
==== Front
Cureus
Cureus
2168-8184
Cureus
2168-8184
Cureus Palo Alto (CA)

10.7759/cureus.68509
Plastic Surgery
General Surgery
Quality Improvement
Preoperative Progressive Pneumoperitoneum and Botulinum Toxin A in a High-Risk Patient With Loss of Domain Inguinoscrotal Hernia
Muacevic Alexander
Adler John R
Baco Stanko J 1
Mišić Jovica 2
Perunicic Vladan 3
Mitric Milos 1
Đukanović Sonja 4
1 General Surgery, Public Health Institution Hospital “Dr Mladen Stojanović”, Prijedor, BIH
2 General Surgery, Saint Luke the Apostle Hospital, Doboj, BIH
3 Surgery, General Hospital, Čačak, SRB
4 Emergency Medicine, Public Health Institution Dom zdravlja Prijedor, Prijedor, BIH
Stanko J. Baco sbaco3@gmail.com
3 9 2024
9 2024
16 9 e685093 9 2024
Copyright © 2024, Baco et al.
2024
Baco et al.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article is available from https://www.cureus.com/articles/251050-preoperative-progressive-pneumoperitoneum-and-botulinum-toxin-a-in-a-high-risk-patient-with-loss-of-domain-inguinoscrotal-hernia
We present a challenging case of a loss of domain (LOD) inguinoscrotal hernia in a 77-year-old high-risk patient, successfully managed with the complementary preoperative use of progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) without complications. Giant inguinoscrotal and LOD hernias, particularly in multimorbid patients, are highly complex and require meticulous preoperative preparation. In this case, PPP was performed with ambient air and a gradual increase in insufflation volume, while BTA was injected at three points on each side, with a total dose of 300 IU. This approach facilitated a complication-free increase in abdominal cavity volume and the repositioning of chronically eventrated abdominal contents. The technique proved safe, feasible, and effective, contributing to atraumatic adhesiolysis, reduced operative time, and avoidance of more invasive surgical methods. A Shouldice pure tissue repair was performed, successfully avoiding the need for prosthetic materials.

inguinoscrotal hernia
multimorbid
amyand’s hernia
tension repair
shouldice technique
botulinum toxine
progressive preoperative pneumoperitoneum
loss of domain
giant inguinal hernia
==== Body
pmcIntroduction

Inguinal hernias are common, accounting for 75% of all abdominal wall hernias and affecting nearly 25% of men and less than 2% of women over their lifetime. Giant inguinoscrotal hernias are defined as hernias that extend below the midpoint of the inner thigh while standing [1,2]. Loss of domain (LOD) hernias are characterized by the inability to achieve simple reduction of their contents and primary fascial closure without additional reconstructive techniques or without significant risk of complications due to increased intra-abdominal pressure (IAP) [3,4]. Managing LOD hernias with chronic displacement of abdominal contents is particularly challenging, especially in multimorbid patients, defined as those with two or more chronic conditions [5].

In ventral LOD hernias, several treatment options have been proposed. The component separation technique, first reported by Albanese and popularized by Ramirez, was a mainstay for complex hernia closure [6,7]. However, due to complications and high recurrence rates, new techniques and modifications have been developed. One such technique is transversus abdominis release (TAR), a modification of the posterior component separation technique, which extends the Rives-Stoppa-Wantz method with sublay mesh placement. TAR is associated with low morbidity and better outcomes, but it is not applicable to inguinal hernias, necessitating other surgical techniques or adjunct preoperative methods [6,8,9].

Progressive pneumoperitoneum (PPP), first described by Moreno in 1947, induces abdominal wall distension by creating the necessary space for hernial sac content reduction [7]. It is an excellent adjuvant technique for the preoperative treatment of LOD hernias, particularly when combined with botulinum toxin A (BTA). BTA, also described as “chemical component separation,” induces reversible paralysis of the lateral abdominal wall muscles, allowing their elongation and facilitating hernia repair [10,11].

