Progressive Pneumoperitoneum for thePneumoperitoneum for ... · Progressive Pneumoperitoneum for...

Progressive Progressive Pneumoperitoneum for thePneumoperitoneum for thePneumoperitoneum for thePneumoperitoneum for theRepair of Massive Inguinal Repair of Massive Inguinal p gp g

HerniasHernias

LixanaLixana Vega Vega VegaVega, MD, MDV gV g V gV g ,,SUNY Downstate Medical CenterSUNY Downstate Medical Center

M h 20M h 20thth 20092009March 20March 20thth, 2009, 2009

www.downstatesurgery.org

ACGME Core Competencies

Patient CarePatient CareMedical knowledgeP i B d L i IPractice Based Learning &ImprovementInterpersonal & Communication SkillsProfessionalismSystems based practiceSystems based practice


Case presentationCase presentation74 y/o male presented to surgery clinic with a massive 74 y/o male presented to surgery clinic with a massive right inguinal hernia, that became progressively larger right inguinal hernia, that became progressively larger

h 20h 20over the past 20 years.over the past 20 years.Intermittent right groin pain.Intermittent right groin pain.

i i ii i iUrinary incontinence.Urinary incontinence.Progressive impairment of activities of daily living Progressive impairment of activities of daily living ( b l i )( b l i )(ambulation). (ambulation). PMHPMH-- Alzheimer's disease recently diagnosedAlzheimer's disease recently diagnosed

dd A AA AMedsMeds-- ASAASAPSHPSH-- deniesdeniesAllergiesAllergies-- NKDANKDA


Physical ExamPhysical ExamAbdomen

Scaphoid, soft, nontender, nondistendednondistended.

Right groinMassive right inguinal hernia withMassive right inguinal hernia with scrotum extending to knee caps.Hernia nontender.S d ll iScrotum does not translluminate.

Left groin- no palpable hernias. Labs WNLLabs – WNL


Abdomen and Pelvis CT ScanAbdomen and Pelvis CT Scanwww.downstatesurgery.org

Abdomen and Pelvis CT Scan Abdomen and Pelvis CT Scan www.downstatesurgery.org

Case Presentation Case Presentation

74 y/o male with massive right inguinal hernia with 74 y/o male with massive right inguinal hernia with loss ofloss of intraabdominalintraabdominal domain, affecting ADL.domain, affecting ADL.loss of loss of intraabdominalintraabdominal domain, affecting ADL.domain, affecting ADL.Standard reduction and primary repair Standard reduction and primary repair

Abd mi l mp rtm t dr mAbd mi l mp rtm t dr mAbdominal compartment syndrome.Abdominal compartment syndrome.Respiratory distress.Respiratory distress.H iH iHernia recurrence.Hernia recurrence.

Progressive Preoperative PneumoperitoneumProgressive Preoperative PneumoperitoneumInsufflationInsufflation of ambient air into peritoneal cavity in of ambient air into peritoneal cavity in order to accommodate herniated viscera at time of order to accommodate herniated viscera at time of h i ih i ihernia repair.hernia repair.


Progressive Preoperative Progressive Preoperative PneumoperitoneumPneumoperitoneumPneumoperitoneumPneumoperitoneum

Peritoneal dialysis catheter placed and one Peritoneal dialysis catheter placed and one li f i i ffl d i h bdli f i i ffl d i h bdliter of air was insufflated into the abdomen.liter of air was insufflated into the abdomen.During each clinic visit (every 2 During each clinic visit (every 2 –– 3 days for a 3 days for a 20 d i d) i l li f20 d i d) i l li f20 day period) approximately one liter of 20 day period) approximately one liter of ambient air was introduced to the abdominal ambient air was introduced to the abdominal cavity via the dialysis cathetercavity via the dialysis cathetercavity via the dialysis catheter. cavity via the dialysis catheter.

Pt tolerated procedure well. Denied abdominal Pt tolerated procedure well. Denied abdominal pain, n/v or dyspnea. pain, n/v or dyspnea.

Pt admitted for bowel prep prior to RIH repair. Pt admitted for bowel prep prior to RIH repair.


Right inguinal hernia repair Right inguinal hernia repair

Long right inguinal incision.Long right inguinal incision.g g gg g gMassive inguinal hernia Massive inguinal hernia extending to right scrotum.extending to right scrotum.

Right colon and loops of smallRight colon and loops of smallRight colon and loops of small Right colon and loops of small bowel within sacbowel within sacContents of spermatic cord were Contents of spermatic cord were identified and isolated.identified and isolated.

