Annals of the Royal College ofSurgeons ofEngland (1993) vol. 75, 186-188

On-table in the management of complicated incisiona

M C Winslet MS FRCS M L Obeid FRCS Lecturer in Surgery Consultant Surgeon V Kumar FRCS SHO in Surgery Department of Surgery, Dudley Road Hospital, Birmingham

Key words: ; Pneumoperitoneum

'On-table' pneumoperitoneum before repair of 'complicated' or the need for synchronous intestinal resection, how- incisional hernias has been used in eight patients considered ever, are relative contraindications to their use (7). to be at high risk of recurrence. In four patients the Progressive preoperative pneumoperitoneum in the man- revealed the presence of occult defects. procedure The agement of giant or difficult incisional hernias, first procedure was uncomplicated and a primary repair without described in 1947 (8) has distinct advantages over the use the need for a prosthetic implant was possible in ali cases. of prosthetic material in the presence of potential sepsis. Six patients remain well with no sign of recurrence at a median follow-up of 96 months (range 22-120 months). Two A major disadvantage of this technique, however, which patients died from conditions unrelated to the method of has limited its use to a few enthusiasts (3,4,6,7,9-16) is repair; acute necrotising on the 10th postopera- the length of time required in hospital before surgery. To tive day and lobar pneumonia 2 months postoperatively. overcome this problem we have evaluated the use of Peroperative pneumoperitoneum is a simple procedure peroperative pneumoperitoneum in the management of which obviates the need for a prosthetic implant in selected complicated incisional hernias. patients. It is therefore particularly useful in the management of incisional hernias associated with sepsis, stomas or in patients requiring synchronous bowel resection. Patients

From 1981 to 1990, eight patients with incisional hernias Small or moderately sized incisional hernias which occur complicated by size, previous repair or the presence of in 3% to 5% of postoperative patients may by repaired multiple predisposing factors, considered to be at high successfully in 95% of cases (1). Successful repair is less risk of recurrence (Table I), had on-table pneumoperi- likely in patients with complicated incisional hernias. toneum induced immediately before standard surgical Here, repair of large or recurrent defects under tension repair. may be followed by cardiopulmonary embarrassment and failure of the repair. In such circumstances, procedures such as phrenec- Method tomy (2), transverse myotomy (3) and omentectomy have been advocated to reduce the risk of recurrence. More After urinary catheterisation and nasogastric decompres- recently, the use of prosthetic implants has become more sion, the apparent margins of the defect were defined widespread (5,6). The presence of infection and stomas with a surgical marker pen. A Veress needle (1.8 mm) was inserted into the peritoneal cavity at a point further- est away from any abdominal scars. Pneumoperitoneum Correspondence to: Mr M C Winslet, University Department was produced by the introduction of CO2 using an of Surgery, Royal Free Hospital, Pond Street, London NW3 automatic insufflator, designed for laparoscopy, until the 2QG became tense. The median volume of CO2 On-table pneumoperitoneum in complicated incisional hernias 187 Table 1. Patient details Initial Complicating Hospital Follow-up Sex Age incision factors Smoker Repair stay (days) (months) Outcome F 49 Pfannenstiel Obesity Yes Keel 6 96 NSR Nine pregnancies F 82 Midline Size No Keel 8 3 Died Cachexia Pneumonia F 83 Right paramedian Multiple defects Ex Single layer 10 22 NSR midline Obesity F 79 Right Size Yes Single layer 9 76 NSR paramedian Recurrence M 60 Right Size Yes Single layer 11 120 NSR paramedian Obesity F 58 Pfannenstiel Recurrence (x 2) No Single layer 13 96 NSR midline Size M 54 Midline Size Yes Single layer 5 37 NSR Obesity F 64 Midline Size Yes Single layer 10 Died paramedian Recurrence (x 3) Pancreatitis Obesity

required was 6 dm3 (range 4-7 dm3). The real margins of Results the hernial defect were then redefined (Fig. 1). Redundant skin, including the scar, was excised to Pneumoperitoneum revealed an occult defect in four expose the hernial sac. The superficial margins of the cases. All eight patients had an uncomplicated pro- defect were defined by sharp dissection and included any cedure. In six patients a single layer interrupted 1/0 occult defects revealed by pneumoperitoneum. While the nylon repair was performed, while in two patients a 'keel' pneumoperitoneum was maintained, the deep margins repair was possible. were defined by a preperitoneal dissection. When a well- There was one postoperative death on day 10 due to defined sac was present, it was opened at a convenient acute necrotising pancreatitis which developed on the 3rd point and the pneumoperitoneum was released. The postoperative day and resulted in multisystem failure. contents were then reduced and the sac closed. In the This patient, with no history of pre-existing hepatobili- absence of a well-defined sac the pneumoperitoneum was ary or pancreatic disease, had suffered from recurrent released by direct puncture at a suitable site. The hernia partial small secondary to incarcer- was then repaired in a standard fashion using a single ation and had undergone three previous conventional layer or keel repair. repairs. Post-mortem examination revealed pulmonary changes compatible with adult respiratory distress syn- drome with moderate basal atelectasis and the classic features of . An 82-year-old female, non-smoker, discharged on day 8 after a successful repair for recurrent incarceration died 2 months later from right lobar pneumonia. Six patients, two of whom underwent repair for a recurrent , remain well with no sign of recurrence at a median follow-up of 96 months (range 22-120 months).

