Progressive Preoperative Pneumoperitoneum (PPP) In Giant Hernia With Loss Of Domain (LOD): Technique and Uses (Goni-Moreno)

Progressive Preoperative Pneumoperitoneum (PPP) In Giant Hernia With Loss Of Domain (LOD): Technique and Uses (Goni-Moreno)

Introduction: Giant hernias with loss of domain are a major therapeutic problem. We define the loss of domain when part of the abdominal viscera remains permanently in the herniary sac, the reintegration of the contents of the hernia into the abdominal cavity be a problem when it come to parietal closure, postoperative respiratory symptoms and the abdominal compartment syndrome. For these hernias, Goni Moreno suggested carrying out preoperative preparation using progressive pneumoperitoneum. This technique makes it possible to increase the width of the muscles, the abdominal volume and the respiratory tolerance to the reintegration of the hernia contents. This video aims to describe the surgical technique for placing an intraperitoneal catheter, and the importance of progressive pneumoperitoneum.

Observation: This is a 35-year-old patient, she weighs 125 kg for 1m68, BMI = 44.3kg/m², operated for cesarean section in 2019 and who presents a giant incisional hernia with loss of domain of 47 % .the patient benefited from prehabilitation before surgery: Weight loss of 15kg, BMI = 39kg/m² Progressive therapeutic pneumoperitoneum for 21 days Antibioprophylaxis, preventive anticoagulation FEV1: 72% Daily respiratory physiotherapy.

SURGICAL TECHNIQUE: 1st stage under local anesthesia.Anatomical landmarks and marking of the incision: 2 finger widths under the rib grill on the midclavicular line.Disinfection with betadine.Local anesthesia with 2% xylocaine and must be carried to the muscular plane.A skin spot is made with a scalpel at the site of the puncture.The puncture is carried out with the Veress needle inserted at 90◦. The operator must clearly distinguish three successive jumps corresponding to the passage of the anterior, posterior aponeurosis and the peritoneum.A safety test is carried out Suction, insufflation of air then suction.- Disassemble the needle.- Guide introduction.- Removal of the Veress needle.- Introduction of dilator.- Introduction of catheter.- Guide removal.- Insufflation 1L (Insufflate between 1L of pneumoperitoneum during the first session).- Fixing the catheter.- Bandage.- Standing AXR.Insufflations are performed daily, directly at the patient's bed using a syringe, with a volume of between 1 l/day For 21 days before surgery depending on the patient's tolerance. Patients must be on preventive anticoagulation and antibiotic prophylaxis.- Tanaka manual calculation.2nd stage: treatment of the hernia by placing a prefacial retromuscular prosthesis.Hernia technique: Iterative incision, Excision of the skin scar.Dissection of the sac, opening of the sac.Adhesiolysis. Check the integrity of the viscera.The catheter.Opening the posterior layer of the rectus muscle sheath. The rectus muscle is removed with scissors from the posterior layer of the sheath up to the external white line.Transversus abdominis release: TAR, by incising this sheath laterally 0.5-1 cm medial to the external white line Closure of peritoneum and the posterior leaf of the sheath.Fixation of the retromuscular prosthesis and two suction drains in contact with the prosthesis.The cutaneous and subcutaneous planes are separated laterally from the aponeurotic plane, up to 4 to 5 cm lateral to the rectus abdominis muscle.Discharge incisions according to the Clotteau-Prémont method, The making of 3 to 4 lines of vertical incisions on the anterior leaf of the aponeurosis on each side. Each incision should measure approximately 1.5 cm and be separated from the other incisions by approximately 1.5 cm.The skin plane is then closed over two suction drains.Measurement of intravesical pressure Placement of a catheter to measure intravesical pressure to detect the risk of abdominal compartment syndrome.Day 21 post-operative.The postoperative course is simple. CT Scan on Day 60.

Conclusion: good preoperative care is the guarantor of simple postoperative outcomes in patients with a giant hernia and loss of domain. Progressive pneumoperitoneum must be part of the therapeutic armamentarium.Dr M.LAIDOUCI Timimoun Hospital General Surgery Department Timimoun Hospital May 23, 2023.