Preoperative progressive pneumoperitoneum in patients with abdominal-wall hernias

Induction of preoperative progressive pneumoperitoneum is an elective procedure in patients with hernias with loss of domain. A prospective study was carried out from June 2003 to May 2005 at the Hospital de Especialidades, Instituto Mexicano del Seguro Social, Leon, Mexico. Preoperative progressive pneumoperitoneum was induced using a double-lumen intraabdominal catheter inserted through a Veress needle and daily insufflation of ambient air. Variables analyzed were age, sex, body mass index, type, location and size of defective hernia, number of previous repairs, number of days pneumoperitoneum was maintained, type of hernioplasty, and incidence of complications. Of 12 patients, 2 were excluded because it was technically impossible to induce pneumoperitoneum. Of the remaining 10 patients, 60% were female and 40% were male. The patients’ average age was 51.5 years, average body mass index was 34.7, and evolution time of their hernias ranged from 8 months to 23 years. Nine patients had ventral hernias and one had an inguinal hernia. Pneumoperitoneum was maintained for an average of 9.3 days and there were no serious complications relating to the puncture or the maintenance of the pneumoperitoneum. One patient who previously had undergone a mastectomy experienced minor complications. We were able to perform hernioplasty on all patients, eight with the Rives technique, one with supra-aponeurotic mesh, and one using the Lichtenstein method for inguinal hernia repair. One patient’s wound became infected postoperatively. Preoperative progressive pneumoperitoneum is a safe procedure that is easy to perform and that facilitates surgical hernia repair in patients with hernia with loss of domain. Complications are infrequent, patient tolerability is adequate, and the proposed modification to the puncture technique makes the procedure even safer.     

Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: the Goldstein test

Over a four-year period 256 infants and children presenting with unilateral inguinal hernias underwent intraoperative diagnostic pneumoperitoneum to evaluate the contralateral groin. Sixty one patients had positive results and underwent contralateral hernia repair. Of the 195 negative tests 3 presented later with either a hernia, communicating hydrocele or cord hydrocele (false negative rate of 1.5%). This test represents a safe, economical, rapid, and accurate means to evaluate the contralateral groin in the pediatric patient presenting with a unilateral inguinal hernia.     

CT在巨大切口疝患者疝修补术前渐进性气腹中的应用

目的探讨腹部CT在指导巨大切口疝患者行疝修补术前渐进性人工气腹（preoperative progressive pneumoperitoneum,PPP）治疗中的价值。 方法选取2011年1月至2014年1月,湖北省枣阳市第一人民医院就诊的巨大切口疝患者10例进行回顾性分析。所有患者均接受腹部64排螺旋CT检查,通过CT影像确定疝囊与腹腔的上下、左右与前后径,按椭圆体体积公式计算疝囊与腹腔体积,并计算疝囊/腹腔体积比。将疝囊/腹腔体积比>25%的6例患者行疝修补术前PPP治疗,随后接受传统疝修补术。 结果术后共随访3年,10例患者中出现切口感染1例,切口疝复发1例,死亡1例,死因为慢性阻塞性肺疾病并发的呼吸衰竭。所有患者均未出现PPP导管相关并发症和腹腔内压增高相关并发症。 结论腹部CT在巨大切口疝的外科治疗中能提供有效的辅助作用,可准确的提供疝囊与腹腔体积的计算依据,为疝修补术前PPP治疗提供客观依据。     

Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach

BACKGROUND: The management of massive ventral hernias with loss of intra-abdominal domain is a challenging surgical dilemma. We report a novel approach for repairing these extremely complicated hernias. METHODS: We retrospectively reviewed our experience with the staged resection of Gore Tex Dual mesh (WL Gore and Associates, Flagstaff, AZ) in the setting of massive abdominal wall defects. The initial stage involves reduction of the hernia and placement of a large sheet of Gore Tex Dual mesh secured to the fascial edges. Subsequent stages involve serial excision of the mesh until the fascia can be approximated in the midline without tension. Finally, the mesh is excised, and the fascia is reapproximated with component separation and AlloDerm (Lifecell Corporation, Branchburg, NJ) underlay. RESULTS: We have performed this procedure on 8 patients, with a mean age of 53 years (range 35-76). All patients had multiply recurrent ventral hernias with an average of 4.3 prior laparotomies (range 2-9). The fascial defect averaged 535 cm2 (300-884 cm2), and on average 6 serial operations were necessary to achieve fascial closure. The average length of stay was 36 days (range 9-90). One patient developed a postoperative wound infection requiring operative debridement, and 1 recurrence was identified during follow-up after an early wound complication. CONCLUSIONS: Serial Gore-Tex excision to facilitate primary fascial closure with AlloDerm sublay is an effective treatment for massive, incisional hernias with loss of abdominal domain and avoids the risks associated with long-term prosthetic fascial closures.     

