Management of complex hernias with loss of domain using daily and fractioned preoperative progressive pneumoperitoneum:
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ORIGINAL ARTICLE
Management of complex hernias with loss of domain using daily and fractioned preoperative progressive pneumoperitoneum: a retrospective single‑center cohort study Leonardo A. C. Cunha1 · Anderson R. S. Cançado2 · Carlos A. B. Silveira3 · Vaner P. S. F. Pinheiro4 · Oto M. S. Neto3 Received: 14 July 2020 / Accepted: 2 September 2020 © Springer-Verlag France SAS, part of Springer Nature 2020
Abstract Purpose The incidence of complex hernias with loss of domain (CHLD) has been increasing and the treatment of these cases may require auxiliary techniques in addition to surgery. This study aims to refine the progressive preoperative pneumoperitonium (PPP) in patients with CHLD, to achieve an increased in wall dimensions. Methods Patients presented with a CHLD undergoing PPP protocol were analyzed between May 2017 and May 2019. Our PPP protocol was to use two daily insufflations of 1000 ml of ambient air during a period of 14 days. We compared the abdominal cavity volume (ACV), the hernial sac volume (HSV) and the volume ratio (VR), before and after our refined PPP. Results During our evaluation period, the protocol was performed on 16 patients. The mean age was 55.73 (± 12.87), and the mean BMI was 31.35 (± 7.33). The median of HSV was 2104.53 ml; Mean ACV was 6722.36 ml, and median of VR was 29.97% (27.46–34.38 IIQ). The averages were: daily volume of gas ± 1526.66 ml, total volume ± 17,350 ml, and the PPP period of ± 10.7 days. The increase in post-PPP ACV was 52.13% (p 15 cm on CT, in addition to full thickness defects or multiple recurrences issues. All patients were hospitalized for a double-lumen type catheter implantation into the peritoneal cavity, and under direct vision by laparoscopy. The catheter was inserted away from the scar or region of the defect, preferable in the region of the right hypochondrium. According to our protocol, we divided 2000 ml of ambient air, into two sessions of 1000 ml injection. One dose was given in the morning and the other one in the afternoon, for up to 14 days. In the presence of any signs of tachycardia, respiratory failure, severe abdominal pain or patient intolerance, the sessions were interrupted and their treatment would reinitiate according to the team’s daily assessment of the patients’ well-being. All cases received prophylactic
Hernia
doses of enoxaparin, 40 units/day, continuous use of an abdominal band, plus respiratory and motor physical therapy. They were also given encouragement to ambulate, and an immunomodulatory diet 7 days prior to surgery. The volume of gas used, types of symptoms, and complications were recorded daily. On the 14th day of the program, we performed a control CT scan for a comparative volumetric study, following the same parameters and calculations as the previous exam. After the end of this preoperative procedures, the patient was submitted to abdominal wall reconstruction. Our surgical approach after the PPP was based on the finds of the tomography images. If all of the visceral contents were totally reduced into th
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