SpringerLink - Journal Article

Original Article

A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain

E. Y. Tanaka¹, J. H. Yoo¹, A. J. Rodrigues Jr.², E. M. Utiyama¹, D. Birolini¹ and S. Rasslan¹

(1)	Department of General Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil

(2)	Department of Anatomy, University of São Paulo Medical School, São Paulo, Brazil

Received: 14 May 2009 Accepted: 25 August 2009 Published online: 12 September 2009

Abstract Preoperative progressive pneumoperitoneum (PPP) is a safe and effective procedure in the treatment of large incisional hernia (size > 10 cm in width or length) with loss of domain (LIHLD). There is no consensus in the literature on the amount of gas that must be insufflated in a PPP program or even how long it should be maintained. We describe a technique for calculating the hernia sac volume (HSV) and abdominal cavity volume (ACV) based on abdominal computerized tomography (ACT) scanning that eliminates the need for subjective criteria for inclusion in a PPP program and shows the amount of gas that must be insufflated into the abdominal cavity in the PPP program. Our technique is indicated for all patients with large or recurrent incisional hernias evaluated by a senior surgeon with suspected LIHLD. We reviewed our experience from 2001 to 2008 of 23 consecutive hernia surgical procedures of LIHLD undergoing preoperative evaluation with CT scanning and PPP. An ACT was required in all patients with suspected LIHLD in order to determine HSV and ACV. The PPP was performed only if the volume ratio HSV/ACV (VR = HSV/ACV) was ≥25% (VR ≥ 25%). We have performed this procedure on 23 patients, with a mean age of 55.6 years (range 31–83). There were 16 women and 7 men with an average age of 55.6 years (range 31–83), and a mean BMI of 38.5 kg/m² (range 23–55.2). Almost all patients (21 of 23 patients—91.30%) were overweight; 43.5% (10 patients) were severely obese (obese class III). The mean calculated volumes for ACV and HSV were 9,410 ml (range 6,060–19,230 ml) and 4,500 ml (range 1,850–6,600 ml), respectively. The PPP is performed by permanent catheter placed in a minor surgical procedure. The total amount of CO₂ insufflated ranged from 2,000 to 7,000 ml (mean 4,000 ml). Patients required a mean of 10 PPP sessions (range 4–18) to achieve the desired volume of gas (that is the same volume that was calculated for the hernia sac). Since PPP sessions were performed once a day, 4–18 days were needed for preoperative preparation with PPP. The mean VR was 36% (ranged from 26 to 73%). We conclude that ACT provides objective data for volume calculation of both hernia sac and abdominal cavity and also for estimation of the volume of gas that should be insufflated into the abdominal cavity in PPP.

Keywords Artificial pneumoperitoneum - Abdominal hernia - Surgical mesh - Treatment outcome - Abdominal wall - Computerized tomography

E. Y. Tanaka
Email: eduardo.tanaka@uol.com.br

References

1.	Kingsnorth A (2006) The management of incisional hernia. Ann R Coll Surg Engl 88:252–260

2.	Kingsnorth A, LeBlanc K (2003) Hernias: inguinal and incisional. Lancet 362:1561–1571

3.	Santora TA, Roslyn JJ (1993) Incisional hernia. Surg Clin North Am 73:557–570

4.	Cassar K, Munro A (2002) Surgical treatment of incisional hernia. Br J Surg 89:534–545

5.	de Vries Reilingh TS, van Geldere D, Langenhorst B, de Jong D, van der Wilt GJ et al (2004) Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques. Hernia 8:56–59

6.	Conze J, Krones CJ, Schumpelick V, Klinge U (2007) Incisional hernia: challenge of re-operations after mesh repair. Langenbecks Arch Surg 392:453–457

7.	Venclauskas L, Silanskaite J, Kanisauskaite J, Kiudelis M (2007) Long-term results of incisional hernia treatment. Medicina (Kaunas) 43:855–860

8.	Koontz AR (1958) Hernias that have forfeited the right of domicile: use of pneumoperitoneum as an aid in their operative cure. South Med J 51:165–168