术前渐进性气腹在老年腹壁巨大切口疝修补术中的应用价值

目的探讨术前渐进性气腹（preoperative progressive pneumoperitoneum,PPP）辅助治疗老年巨大切口疝的临床应用价值。 方法回顾性分析2017年2月至2018年2月,中山大学附属第六医院采用术前渐进性气腹行术前准备治疗的19例巨大切口疝老年患者的临床资料。患者气腹前后行腹部CT扫描、肺功能、动脉血气分析检查。主要观察以下指标：（1）PPP情况：气腹天数、完成情况、注入空气量等;（2）气腹前后,疝囊容积、腹腔容积、肺功能指标及动脉血气（PaO₂、PaCO₂）变化;（3）手术、术后恢复及随访情况。 结果（1）PPP情况：19例患者气腹时间11~18（15.1±1.6）d,18例患者顺利完成人工气腹准备,注入空气总量4 400~7 200（5 910.5±615.4）mL。（2）气腹前后,疝囊容积、腹腔容积、肺功能指标及动脉血气变化：气腹前后,疝囊容积分别为（1 086.7±438.9）mL、（1 275.8±521.4）mL,二者比较差异具有统计学意义（t=3.228,P<0.05）,PPP后增加（189±255.3）mL;腹腔容积分别为（6 144.0±1 758.4）mL、（8 748.5±2 084.5）mL,二者比较差异具有统计学意义（t=8.856,P<0.05）,PPP后增加（2 604.5±1 322.3）mL;疝囊容积/腹腔容积分别为10.9~28.5（17.8±5.5）%、7.3~24.9（14.7±5.6）%,二者比较差异具有统计学意义（t=3.327,P<0.05）;气腹后腹腔容积增加量远远大于气腹前疝囊容积。气腹后,FVC、FEV1/FVC%、PEF、MEF75、MEF50、MMEF75/25分别平均下降5.11%、2.45%、3.69%、1.73%、4.55%、6.8%,差异均无统计学意义（t=1.595、1.605、0.243、0.663、1.682、1.720,P>0.05）;FEV1下降6.52%,差异有统计学意义（t=2.137,P<0.05）;PaO₂平均下降5.71%,差异无统计学意义（t=1.461,P>0.05）;PaCO₂平均下降9.14%,差异有统计学意义（t=3.392,P<0.05）。（3）手术、术后恢复及随访情况：19例患者顺利完成手术,17例患者缺损完全关闭,手术时间137~265（173.9±34.7）min。术后无腹腔间隔室综合征、心肺衰竭等严重并发症发生。术后住院时间4~12（8.1±2.0）d。19例患者均获得随访,随访时间6~18（13.2±3.5）个月,无1例复发。 结论PPP应用于老年腹壁巨大切口疝患者安全有效,值得临床推广和应用。     

Use of progressive pneumoperitoneum in the repair of giant hernias

Summary Preoperative progressive pneumoperitoneum is a well-known, but sporadically used procedure in preparing patients with giant inguinal or incisional hernias for operation. The technique requires the frequent insufflation of air into the abdominal cavity in order to make room to accommodate herniated viscera and facilitate fascial repair with minimal tension. In 11 patients with giant inguinal and incisional hernias a preoperative progressive pneumoperitoneum was performed. Due to a lack of compliance it had to be terminated without operation in one patient. Minor complications appeared in almost all patients, but after pneumoperitoneum a tension-free closure of the fascial defect was successful in all patients. The direct suture of the defect was successful in 4 patients with primary hernias, while in all cases of recurrent hernias an additional fascial augmentation by alloplastic meshes was required. Until now no recurrences have appeared. We conclude that the progressive pneumoperitoneum is a useful adjunct in the preoperative preparation of patients with giant hernias. It is not a competing, but a complementary procedure to mesh repair in patients with huge defects or fascial weakness.     

Progressive pneumoperitoneum increases the length of abdominal muscles

The aim of this prospective observational study was to determine the effects of progressive preoperative pneumoperitoneum (PPP) on the size of large incisional hernia (IH) and abdominal muscles by abdominal computed tomography (CT) scan. PPP was performed in 18 patients. All IH were large. A mean volume of 12.8 l was insufflated over a mean period of 14.8 days. Respectively, before and after PPP, the mean IH height and width was 117 and 130 mm (P < 0.05) and 101 and 115 mm (P < 0.05), the mean width of the right and left rectus abdominis was 99 and 109 mm (P < 0.05) and 100 and 113 mm (P < 0.05), and the length of the right and left anterolateral muscles was 198 and 233 mm (P < 0.05) and 185 and 210 mm (P < 0.01). In conclusion, PPP increases the abdominal wall muscle length and has the same impact on the IH orifice. PPP would facilitate the fascial repair of otherwise untreatable large IH.     

Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese

INTRODUCTION: Complex ventral incisional hernias (VIH) in the morbidly obese remain a difficult management problem for the general surgeon. Multiple methods of repair with variable rates of success are described. The outcomes and techniques of a fascial component separation technique with synthetic mesh reinforcement in the morbidly obese are described. METHODS: Records of patients undergoing VIH repair between June 1996 and May 2007 who had a body mass index (BMI) greater than 30 kg/m(2) were reviewed from a prospectively maintained database. Patient demographics, BMI, hernia characteristics, perioperative and long-term complications, and long-term hernia recurrence rate were documented. RESULTS: A total of 90 patients (22 men and 68 women) meeting study criteria were identified. The mean age was 55 years (range 30-82 years). Mean BMI was 39.9 (range 30-68). Recurrent hernias were present in 43 patients (48%) Mean number of recurrences was 1.5 (range 1-5). A total of 42 patients (47%) had multiple fascial defects. Major perioperative morbidity was 8% and perioperative mortality was 1.1%. Postoperative wound infections occurred in 9 patients (10%). Hernia recurrence was observed in 5 patients (5.5%) with a mean follow-up of 50 months (range 1-132). CONCLUSIONS: Fascial component separation can be performed with acceptable perioperative morbidity and mortality. Rates of wound sepsis, mesh infection, mesh explantation and gastrointestinal mesh erosion are low. Operative time, hospital length of stay, and long-term VIH recurrence are also acceptably low. Fascial component separation is a viable technique for repair of complex VIH in the morbidly obese population.     

Laparoscopic incisional hernia repair in obese patients.

BACKGROUND AND OBJECTIVES: Laparoscopic incisional hernia repair is coming to the forefront as a preferred method of repair due to the advantages offered by minimally invasive techniques. To evaluate safety and feasibility of this approach in obese patients when performed by a general surgeon trained in basic laparoscopy with no prior experience in this technique, we reviewed our early experience in the first 18 patients. METHODS: All patients with incisional hernias presenting to a single surgeon from 2000 to 2002 were offered laparoscopic repair. Patients were informed about the limited experience of the surgeon in this particular field. Those who consented were repaired laparoscopically using a standard 4-port technique, one 12-mm port and three 5-mm ports. All patients with body mass index > or =30 were included in this review. A retrospective review of the data included demographics, operative time, blood loss, hospital stay, postoperative complications, and patient satisfaction. RESULTS: Nineteen laparoscopic repairs were completed in 18 patients. No conversions to open repair were necessary. All patients were females except for 2. All hernia sacs were left in place, some of which were empty while others required extensive lysis of adhesions to release sac contents. Mean fascial defect was 102.5 cm2. One defect was closed primarily without mesh, while the rest were closed using Composix mesh in 1 and Dual Plus Gore-Tex mesh in the rest. Three patients were discharged from the recovery room. Mean follow-up was 24 months. No wound or mesh infections occurred. Eight patients had no complications. Eight patients had asymptomatic seromas. Two patients had hematomas; none of them required drainage. One patient had nonspecific dizziness. One patient presented with bowel obstruction secondary to early recurrence (within a week). The repair was salvaged laparoscopically. Upon evaluation by telephone calls, all patients indicated extreme satisfaction with the results. CONCLUSIONS: A general surgeon with training in basic laparoscopy can safely perform laparoscopic incisional hernia repair on obese patients with minimal complications. The procedure requires a short leaning curve of no more than 3 cases and few extra materials to be feasible at any hospital in the US. Patient satisfaction with this technique is certainly gratifying.     

Sutureless laparoscopic ventral hernia repair in obese patients

Background and Objective:

Transfascial sutures (TFS) are a standard component of laparoscopic ventral herniorrhaphy (LVHR) that contribute to the durability of repair, but also pain and, resultantly, hospital stay. We sought to examine LVHR without TFS in obese patients with small abdominal wall hernias.

Methods:

Between September 2002 and December 2007, 174 patients underwent LVHR at Yale-New Haven Hospital. Patients with BMI >30kg/m² and small primary abdominal wall hernias were eligible for repair without TFS. Correlation between BMI, defect surface area, operative time, and postoperative stay was assessed.

Results:

Fourteen patients underwent LVHR with no TFS, 2 with normal BMI and recurrent hernia after open repair and 12 with BMI>30 kg/m² and primary small hernia. Mean age was 38.8 years. The average defect size was 5.3cm²; mean operative time (OT) was 42 minutes. Eleven patients (92%) were discharged home the day of surgery. No infectious or bleeding complications occurred. One patient required chronic pain management, and 8 patients (67%) developed seromas that resorbed spontaneously. There was no hernia recurrence at 7-month follow-up.

Conclusion:

LVHR is feasible without TFS provided the hernia defect is small. Surgery can be performed on an outpatient basis in obese individuals with minimal postoperative morbidity.     