Contents of the hernia were Contents of the hernia were reduced to the abdomen after reduced to the abdomen after incision on the anteriorincision on the anteriorincision on the anterior incision on the anterior abdominal wall, lateral to abdominal wall, lateral to internal ring.internal ring.

Residual hernia sac wasResidual hernia sac was resectedresectedResidual hernia sac was Residual hernia sac was resectedresected. .


Right inguinal hernia repairRight inguinal hernia repairRight inguinal hernia repairRight inguinal hernia repair

Vas deferens and testicle were Vas deferens and testicle were placed in the scrotum.placed in the scrotum.The hernia defect extended from The hernia defect extended from h bi b l d hh bi b l d hthe pubic tubercle, towards the the pubic tubercle, towards the

internal ring including the entire internal ring including the entire inguinal floor. inguinal floor. ProcedProced mesh 4 x 5.5cm (with mesh 4 x 5.5cm (with keyhole for spermatic cord) was keyhole for spermatic cord) was secured with 0 Tevdek suture tosecured with 0 Tevdek suture tosecured with 0 Tevdek suture to secured with 0 Tevdek suture to pubic tubercle, inguinal ligament pubic tubercle, inguinal ligament and superior edge of internal and superior edge of internal oblique muscle aponeurosis.oblique muscle aponeurosis.


Right inguinal hernia repairRight inguinal hernia repair

Aponeurosis of external oblique Aponeurosis of external oblique muscle was closed with 2muscle was closed with 2--00 vicrylvicrylmuscle was closed with 2muscle was closed with 2 0 0 vicrylvicrylrunning sutures.running sutures.Peak airway pressures increased Peak airway pressures increased slightly from low 20s to upper slightly from low 20s to upper 20s. No respiratory distress upon 20s. No respiratory distress upon full reduction of herniated full reduction of herniated viscera. viscera. Peritoneal dialysis catheter Peritoneal dialysis catheter

d id i i f bili li f bili lremoved via removed via infraumbilicalinfraumbilicalincision .incision .Pt was Pt was extubatedextubated in OR and in OR and transferred to SICU.transferred to SICU.


PostPost--op courseop coursePOD #2POD #2

Pt started on clears. Pt started on clears. Abdomen became mildly distended. Abdomen became mildly distended. AXR showed large stomach air bubble. AXR showed large stomach air bubble. Pt placed NPO NGT placedPt placed NPO NGT placedPt placed NPO. NGT placed. Pt placed NPO. NGT placed. Bladder pressures WNLBladder pressures WNL

POD#5POD#5POD#5POD#5Abdominal distention improved. Pt started on clears.Abdominal distention improved. Pt started on clears.

POD #8POD #8POD #8POD #8Tolerating clears, +flatus, +BM, transferred to floor. Tolerating clears, +flatus, +BM, transferred to floor.

POD #9POD #9POD #9 POD #9 Advanced to regular dietAdvanced to regular diet


PostPost--op courseop course

POD#10POD#10Mild respiratory distress Mild respiratory distress Chest CT positive for PE Chest CT positive for PE Pt transferred to SICU and started on heparin drip. Pt transferred to SICU and started on heparin drip. A h d dA h d dAXR showed gastric distention. AXR showed gastric distention.

POD #14POD #14-- Abdominal distention persistedAbdominal distention persistedCT i i fCT i i f i bd i li bd i l h d 1 5h d 1 5CT scan positive for CT scan positive for intraabdominalintraabdominal hematoma and 1.5cm hematoma and 1.5cm pseudoaneurysmpseudoaneurysm of of pancreaticoduodenalpancreaticoduodenal artery (PDA) artery (PDA)

POD#15POD#15-- angiogram and coilangiogram and coil embolizationembolization of inferior PDAof inferior PDAPOD#15POD#15 angiogram and coil angiogram and coil embolizationembolization of inferior PDA.of inferior PDA.POD #16POD #16-- Pt started on clears, transferred to floor.Pt started on clears, transferred to floor.POD #17POD #17 Advanced to regular dietAdvanced to regular dietPOD #17POD #17-- Advanced to regular diet.Advanced to regular diet.POD #24POD #24-- discharged to rehab facility. discharged to rehab facility.


Progressive Progressive Pneumoperitoneum for thePneumoperitoneum for theRepair of Massive InguinalRepair of Massive InguinalRepair of Massive Inguinal Repair of Massive Inguinal

HerniasHernias


MegaherniaMegahernia

Hernia that exceeds Hernia that exceeds 20cm in diameter and 20cm in diameter and has lost its right of has lost its right of domicile in the peritoneal domicile in the peritoneal cavity for a period of one cavity for a period of one year.year.¹¹


Loss of domain inducesLoss of domain inducesLoss of domain inducesLoss of domain induces

Impaired venous and lymphatic return fromImpaired venous and lymphatic return fromImpaired venous and lymphatic return from Impaired venous and lymphatic return from viscera due to compression from the hernia viscera due to compression from the hernia defectdefect ¹¹defect.defect.