We present a challenging case of an LOD inguinoscrotal hernia in a high-risk patient, where the complementary preoperative use of PPP and BTA led to excellent results without serious complications. The patient experienced a successful recovery and was discharged on postoperative day 3.

Case presentation

A 77-year-old man presented to our ambulance with a giant right-sided inguinoscrotal hernia that he had experienced for over 10 years (Figure 1). Due to the hernia’s enormous size, extending almost down to his knees, he suffered from abdominal and groin pain, a buried penis, difficulty with normal daily activities such as walking and dressing, and spontaneous urinary leakage. His high operative risk had led to multiple previous denials of surgery. The patient’s comorbidities included hypertension, chronic renal failure, ischemic cardiomyopathy, NYHA II heart failure, severe mitral valve insufficiency, intermittent left bundle branch block, atrioventricular block gradus primus, prostatic hyperplasia, and NSTEMI myocardial infarction three years prior. A preoperative CT scan revealed a 33 cm long hernial sac completely filled with small and large intestines (Figure 2).

Figure 1 Initial examination showing a massive right inguinoscrotal hernia

Figure 2 Preoperative CT scan (sagittal view) showing a 33 cm long hernial sac filled with small and large intestines, along with the mesentery

Under local anesthesia, we placed a simple Foley catheter into the abdominal cavity through a 20-mm vertical subxiphoid incision to induce pneumoperitoneum (Figure 3). We did not use a triple valve catheter, a central venous catheter, or bacterial filters as described in other case reports. The procedure was well tolerated, and the patient was discharged on the same day with only oral analgesics.

Figure 3 Intraoperative image of catheter placement under local anesthesia for pneumoperitoneum induction

Initially, we insufflated 600 cc of ambient air daily for the first three days, followed by ambulatory insufflation of 700 cc per day for the next seven days. IAP was not monitored. A surgical site infection occurred due to irregular wound dressing, which was resolved with daily cleansing using water and soap. The abdominal distention caused only mild discomfort after each insufflation.

After 10 days and an insufflated volume of 6.7 L, we were not satisfied with the progress of abdominal wall distention, so we proposed BTA to the patient. We injected 300 IU of BTA between the external and internal oblique muscles, 150 IU on each side of the abdominal wall at three points between the costal margin, iliac crest, and lateral to the semilunar line. The procedure was performed under ultrasound guidance and with informed consent (Figure 4).

Figure 4 BTA injection points are located between the costal margin, iliac crest, and lateral to the semilunar line

The red arrow indicates the placement of the intraperitoneal Foley catheter.

Two weeks after the BTA injection, we conducted a follow-up abdominal CT scan. The patient continued with daily self-sufflation at home. Five days before surgery, the patient was admitted to the hospital and underwent insufflation with 1,000 cc of room air three times and then 1,400 cc twice. The total insufflation period was 20 days, with daily volumes ranging from 600 to 1400 cc, amounting to a total of 20.7 L of ambient air.

Following BTA application and the increased insufflation volume, the patient experienced more pronounced abdominal and groin pain and distention, particularly when standing. The abdomen was noticeably more distended. A control CT scan revealed an enlargement of the abdominal cavity, providing sufficient space for the herniated viscera (Figure 5).

Figure 5 Control CT scan showing a noticeable enlargement of the abdominal cavity (green arrows) and sufficient space created for herniated viscera

Perioperatively, 30 minutes before surgery, the patient received 1 g of cefazolin, 0.5 g of metronidazole, and deep vein thrombosis prophylaxis. During the operation, we opened the hernia sac, revealing an appendix, colon ascendens, and numerous small bowel loops (Figure 6, Figure 7). We restored the hernia contents without the need for bowel resection and performed a Shouldice natural tissue repair (Figure 8). The surgery lasted 90 minutes.

