|Year : 2022 | Volume
| Issue : 1 | Page : 36-41
Progressive pneumoperitoneum: Where do we stand in 2021?
Mathias Allaeys1, Gabrielle H van Ramshorst2, Frederik Berrevoet1
1 Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
2 Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
|Date of Submission||12-Aug-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||23-Feb-2022|
Dr. Mathias Allaeys
Corneel Heymanslaan 10, 9000 Gent.
Source of Support: None, Conflict of Interest: None
Progressive pneumoperitoneum (PPP) is a technique in which the abdomen is artificially and gradually insufflated over a period of time. The technique was first applied in hernia repair in the 1940s and is now regarded as a useful adjunct in the treatment of complex or giant hernias and those associated with “loss of domain” (LOD). With gradual insufflation, the abdomen becomes progressively distended, promoting soft tissue elongation and preparing it for the post-repair surplus volume of the herniated content. PPP also helps with preoperative pulmonary stabilization and preparation, and it induces pneumatic lysis of intestinal adhesions. In contrast to the longevity of the technique, the heterogeneity in indications and technical variations is remarkable. Indications vary greatly in literature, being either based on clinical judgment or different volumetric cut-off values. Neither is there any consensus on which gas should be used, what volume should be injected, in what frequency, and for how long the pneumoperitoneum should be maintained. There is a clear need for an international consensus concerning LOD hernias and how they are defined. As setting up randomized controlled trials on PPP is not feasible, further research should rely on high-quality observational studies. For reviews and meta-analysis to have any meaningful conclusions, these studies should follow, and adhere to, clear guidelines on the manner of reporting. However, PPP remains a very powerful adjunct in the treatment of large and complex hernias with LOD and has proven its value over time.
Keywords: Abdominal wall, hernia, loss of domain, progressive pneumoperitoneum
|How to cite this article:|
Allaeys M, van Ramshorst GH, Berrevoet F. Progressive pneumoperitoneum: Where do we stand in 2021?. Int J Abdom Wall Hernia Surg 2022;5:36-41
| Introduction|| |
Progressive pneumoperitoneum (PPP) is a technique in which the abdomen is artificially and gradually insufflated over a period of time. Its origin dates back to the treatment of tuberculosis, before the era of targeted medication, where the associated elevation of the diaphragm and heightened intrathoracic pressure was thought to help collapse tuberculous caverns. In the 1940s, the technique was first applied in hernia repair and is now regarded as a useful adjunct in the treatment of complex or giant hernias and those associated with “loss of domain” (LOD).
PPP acts as a pneumatic tissue expander. With gradual insufflation, the abdomen becomes progressively distended, promoting soft tissue elongation and preparing it for the post-repair surplus volume of the herniated content. This avoids having to perform a repair under tension and helps to steer clear of possible severe complications such as abdominal compartment syndrome and respiratory insufficiency.
PPP also helps with preoperative pulmonary stabilization and preparation. In giant hernias, the abdominal pressure will gradually decrease, causing the diaphragm to descend, altering ventilatory equilibrium. Rather than canceling this mismatch, PPP induces a restrictive syndrome very similar to the surgical treatment of the hernia itself. However, it does so gradually, causing respiratory adaption, whereas there is no adaptation in reinstatement of an incisional hernia. It is generally accepted that if patients cannot tolerate the pneumoperitoneum, hernia repair will not be tolerated either.
One final benefit of PPP is that it induces pneumatic lysis of intestinal adhesions, rendering definitive surgical repair less cumbersome. In the only prospective non-randomized trial available, operating time was significantly reduced in the PPP group, which was mainly attributed to the fact that the division of parietal adhesions was less time-consuming.
| Indications|| |
The most popular indication for PPP is an inguinal or ventral loss-of-domain hernia. The term refers to the loss of abdominopelvic compartment volume and thus forcing abdominal viscera to reside within the hernia sac. This significant portion of herniated viscera has lost the so-called “right of domain.” Until recently however, this criterion was poorly defined. Most publications reside on clinical evaluation, where LOD is appraised by not being able to reduce the hernia on physical examination.