Discussion Large, complicated incisional hernias are associated with various pathophysiological changes, including a reduc- tion in the capacity of the abdominal cavity, an enlarge- ment of the peritoneal cavity and contracture of the Figure 1. Real and apparent margins of a large recurrent abdominal flank muscle. The reduction in abdominal incisional hermia. muscle contribution to respiratory movement further 188 M C Winslet et al. produces a secondary impairment in pulmonary function at the site of repair while reducing the period of preoper- and venous return (17). Attempted reduction of the ative hospitalisation. abdominal contents and closure of such a defect may result in reduced venous return, diaphragmatic eleva- tion, respiratory distress, and atelectasis. The production of progressive preoperative pneumo- References is considered to improve respiratory function and spirometry (12,13,18). The restoration of intra- I Giles GR. The abdominal wall and hernias. In: Cuschieri A, abdominal pressure may also improve diaphragmatic Giles GR, Moossa AR eds. Essential Surgical Practice 2nd muscular function and tone, and improve venous blood Edition. London: Wright 1266. 2 Touroff ASW. Phrenicectomy as aid to repair of large flow with stretching of the abdominal wall facilitating abdominal hernias. jAMA 1954;154: 330-2. repair of the defect under reduced tension (7,19). 3 Ziffrin SE, Wassack NA. An operative approach to the Peroperatively there may be a reduction in the degree of treatment of gigantic hernias. Surg Gynecol Obstet 1950;91: mesenteric and visceral oedema, lysis and thinning of 709-10. adhesions to the hernial ring and sac, a reduction in the 4 Connolly DP, Peir FR. Giant hernias managed by pneumo- volume of hollow organs and identification of occult peritoneum. JAMA 1969;209:71-4. defects which may contribute to possible future recur- 5 Smith RS. The use of prosthetic materials in the repair of rence (7). It has also been suggested that the production hernias. Surg Clin North Am 1971;51: 1387-99. of progressive pneumoperitoneum may also shorten the 6 Larson GM, Harrower HW. Plastic mesh repair of in- duration of the operation, reduce the incidence of post- cisional hernias. Am J Surg 1978;135:559-63. operative complications, and lower the recurrence rate 7 Raynor RW, Del Guercio LRM. Update on the use of preoperative pneumoperitoneum prior to the repair of large (17). hernias of the abdominal wall. Surg Gynecol Obstet 1985; A major disadvantage of progressive pneumoperi- 161: 367-71. toneum is the reported preoperative period of hospital- 8 Moreno IG. Chronic eventrations and large hernias: pre- isation, ranging from 6 to 16 days (4,17). Immediate operative treatment by progressive pneumoperitoneum. peroperative pneumoperitoneum production appears to Surgery 1947;22:945-53. retain all the benefits of the progressive technique with- 9 Koontz AK, Craven JW. Preoperative pneumoperitoneum out requiring prolonged hospitalisation. Although objec- as an aid in the handling of gigantic hernias. Ann Surg tive assessment of abdominal electromyography is 1954;140: 759-62. lacking, immediate pneumoperitoneum appeared to faci- 10 Mansuy MM, Hager HG. Pneumoperitoneum in prepar- litate reduction of the hernial contents and apposition of ation for correction of giant hernias. N Engl 7 Med 1958; the anterior abdominal wall considerably, without ten- 258:33-34. 11 Steichen FML. A simple method for establishing, maintain- sion, allowing a 'keel' repair in two instances. In four ing and regulating surgically induced pneumoperitoneum cases it also allowed identification of further occult in preparation for large hernia repairs. Surgery 1965;58: defects which may have precluded a successful repair 1031-2. using standard techniques. 12 Johnson WC. Preoperative progressive pneumoperitoneum There were no peroperative complications during the in preparation for repair of large hernias of the abdominal induction of pneumoperitoneum, although haematoma wall. AmJ7 Surg 1972;124:63-8. formation, subcutaneous emphysema, respiratory embar- 13 Barst HH. Pneumoperitoneum as an aid in the surgical rassment, and rarely perforation or air emboli have been treatment of giant herniae. Br J Surg 1972;59:360-4. reported (13,20). All patients were given intensive post- 14 Ashidillo R, Merrel R, Sanchez J, Olmedo S. Ventral operative physiotherapy to minimise pulmonary compli- herniorrhaphy aided by pneumoperitoneum. Arch Surg cations with no resultant postoperative morbidity. Two 1986;121:935-6. 15 Mason EE. Pneumoperitoneum in the management of giant deaths occurred in this series but neither was considered hernias. Surgery 1956;39:143-51. directly related to the operative technique employed, 16 Cady F, Broke-Cowden GL. Repair of massive abdominal although a degree of diaphragmatic splinting and a basal wall defects: combined use of pneumoperitoneum and atelectasis (7) may have contributed to the lobar pneumo- Marlex mesh. Surg Clin North Am 1976;56:559-70. nia in one patient, which occurred 3 months postopera- 17 Caldironi MW, Romano M, Bozza F et al. Progressive tively. pneumoperitoneum in the management of giant unusual There has been no sign of recurrence in the six patients hernias: a study of 41 patients. BrJ Surg 1990;77:306-8. followed up for a median of 96 months. This compares 18 Moreno IG. The radical treatment of hernias and volumi- favourably with the large series of Caldironi et al. (17) nous chronic eventration: preparation with progressive who reported two recurrences in a series of 41 patients pneumoperitoneum. In: Nyhus LM, Canden RE eds. who had 16 of whom Hernia. Philadelphia: JB Lippincott Co, 1978:536-60. progressive pneumoperitoneum, 19 Deftel M, Vasic V. A secure method of repair of large required simultaneous insertion of a Dacron® mesh. ventral hernia with Marlex mesh to eliminate tension. AmJ Initial peroperative pneumoperitoneum production is Surg 1979;137:276-7. a simple, low-risk procedure which may facilitate the 20 Johnson WC. Letter to the editor. JAMA 1971;217:968. surgical management of selected patients with compli- cated incisional hernias by facilitating dissection of tissue planes, revealing occult defects and minimising tension Received 18 August 1992