Abstract: Objective:To investigate the application value of the preoperative progressive pneumoperitoneum (PPP) in parastomal hernia repair.
Methods:The retrospective crosssectional study was conducted. The clinical data of 28 patients who underwent parastomal hernia repair using PPP in the Sixth Affiliated Hospital of Sun Yatsen University from December 2014 to February 2017 were collected. Patients received abdominal computed tomography (CT) scan after admission, and volumes of the hernia sac and abdominal cavity and (volume of the hernia sac / total volume of the abdominal cavity)×100.0% were respectively calculated. Open or laparoscopic parastomal hernia repair was selected based on the effects of artificial pneumoperitoneum. Observation indicators: (1) PPP situations: ① completion; ② changes of volumes of the hernia sac and abdominal cavity before and after PPP; ③ adhesion and retraction of parastomal hernia contents after PPP; (2) surgical and postoperative recovery situations; (3) followup situations. Followup using outpatient examination and telephone interview was performed to detect the postoperative longterm complications and recurrence of parastomal hernia up to May 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Repeated measurement data were evaluated with the repeated measures ANOVA.
Results:(1) PPP situations: ① completion: 28 patients received successful ultrasoundguided indwelling catcher. Twentyfour patients completed PPP, with a completion rate of 85.7% (24/28)and an air injection volume of (3 995±531)mL, and 4 stopped PPP. Eighteen patients had varying degrees of abdominal pain, abdominal distension and scapular pain, including 17 with tolerance and 1 with disappearing of symptoms at day 6. Of 5 patients with shortness of breath, 3 were improved or well tolerated through breathing exercises, and symptoms of 2 disappeared at day 7 and 9. Three patients had mild subcutaneous emphysema. The arterial CO₂ tension of 1 patient was high and then returned to normal at day 7. Some patients had simultaneously multiple adverse reactions. ② Changes of volumes of the hernia sac and abdominal cavity before and after PPP: volumes of the hernia sac before and after PPP were (699±231)mL and (993±332)mL, with a statistically significant difference (F=129.29, P<0.05), and increasing volume of the hernia sac was (294±167)mL, with an increasing rate of 43%±15%. Volumes of the abdominal cavity before and after PPP were (6 520±745)mL and (9 196±909)mL, with a statistically significant difference (F=429.42, P<0.05), and increasing volume of the abdominal cavity was (2 715±709)mL, with an increasing rate of 42%±12%. (Volume of the hernia sac / total volume of the abdominal cavity)×100.0% before and after PPP were 9.6%±2.7% (less than or equal to 10.0% in 20 patients, more than 10.0% and less than or equal to 15.0% in 6 patients, and more than 15.0% in 2 patients) and 9.7%±2.8%, with no statistically significant difference (F=0.44, P>0.05). ③ Adhesion and retraction of parastomal hernia contents after PPP: results of abdominal CT showed anterior abdominal bulging, abdominal contents prostrated at the base of the abdominal cavity due to gravity, and gas was full of gaps. Abdominal adhesion signs: adhesions of banded fibrous connective tissue established a connection between the base of the abdominal cavity and anterior abdominal wall, and intestinal canals were found inside the adhesions. Parastomal hernia contents of 28 patients had varying degrees of retraction to abdominal cavity, including 9 with complete retraction, 13 with a great amount of retraction (retraction volume >50%) and 6 with a small amount of retraction (retraction volume <50%). Four patients were accompanied by incomplete stoma obstruction, and then obstruction disappeared or relieved after PPP. (2) Surgical and postoperative recovery situations: all the 28 patients underwent successful operations, without intestinal canal injury. Three patients received open parastomal hernia repair, including 2 receiving preperitoneal mesh repair using 8 layers Biodesign meshes (deep venous catheter for local drainage was placed and then removed at postoperative day 2 and 3) and 1 receiving Sugarbaker surgery using PCOPM mesh (peritoneal drainagetube was placed and then removed at postoperative day 2). Other 25 patients received laparoscopic parastomal hernia repair and Sugarbaker surgery using PCOPM and Sepramesh meshes (no drainagetube was placed). Bladder pressure of 28 patients at postoperative day 3 was (13±6)cmH₂O (1 cmH₂O=0.098 kPa), without an abnormal high pressure. Nine patients with postoperative complications were improved by conservative treatment, including 3 with seroma, 3 with delayed stoma defecation or incomplete intestinal obstruction, 2 with pulmonary infection and 1 with urinary tract infection. There were no occurrences of abdominal compartment syndrome, cardiac failure, lung failure, renal failure, other severe complications and perioperative death. Duration of postoperative hospital stay was (7.2±1.5)days. (3) Followup situations: 25 of 28 patients were followed up for 3-25 months, with a median time of 11 months. During followup, 2 patients had chronic pain around the operation and a sense of discomfort and then were improved by symptomatic treatment, and 1 with parastomal hernia recurrence at postoperative month 6 after open preperitoneal mesh repair underwent again open preperitoneal mesh repair, without recurrence. There were no occurrence of tardive mesh infection and other longterm complications.
Conclusion:PPP in the treatment of parastomal hernia repair is safe and feasible.