In 2010, Tanaka et al. reported on a computed tomography (CT) scan method for calculating hernia sac and abdominal cavity volumes (ACVs). They defined LOD as the ratio of the hernia sac volume (HSV) to ACV: LOD = HSV/ACV. The cutoff value as an indication for PPP was set at 25%, with this value being chosen at random to standardize case selection. In 2011, Sabbagh et al. published their method, defining LOD as a percentage of the total peritoneal volume (TPV): LOD = HSV/TPV. Here, the cutoff value was set at 20%. This was based on a publication by Kingsnorth et al., stating that above this value, physiological respiratory adaptation is necessary. In their prospective series, Sabbagh et al. were able to demonstrate that in a multivariate analysis, an HSV/TPV ratio <20% was the only significant predictive factor of tension-free closure. Both these definitions have been used variably, leading to confusion and expressing the need for a standardized volumetric definition.
In 2020, an International Delphi consensus was published to address this issue. The Sabbagh method was the definition of choice, stating that it was conceptually easier and more practical in a clinical setting. To this day, however, and even in recent publications, both methods continue to be intermingled.
As shown in the systematic review by Martínez-Hoed et al., the specific indication for PPP remains unclear. In most of the published studies, the use of PPP was based on the surgeon’s clinical judgment. Others used the aforementioned volumetric methods, but with different cutoff values for LOD. Some used a volumetric method combined with a transverse hernia width larger than 10 cm. This underlines the fact that LOD remains poorly understood. By adhering to the recent Delphi consensus in future publications, hopefully upcoming reports will be more uniform and comparable, making meta-analysis more impactful.
| Technique|| |
As stated, PPP consists of gradually and artificially insufflating the abdomen. Different methods to achieve this have been reported, ranging from single punctures with spinal needle and placement of a pigtail catheter, Foley catheter, central venous catheter, to multiple punctures with a Verres needle. Surgical implantation of access devices is also being performed. Introduction of a double lumen catheter into the peritoneal cavity under laparoscopic view has been suggested, as well as surgical cutdown with implantation of subcutaneous reservoir ports or peritoneal dialysis catheters.
In the first cases published, the gas used for insufflation was ambient air filtered through bottles containing iodine. This was mainly because of the fear of introducing bacteria and causing peritonitis. Since then, different gases have been proposed for insufflation: CO2, NO2, and medical grade air. In most recent cases, unfiltered ambient air is being used, as associated peritonitis has never been reported. Also, air has a lower peritoneal reabsorption rate, which makes maintenance of the pneumoperitoneum easier.
Concerning the frequency at which insufflations take place, the amount of gas insufflated in one session, and the period between insufflation sessions, the same inconsistency holds true. Single session gas volume ranges from 200 to 6,800 cc, with a predominance of volumes between 200 and 1,300 cc. One single daily insufflation is the most reported. However, twice daily insufflations are also being used, as well as rest periods of multiple days between sessions. Single sessions are ended based on patient’s discomfort and physical signs, by targeted volume, or by reaching a monitored pressure limit.
The period through which the pneumoperitoneum should be maintained has not been clearly defined. It has been suggested that PPP has no further benefit after 6–10 days. In contrast, in a series by Yurtkap et al., CT scans at 7 days after starting PPP showed only partial reduction of the hernia content in most of their patients, with limited air accumulation in the abdominal cavity itself. Therefore, PPP was continued for a maximum of 21 days. In the literature, no clear indication has been reported on limitation of the PPP period. This seems to be primarily based on clinical judgment and radiologic findings, although some authors target a specific predefined volume. Overall, the average volume reached at the end of the PPP period is around 10,000 cc.
Although a lot of studies perform PPP in an ambulatory setting, sometimes with an initial hospitalization of around 2 days, other authors vow that patients should be hospitalized for the complete duration of the PPP., This is understandable, regarding the potential severe morbidity and the paucity of experience with the technique in outpatient setting.