Dilation of mesentery and bowel wall edema. Dilation of mesentery and bowel wall edema. Impairs reductionImpairs reductionImpairs reductionImpairs reduction

Decrease in Decrease in intraabdominalintraabdominal pressurepressureDecrease capacity of the abdominal cavityDecrease capacity of the abdominal cavityHemidiaphragmHemidiaphragm lowers altering lowers altering ventilatoryventilatory

h ih imechanism.mechanism.


Possible complications of Possible complications of red ctionred ctionreductionreduction

Increased abdominal pressureIncreased abdominal pressureIncreased abdominal pressureIncreased abdominal pressureDecreased venous return. Decreased venous return. Abdominal compartment syndromeAbdominal compartment syndromeAbdominal compartment syndrome.Abdominal compartment syndrome.

Elevation of diaphragm Elevation of diaphragm Increased thoracic pressure causing respiratory Increased thoracic pressure causing respiratory distress.distress.22

D hi i h h iD hi i h h i 11Dehiscence with hernia recurrence.Dehiscence with hernia recurrence. 11


Alternatives of repairAlternatives of repair

Resection Resection omentumomentum and bowel.and bowel.Increase morbidity/mortality associated with bowel Increase morbidity/mortality associated with bowel resection.resection.

Short gut syndrome Short gut syndrome -- nutritional problems nutritional problems

Requires a separate incision.Requires a separate incision. 11

PhrenectomyPhrenectomy ((TournoffTournoff --1950s)1950s)Respiratory complications.Respiratory complications. 33Respiratory complications.Respiratory complications.



Creation of ventral hernia(Creation of ventral hernia(ZiffrinZiffrin and Womackand Womack--1950)1950)4 4

Long transverse abdominal incision. Long transverse abdominal incision. Division of abdominal wall except the peritoneum. Division of abdominal wall except the peritoneum. Reduction and repair of inguinal hernia.Reduction and repair of inguinal hernia.Peritoneum protrudes through Peritoneum protrudes through unsuturedunsutured fascia (ventral fascia (ventral herniationherniation).).Closure of fascia (ventral hernia repair) 12 days later.Closure of fascia (ventral hernia repair) 12 days later.Useful when size of hernia was misjudged preUseful when size of hernia was misjudged pre--op, and op, and when pt develops circulatory or when pt develops circulatory or repiratoryrepiratory distress intradistress intra--op.op.Requires a second surgical procedure. Requires a second surgical procedure.



P ti P i P itP ti P i P itPreoperative Progressive PneumoperitoneumPreoperative Progressive PneumoperitoneumIvan GoIvan Gonni Moreno (1940s)i Moreno (1940s)

Intraperitoneal injection of oxygen to expand the Intraperitoneal injection of oxygen to expand the abdominal cavity before hernia repair, making room to abdominal cavity before hernia repair, making room to accommodate herniated visceraaccommodate herniated visceraaccommodate herniated viscera. accommodate herniated viscera. First case reported was repair of incarcerated epigastric First case reported was repair of incarcerated epigastric herniahernia 55hernia.hernia.Reported 3% recurrance rate in a series of 487 giant Reported 3% recurrance rate in a series of 487 giant hernia repairshernia repairshernia repairs.hernia repairs.


Alternatives of repairAlternatives of repairAlternatives of repairAlternatives of repair

Preoperative Progressive PneumoperitoneumPreoperative Progressive PneumoperitoneumPreoperative Progressive PneumoperitoneumPreoperative Progressive PneumoperitoneumKoontz and Graves (1954)Koontz and Graves (1954)

Reported successfull repair abdominal wallReported successfull repair abdominal wallReported successfull repair abdominal wall Reported successfull repair abdominal wall hernias with loss of domicile with this technique.hernias with loss of domicile with this technique.44

This technique was then applied to inguinal herniaThis technique was then applied to inguinal herniaThis technique was then applied to inguinal hernia This technique was then applied to inguinal hernia repairs and for repair of omphaloceles.repairs and for repair of omphaloceles. 33


Preoperative Progressive Preoperative Progressive PneumoperitoneumPneumoperitoneumPneumoperitoneumPneumoperitoneum

IndicationIndicationIndicationIndicationRepair massive abdominal wall hernias with loss of Repair massive abdominal wall hernias with loss of intraabdominalintraabdominal domaindomain 66intraabdominalintraabdominal domain. domain.