9.	An G, West MA (2008) Abdominal compartment syndrome: a concise clinical review. Crit Care Med 36:1304–1310

10.	Hartman V, Malbrain M, Daelemans R, Meersman P, Zachee P (2006) Pseudo-pulmonary embolism as a sign of acute heparin-induced thrombocytopenia in hemodialysis patients: safety of resuming heparin after disappearance of HIT antibodies. Nephron Clin Pract 104:c143–c148

11.	Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M et al (2001) Classification and surgical treatment of incisional hernia. Results of an experts’ meeting. Langenbecks Arch Surg 386:65–73

12.	Goni Moreno I (1940) Discussion de un articulo em eventraciones postoperatorias. In: Goni Moreno I (ed) XII Congresso Argentino de Cirurgia. Buenos Aires

13.	Koontz AR, Graves JW (1954) Preoperative pneumoperitoneum as an aid in the handling of gigantic hernias. Ann Surg 140:759–762

14.	Dumont F, Fuks D, Verhaeghe P, Brehant O, Sabbagh C et al (2009) Progressive pneumoperitoneum increases the length of abdominal muscles. Hernia 13:183–187

15.	Szekeres P, Kremer I, Bukovacz R, Varga J (2007) Preoperative progressive pneumoperitoneum in the treatment of giant abdominal hernias. Magy Seb 60:253–256

16.	Rodriguez Ortega M, Fernandez Lobato R, Garaulet Gonzalez P, Rios Blanco R, Jimenez Carneros V et al (2006) Neumoperitoneo en el tratamiento de hernias gigantes. Cir Esp 80:220–223

17.	Filipi CJ, Schumpelick V (2002) 2002—AHS meeting minutes at Tucson. Hernia 6:91–92

18.	Moreno IG (1940) Discussion de un articulo em eventraciones postoperatorias. 12th Argentinian Congress of Surgery, pp 85–87

19.	Alfonsi P, Vieillard-Baron A, Coggia M, Guignard B, Goeau-Brissonniere O et al (2006) Cardiac function during intraperitoneal CO2 insufflation for aortic surgery: a transesophageal echocardiographic study. Anesth Analg 102:1304–1310

20.	Hanly EJ, Mendoza-Sagaon M, Murata K, Hardacre JM, De Maio A et al (2003) CO2 pneumoperitoneum modifies the inflammatory response to sepsis. Ann Surg 237:343–350

21.	Sefr R, Puszkailer K, Frana J, Penka I (2001) Effect of carbon dioxide pneumoperitoneum on selected parameters of the acid–base equilibrium in laparoscopic cholecystectomy. Rozhl Chir 80:206–212

22.	Takiguchi S, Matsuura N, Hamada Y, Taniguchi E, Sekimoto M et al (2000) Influence of CO₂ pneumoperitoneum during laparoscopic surgery on cancer cell growth. Surg Endosc 14:41–44

23.	Kuntz C, Wunsch A, Bodeker C, Bay F, Rosch R et al (2000) Effect of pressure and gas type on intraabdominal, subcutaneous, and blood pH in laparoscopy. Surg Endosc 14:367–371

24.	Bouvy ND, Giuffrida MC, Tseng LN, Steyerberg EW, Marquet RL et al (1998) Effects of carbon dioxide pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy on body weight and tumor growth. Arch Surg 133:652–656

25.	Backlund M, Kellokumpu I, Scheinin T, von Smitten K, Tikkanen I et al (1998) Effect of temperature of insufflated CO2 during and after prolonged laparoscopic surgery. Surg Endosc 12:1126–1130

26.	Draper K, Jefson R, Jongeward R Jr, McLeod M (1997) Duration of postlaparoscopic pneumoperitoneum. Surg Endosc 11:809–811

27.	Rubio-Martinez CJ, Lang-Lenton Leon M, Rodriguez-Ponte-Cuadrillero EM, Boralla-Rivera G, Ramirez-Felipe J et al (1996) Anesthesia in laparoscopic cholecystectomy with CO₂: comparison of the hemodynamic and respiratory behavior using 2 different anesthetic techniques. Rev Esp Anestesiol Reanim 43:12–16

28.	Chmielnicki Z, Noras K, Boldys S, Celarek B (1994) Effect of CO₂ insufflation into the peritoneal cavity on selected indices of respiratory system function during laparoscopic cholecystectomy. Wiad Lek 47:503–505