As far as medical prevention measures go, prophylactic low molecular heparin is widely accepted for the duration of the PPP. As in laparoscopy, the heightened intra-abdominal pressure is thought to promote venous stasis and with it possible thromboembolic events. However, this complication has rarely been reported in the literature. The use of an abdominal binder is less consistent, with authors claiming that the use of a binder would help decrease the LOD ratio during PPP. Others claim that the air in the hernia sac primarily helps with lysis of the adhesions and thus avoid the use of a binder. Antibiotics are used only rarely, as the peritoneal cavity seems to endure unfiltered ambient air pretty well, and PPP-induced peritonitis has never been reported.
| Ethics committee approval|| |
It was not applicable for this article.
| Results|| |
In 2009 the first quantitative data were published regarding the effect of PPP on the dimensions of the abdominal wall. The group from Amiens demonstrated a significant increase in muscle length of both the rectus muscles and the anterolateral abdominal wall. In contrast, this passive stretching of the abdominal wall was not capable of occluding the wall defect, because the hernia width also significantly increased.
The effect of PPP on HSV and abdominal compartment volume (ACV) is of interest as well. All volumetric studies were able to show a significant increase in ACV,,,, confirming that PPP enlarges the abdominal capacity, preparing it for the reintegration of the herniated viscera. In the three studies in which ambient air was used, a significant increase in HSV was also reported.,, Only one study demonstrated a marked decrease in HSV, attributing it to the use of CO2. The HSV to TPV ratio has been shown to increase slightly, but never with statistical significance.,, Again, only Valezi et al. were able to show a significant decrease in the HSV/TPV ratio. In summary, PPP expands the HSV as much as the ACV in most cases, but the notion that PPP only expands the hernia sac does not hold true.
The review by Martínez-Hoed et al. concludes to an overall fascial closure rate of 86%, whereas the analysis by van Rooijen et al. claims a fascial closure rate up to 95%. These results are favorable, although not without bias. Both these reviews were primarily based on observational case series, with the only prospective non-randomized trial dating back to 1986. Because of the rarity of indications, the heterogeneity of reported patient groups, and the different modalities with which surgical repair was executed, it becomes very difficult to draw definitive conclusions. Moreover, as in recent studies botulinum toxin A (BTA) injections and PPP seem to go hand in hand, it becomes increasingly difficult to interpret PPP as a sole adjunct.
| Complications|| |
The most frequent complications associated with PPP are those of mild pain, respiratory discomfort, and subcutaneous emphysema. Pneumomediastinum and hematoma or hemoperitoneum have also been reported, with the latter two being attributed to the device used for insufflation. Bowel perforation and pneumothorax were seen less frequently and, in most cases, resolved spontaneously without the need for surgical intervention. Death related to PPP has been reported several times: these are mostly attributed to respiratory failure in patients with a history of pulmonary problems,, emphasizing the need for thorough pulmonary evaluation prior to PPP. One patient presented with acute respiratory failure because of an abdominal compartment syndrome and died due to progressive multi-organ failure. One other patient died owing to a hemorrhage after catheter insertion for insufflation, causing hypovolemic shock and subsequent multi-organ failure. In the review by Martínez-Hoed et al., for a total of 1,216 patients who underwent PPP, 151 experienced complications, although these were almost exclusively of minor severity. Despite this, many more complications might have occurred, as reporting bias is highly suspected.
van Rooijen et al. reviewed 13 articles in relation to post-operative complications. In the 13 included articles, 582 patients experienced 178 SSOs (30.6%), with some patients experiencing multiple surgical site occurrence (SSOs). With regard to infections, a cumulative surgical site infection (SSI) rate of 10% was found after the use of PPP.
