Pneumoperitoneum in the Treatment of Giant Hernias, with Special Reference to Obesity
Pneumoperitoneum, the injection of air into the abdominal cavity, is an accessory treatment that should be considered in the successful and permanent repair of giant hernias. Pneumoperitoneum was used for the treatment of pulmonary tuberculosis from 1931
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Pneumoperitoneum in the Treatment of Giant Hernias, with Special Reference to Obesity Edward E. Mason
Pneumoperitoneum, the injection of air into the abdominal cavity, is an accessory treatment that should be considered in the successful and permanent repair of giant hernias. Pneumoperitoneum was used for the treatment of pulmonary tuberculosis from 1931 until the introduction of streptomycin. Increased pressure within the abdomen caused elevation of the diaphragm, decreased the intrathoracic space, and thus assisted in the obliteration of cavities. Ivan Gani-Moreno, l in Argentina, first used pneumoperitoneum in 1940 to reestablish space in the abdominal cavity of patients with giant hernias. Koontz 2 reported his experience with pneumoperitoneum in 1954 with four patients and again in 1958 with five more patients. The experience with pneumoperitoneum in patients with giant hernias at the University of Iowa Hospitals and Clinics began in 1953. 3 There are several problems to be considered in the management of giant hernia. Of utmost importance is the loss of abdominal space. Viscera are forced out into the hernial sac over time, and the abdominal cavity shrinks around the viscera that remain within it. Abdominal space can be regained through the stretching effect of,intraabdominal air. The abdominal wall may require a prosthesis even after the preparation of the patient with pneumoperitoneum. The final decision about the use of a prosthesis or reinforcement is usually made at the time of operation, although it should be anticipated and planned. Raynor and Del Guerci04 observed that penumoperitoneum and a prosthesis are not mutually exclusive. They may both be needed in some patients. Severe obesity adds a third dimension to the plan for repair. Obesity may be etiological in the occurrence, recurrence, and large size of a hernia. Severe obesity does not respond to diet or other nonsurgical measures, and, when it does respond, there is likely to be recurrent weight gain. 5 If the hernia has been unsuccessfully repaired, excessive weight may well have contributed to the recurrence. Operative treatment of the obesity may take precedence over the hernia repair. These three branches of the decision tree (effective treatment of obesity with an operation to facilitate weight loss, pneumoperitoneum, and prostheses) are reviewed in the order in which they must be considered when planning treatment. Time is required to accomplish all that needs to be corrected in the elective situation. In an emergency, a giant hernia requires the same planning for ultimate repair, but the emergency should be dealt with in a safe manner even if the size of the hernia makes an emergency repair impossible. This also is reviewed. R. Bendavid et al. (eds.), Abdominal Wall Hernias © Springer Science+Business Media New York 2001
Surgical Treatment of Severe Obesity If severe obesity was a significant factor in the development of a giant hernia and the patient's weight appears likely to cause failure of repair, the obesity must be treated before
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