Figure 6 Intraoperative image of the hernial sac prepared and filled with air

Figure 7 Hernial sac after partial reduction of herniated contents, showing the small bowel (blue arrows), cecum (black arrow), and appendix (red arrow), indicating an Amyand’s hernia

Figure 8 Immediate postoperative image showing the outcome of the Shouldice repair

The patient’s recovery proceeded smoothly, and they were discharged on the 10th postoperative day. During the first outpatient follow-up, an inguinal wound hematoma was noted after seven days, which resolved spontaneously. Five months postoperation, there is no sign of recurrence, and the patient reports high satisfaction with their quality of life (Figure 9).

Figure 9 Image of the surgical site six months postoperation

Discussion

The classification of hernias has seen various proposals, aiming to enhance the utility of LOD as an outcome predictor and standardize morphological descriptions. International specialists have reached a consensus on defining LOD hernias to minimize clinical inconsistencies. This definition specifies that LOD hernias either pose a significant risk of complications due to increased IAP or require additional reconstructive procedures beyond primary fascial closure and simple content reduction [4]. An alternative definition considers hernias with more than 20% of abdominal contents as straightforward [12]. There is ongoing debate about the distinction between reversible and irreversible LOD hernias, with no clear cutoff point [4].

Managing LOD hernias, which involve chronic displacement of abdominal contents, is particularly challenging. These high-risk operations should be performed by experienced hernia specialists, especially in multimorbid patients, as multimorbidity significantly impacts functioning and survival, contributing to nearly 70% of postoperative deaths [13]. PPP is a prehabilitation technique that can expand the abdominal cavity, creating space for chronically impacted contents and reducing the risk of compartment syndrome and related complications. The PPP catheter placement procedure is reproducible even in low-resource settings, using ambient air and local anesthesia. While some studies have used CO2 for PPP creation, its rapid resorption makes it less suitable [14]. Our experience showed no complications from room air insufflation. However, PPP alone initially did not yield satisfactory results, and we observed discomfort when the injected air volume exceeded 1,000 cc, suggesting a gradual approach is preferable. Prolonged PPP can lead to effective pneumatic adhesiolysis, and IAP measurement is not obligatory.

BTA, known for its use in treating hyperhidrosis and wrinkles by paralyzing muscles, also reduces abdominal wall tension in hernia surgery [15]. BTA allows for reversible separation of abdominal wall components, reducing the need for invasive surgery and associated complications. Our experience with BTA, administered at three points on each side with a dose of 300 IU, showed satisfactory results. BTA’s maximum effect appears after 10-14 days and lasts approximately three months [16,17]. We opted not to use mesh implantation or drains, based on the patient’s health status, local findings, and the operator’s expertise, with very satisfactory results from the Shouldice operation. Studies indicate a recurrence rate below 1% with the Shouldice technique, which is particularly advantageous in low-resource settings [18]. In our case, the combined use of PPP and BTA achieved pneumatic adhesions, dissection of the hernial sac, and a significant reduction in operative time. This approach is crucial for multimorbid patients, avoiding more invasive techniques such as component separation, small bowel resection, or hemicolectomies.

Conclusions

Giant inguinoscrotal and LOD hernias, especially in multimorbid patients, require preoperative prehabilitation. In our experience, PPP alone was insufficient for optimal conditions. However, when combined with BTA, we achieved excellent results. This approach is safe, feasible, and effective, facilitating pneumatic, nontraumatic adhesiolysis, reducing surgery time, and minimizing the need for more invasive techniques such as hemicolectomies, component separation, or TAR. The catheter placement procedure is reproducible even in low-resource settings and can be performed under local anesthesia. It is crucial to close the fascia with a non-resorbable suture for pneumoperitoneum creation and maintain regular wound care. We found that a BTA injection at three points on each side with a total dose of 300 IU was sufficient. Due to notable discomfort with injected volumes exceeding 1000 cc per day, we recommend a gradual and slower increase in volume over an extended period.

We are grateful to our colleagues, Drs. Ruzica Kos and Gorana Andjic, radiologists, for their technical expertise and assistance with the ultrasound-guided and accurate targeting of structures for the botulinum toxin injections.