The same review reported on a pooled recurrence rate of 3%, but this also included patients treated with a combination of PPP and BTA administration. The method of recurrence diagnosis was frequently based on physical examination alone rather than imaging, and most studies did not report on the method of detection at all.
| Our Method|| |
In our center, management of complex giant ventral hernias is streamlined through the use of a treatment algorithm. This algorithm is based both on hernia width and presence or absence of LOD [Figure 1], with the primary goal of achieving complete anterior fascial closure. In this manner, PPP is reserved for large hernias with a width over 18 cm and those associated with LOD. As is apparent from the algorithm, BTA injections into the lateral abdominal wall can be considered if the surgeon estimates that anterior closure might still not be feasible despite the use of component separation techniques. BTA injections are administered by ultrasound guidance on an outpatient basis, 4 weeks prior to surgery, and according to the protocol written by Zielinski et al.
For the PPP, after cardiopulmonary evaluation, a catheter (Medionics’ Swan Neck Coil 2 cuff peritoneal dialysis, inner diameter of 2.6 mm and outer diameter of 5 mm) is placed through open surgery, under general anesthesia, subcostally in the right or left hypochondriac region at the day of admission. Up to 2 L of ambient air is insufflated into the abdominal cavity at day 0. On a daily basis and until hernia repair, ambient air is insufflated into the abdominal cavity for a maximum of 1,000 cc daily or up until the patient is no longer comfortable. All patients are hospitalized during insufflation. Thromboprophylaxis (low molecular weight heparin) is administered daily, starting at prophylactic dose but increasing to therapeutic dose after 2–3 days. PPP is maintained for a targeted period of 10–12 days, after which a CT scan is performed [Figure 2]. In case of a satisfactory result, surgical repair is carried out subsequently [Figure 3]; otherwise PPP is continued and the effect re-evaluated.
| Discussion|| |
Since its inception in the 1940s by Goñi Moreno, PPP has become widely accepted in the treatment of giant inguinal, ventral, or incisional hernias. Recent reporting even shows favorable results in parastomal hernia repair. PPP primes the abdominal cavity for the added volume of visceral contents when reducing the hernia, thus lowering the rate of post-operative intra-abdominal hypertension and increasing the rate of anterior fascial closure.
A steady stream of publications on the subject can be found since the mid-50s, with a marked increase in reporting in the last 15 years. Most of these studies however are observational, of low quality, and with bias present. Comparative information is scarce., This results in a lot still being unclear surrounding the PPP technique. To this day, there are no standardized indication criteria, and a lot of variation exists within the technique itself. What gas should be used? What volume should be injected? What is the best technique for insufflation? For how long before surgery does the PPP need to be maintained? What are the criteria for ending the PPP period? Should any preventive medical measures be taken before or during the PPP procedure?
With one recent systematic review on PPP alone and one systematic review and meta-analysis on the combination of PPP and BTA, it is clear that effort is being undertaken to address these issues. However, the quality of these reviews suffers because the included articles display numerous methodological problems: short follow-up periods, retrospective design, no clear description of patient population, obscurity on indication, etc.
As surgical techniques are advancing, with newer and less traumatic release techniques to achieve fascial medicalization, the interpretation of the value of a single adjunct becomes more and more difficult. Patients with complex and giant hernias with LOD are a very specific population, suffering from increased comorbidities. Hernia repair in this case is never as simple as using a single method to achieve a goal. Rather, strategies are tailored to an individual patient, which paves the way for possible overtreatment.
There is a clear need for an international consensus concerning LOD hernias and how they are defined. Once this is established, reports and studies should adhere to a uniform manner of reporting. As setting up randomized control trials on PPP is not feasible, further research should rely on high-quality observational studies. For reviews and meta-analysis to have any meaningful conclusions, these studies should follow, and adhere to, clear guidelines on the manner of reporting.
In conclusion, PPP remains a very powerful adjunct in the treatment of large and complex hernias with LOD and has proven its value over time. However, surgeons should have some reservations on the use of PPP, as complications are not infrequent and possibly severe. In contrast, in this advanced population, the benefits of increasing the abdominal cavity and achieving hernia repair may outweigh the risks.
Financial support and sponsorship
Conflicts of interest
Prof. Frederik Berrevoet is an Editorial Board member of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and their research groups.
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[Figure 1], [Figure 2], [Figure 3]