Laparoscopic sleeve gastrectomy: an alternative for recurrent paraesophageal hernias in obese patients.

BACKGROUND: Recurrent paraesophageal hernias in obese patients are technically challenging and have a high recurrence rate. We sought to develop an alternative to the traditional approaches for this problem. This article describes the use of a sleeve gastrectomy in an obese patient with a large recurrent paraesophageal hernia. CASE REPORT: A morbidly obese 70-year-old woman presented with a 1-year history of chest pain, cough, dysphagia, and dyspnea. She had undergone an open paraesophageal hernia repair 8 years earlier. Diagnostic workup revealed a recurrent large paraesophageal hernia. Laparoscopically, we took down all adhesions, excised the hernia sac, reduced the stomach and distal esophagus into the abdomen, and closed the hiatus. We then resected the greater curvature and fundus of the stomach, leaving the lesser curve in a sleeve configuration. Eighteen months after the operation, the patient's chest pain, cough, dyspnea, and dysphagia were resolved. In addition, she has lost 57 pounds (255 to 198). CONCLUSION: A sleeve gastrectomy is a potentially useful alternative to fundoplication or gastropexy, or both of these, in the treatment of obese patients with complex paraesophageal hernias.     

Sarcopenia and sarcopenic obesity in patients with complex abdominal wall hernias

Background

Chronic muscle wasting, or sarcopenia, has been associated with poor-health outcomes after major surgical procedures. Here, we explore the utility of CT-generated determinations of sarcopenia as markers of risk in patients undergoing evaluation for complex ventral hernia repair.

Methods

In 148 successive patients being evaluated for complex ventral hernia repair, CT scans were analyzed retrospectively for attributes of the hernia and indices of core-muscle mass, correlating them with preoperative clinical/laboratory profiles and outcomes in 82 patients who had undergone surgery.

Results

Prevalence of sarcopenia, and sarcopenia corrected for obesity, was 26% and 20% respectively. Sarcopenia was associated with age, some laboratory indicators, and increased hospital length of stay but not with a higher likelihood of surgical site occurrence.

Conclusions

Obesity may obscure the value of sarcopenia as a marker of metabolic disturbance and postoperative outcome. Image-based measurements of core-muscle mass should be used with caution as predictors of risk in similar surgical populations.     

Barriers to weight loss in obese patients with knee osteoarthritis

INTRODUCTION

Obesity contributes to the development of knee osteoarthritis and complicates its surgical treatment. The aim of this study was to explore barriers to effective weight management in obese patients with knee osteoarthritis.

PATIENTS AND METHODS

A cross-sectional questionnaire study was performed in an elective out-patient setting and on an orthopaedic ward on patients with a body mass index (BMI) of 30 kg/m² or over and knee osteoarthritis.

RESULTS

Of 47 patients approached, 45 agreed to participate. Forty of 45 patients (89%) had tried to lose weight at some point, 35 of 40 (87.5%) by adjusting their diet. Forty of 45 (89%) patients considered lack of motivation to be the greatest barrier to weight loss and only 13 of 45 (28%) pain in the knee. Patients with a BMI of less than 40 kg/m² expressed a preference for dietary advice to help with weight loss, compared with those with a BMI of over 40 kg/m² who expressed a preference for an NHS or other support group.

CONCLUSIONS

Obesity is a significant problem for many patients with knee osteoarthritis. Attendance at an orthopaedic clinic is an opportunity to address obesity, by providing information about diet and possibly support groups for morbidly obese patients. Patients may be motivated to lose weight to improve their symptoms.     

肥胖患者术前肺功能评估的研究进展

肥胖可引起一系列呼吸系统病理生理改变,导致肺功能受损,围术期肺部并发症明显增加.因此,术前对肥胖患者进行准确肺功能评估具有重要意义.目前尚无肥胖患者术前肺功能评估的标准方案.本文就近年来肥胖患者肺功能评估的研究进展进行综述,包括肺功能检测、肺弥散功能的评价、运动试验、与肥胖相关呼吸系统合并症的筛查等,为客观评价肥胖患者...     

Preoperative progressive pneumoperitoneum and botulinum toxin type A in patients with large incisional hernia

Hernia - Combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BT) has not been previously reported in the management of large incisional hernia (LIH)....     

Use of progressive pneumoperitoneum in the treatment of giant abdominal hernias

The preoperative use of progressive pneumoperitoneum in the treatment of large or complicated ventral hernias is established to be safe and useful. Indications for use of this technique include massive hernias, hernias that are repaired in a contaminated field, hernias in patients considered poor operative risks, and recurrent hernias. Five patients are described in whom this technique was used; all five hernias were closed primarily without tension, mesh, or postoperative complications. follow-up reveals no evidence of recurrence.