 patients were available for follow-up for a mean of 25.3 months, only two hernias recurred both within 4 months of the operation.

The place for pneumoperitoneum in the repair of massive hernia

Progressive pneumoperitoneum before the repair of massive abdominal and inguinal hernias, first introduced in 1940, remains an important technique in preparing patients for the operation. Reports of its use have appeared sporadically in the surgical literature. This article recounts the technique of progressive preoperative pneumoperitoneum, its advantages and complications, and the variety of situations in which it is useful. Surgeons treating large hernias accompanied by loss of domain of abdominal viscera should consider preoperative progressive pneumoperitoneum as a helpful and often necessary adjunct to hernial repair.

The treatment of complicated groin and incisional hernias

One hundred years ago, Edoardo Bassini said: "L'ernia é una malattia meccanica." Before that, Ambroise Paré (1598) and Joseph-Pierre Desault (1798) asserted the mechanical nature of strangulation. Beside strangulation, the most serious of all complications even today, I have studied huge hernias, which are natural complications, and recurrent hernias, which are the complications of suboptimal repairs. In this article, I consider the general features and diagnostic and technical consequences of the repair of groin and incisional hernias. The treatment of strangulating hernias, usually an emergency operation, has not seen any recent technical progress. Huge and recurrent hernias, however, usually allow time for adequate surgical preparation. These hernias are also amenable to modern prosthetic repairs. In prosthetic repairs, large pieces of polyester mesh are inserted beneath the muscular wall outside the peritoneum. They act as artificial, nonabsorbable endoabdominal fascia, making the abdominal wall instantly and definitively pressure tight. The state of hernial surgery has advanced to the point that one must consider the systematic surgical cure of all diagnosed hernias.

Giant inguinal hernia

Giant inguinal herniae present a major challenge in management. This case details clinical features of an enormous inguinoscrotal hernia associated with septic gangrene and elephantiasis of the scrotum. Two initial operations were required for control of sepsis, followed by a two-staged hernial repair, involving a total colectomy and a subsequent neoscrotal repair. The problems of loss of domain within the abdominal cavity and the special features presented by this case are discussed.

Abdominal wall resection and reconstruction with the aid of Marlex mesh

Treatment of malignant tumours of the abdominal wall is primarily surgical and should consist of ample excision with margin of 4-6 cm into the adjacent healthy tissue. When primary closure of the defect in the abdominal wall is not feasible, it can be repaired with the aid of Marlex mesh, combined if necessary with a pedicled omentum flap and free skin grafts. Major resections of the abdominal wall are thus made possible.