Disclosures

Author Contributions

Human subjects: Consent was obtained or waived by all participants in this study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Concept and design:  Stanko J. Baco, Milos Mitric, Sonja Đukanović, Vladan Perunicic

Acquisition, analysis, or interpretation of data:  Stanko J. Baco, Milos Mitric, Jovica Mišić, Vladan Perunicic

Drafting of the manuscript:  Stanko J. Baco, Sonja Đukanović

Critical review of the manuscript for important intellectual content:  Stanko J. Baco, Milos Mitric, Jovica Mišić, Sonja Đukanović, Vladan Perunicic

Supervision:  Stanko J. Baco, Jovica Mišić, Sonja Đukanović, Vladan Perunicic
==== Refs
References

1 Inguinal hernia StatPearls [Internet] Hammoud M Gerken J Treasure Island (FL) StatPearls Publishing 2024 https://pubmed.ncbi.nlm.nih.gov/30020704/
2 Inguinal hernias BMJ Jenkins JT O'Dwyer PJ 269 272 336 2008 18244999
3 What exactly is meant by "loss of domain" for ventral hernia? Systematic review of definitions World J Surg Parker SG Halligan S Blackburn S Plumb AA Archer L Mallett S Windsor AC 396 404 43 2019 30187090
4 Definitions for loss of domain: an international Delphi consensus of expert surgeons World J Surg Parker SG Halligan S Liang MK 1070 1078 44 2020 31848677
5 Comorbidity or multimorbidity: what’s in a name? A review of literature Eur J Gen Pract van den Akker M Buntinx F Knottnerus JA 65 70 2 1996
6 "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study Plast Reconstr Surg Ramirez OM Ruas E Dellon AL 519 526 86 1990 2143588
7 Chronic eventrations and large hernias; preoperative treatment by progressive pneumoperitomeum; original procedure Surgery Moreno IG 945 953 22 1947 https://pubmed.ncbi.nlm.nih.gov/20271801/ 20271801
8 Transversus abdominis muscle release in giant incisional hernia Cureus Baco S Mitric M 0 14 2022
9 Restoration of abdominal wall integrity as a salvage procedure in difficult recurrent abdominal wall hernias using a method of wide myofascial release Plast Reconstr Surg Levine JP Karp NS 707 716 107 2001 11304595
10 Botulinum toxin: mechanisms of action Eur Neurol Dressler D Adib Saberi F 3 9 53 2005
11 Botulinum toxin and progressive pneumoperitoneum in loss of domain ventral hernias: a systematic review J Abdom Wall Surg Giuffrida M Biolchini F Capelli P Banchini F Perrone G 12650 3 2024 38572390
12 Definition of giant ventral hernias: development of standardization through a practice survey Int J Surg Passot G Villeneuve L Sabbagh C 136 140 28 2016 26889971
13 Effect of chronic diseases and multimorbidity on survival and functioning in elderly adults J Am Geriatr Soc Rizzuto D Melis RJ Angleman S Qiu C Marengoni A 1056 1060 65 2017 28306158
14 Influence of gas type, pressure, and temperature in laparoscopy—a systematic review Ann Laparosc Endosc Surg Galetin T Galetin A 7 2022
15 Botulinum toxin a as an adjunct to abdominal wall reconstruction for incisional hernia Plast Reconstr Surg Glob Open Soltanizadeh S Helgstrand F Jorgensen LN 0 5 2017
16 Comparison of two versus three bilateral botulinum toxin injections prior to abdominal wall reconstruction J Abdom Wall Surg Timmer AS Ibrahim F Claessen JJ Aehling CJ Kemper TC Rutten MV Boermeester MA 11382 2 2023 38312410
17 Botulinum toxin abdominal wall injection and post-omphalocele ventral hernia repair: database and proposal of a protocol Ann Pediatr Surg de Jesus LE Leve TC Fulgencio C Dekermacher S 16 2020
18 Short-stay surgery (Shouldice technique) for repair of inguinal hernia Ann R Coll Surg Engl Glassow F 133 139 58 1976 https://pubmed.ncbi.nlm.nih.gov/773247/ 773247