ContraindicationsContraindicationsAd d d p l ditiAd d d p l ditiAdvanced age and poor general condition.Advanced age and poor general condition.Cardiac Cardiac decompensationdecompensation.. 11


Advantages of Preoperative Advantages of Preoperative Progressive PneumoperitoneumProgressive PneumoperitoneumProgressive Pneumoperitoneum Progressive Pneumoperitoneum

S h h bd i l ll i l iS h h bd i l ll i l iStretches the abdominal wall, creating a larger cavity Stretches the abdominal wall, creating a larger cavity for operative reduction of herniated viscera.for operative reduction of herniated viscera.S h h h i i l i fS h h h i i l i fStretches the hernia sac causing elongation of Stretches the hernia sac causing elongation of adhesions, for an easier dissection.adhesions, for an easier dissection.

d d ld d lInduces preoperative respiratory and circulatory Induces preoperative respiratory and circulatory adjustments to the elevation of the diaphragm.adjustments to the elevation of the diaphragm. 55

f d hf d hIncreases tone of diaphragm.Increases tone of diaphragm.


Technique for Establishing Technique for Establishing PneumoperitoneumPneumoperitoneumPneumoperitoneum Pneumoperitoneum

Intermittent Intermittent percutaneouspercutaneous puncture of abdominal wallpuncture of abdominal wallS i l dl 16S i l dl 16 i hi hSpinal needle or a 16Spinal needle or a 16--gauge gauge angiocathangiocath..Increased risk of bowel perforation.Increased risk of bowel perforation.

Abdominal indwelling catheterAbdominal indwelling catheterStarted by Steichen in 1965. Started by Steichen in 1965. 33

Modified Modified SeldingerSeldinger technique.technique.Catheter connected to a 3Catheter connected to a 3--way stopway stop--cock attached to a cock attached to a y py psyringe.syringe.


Technique for Establishing Technique for Establishing PneumoperitoneumPneumoperitoneum

Injection of 500 to 1500Injection of 500 to 1500Injection of 500 to 1500 Injection of 500 to 1500 ml of ambient air upon ml of ambient air upon the first treatment.the first treatment.Injection of air is Injection of air is stopped ifstopped if

Diffuse abdominal painDiffuse abdominal painlumbar or shoulder pain, lumbar or shoulder pain, dd 22dyspnea or palpitations. dyspnea or palpitations. 22

Air is withdrawn if Air is withdrawn if di mf rt p r i tdi mf rt p r i tdiscomfort persists. discomfort persists.


Technique for Establishing Technique for Establishing PneumoperitoneumPneumoperitoneum

Total amount of air injected Total amount of air injected jjdepends on depends on

size of hernia and abdominal cavitysize of hernia and abdominal cavityf df dpresence of adhesions presence of adhesions

individual patient tolerance.individual patient tolerance. 77

Air injections every 2Air injections every 2 5 days for5 days forAir injections every 2 Air injections every 2 -- 5 days for 5 days for ten days to three weeks prior to ten days to three weeks prior to surgery.surgery.Insufflations done as outpatient, Insufflations done as outpatient, bed rest not necessary. bed rest not necessary. S iS i 88Spirometry preSpirometry pre--op.op.8 8


Results of Progressive Preoperative Results of Progressive Preoperative Pneumoperitoneum Pneumoperitoneum

Hernia repairs Period of i

Type of Results and complications pneumoperito-

neumrepair

Ali et al(1975

1 inguinal 19 days via McVay Successful hernia reduction d i i(1975-

Washington DC) 1puncture w. a spinal needle

and primary repair

Coopwood et al (1987

1 inguinal 5-6 days via 16G

Lichtenstein No recurrance at 2 yr f/uN li i(1987-

Tennessee)81 incsicional puncture w. 16G

angiocather No complications

Mayagoitia et al(2005 M i ) 6

1 inguinal, 11 l

9.3 days via i d lli th

Lichtenstein Failed pneumoperitoneum 2 W d i f 1(2005-Mexico) 6 11 ventral indwelling cath Wound infx 1

SQ emphysema 1Abdominal discomfort

Rodriguez Ortega 2 inguinal, 1-3 weeks via Lichtenstein No recurrences in 10mo-g get al

(2005-Spain)2

2 inguinal, 1 umbilical, 1 incisional

1 3 weeks via JP drain

Lichtenstein No recurrences in 10mo11yrs f/u


Complications of Preoperative Complications of Preoperative Progressive PneumoperitoneumProgressive Pneumoperitoneum

Organ perforationOrgan perforationOrgan perforation.Organ perforation.Subcutaneous emphysema.Subcutaneous emphysema.E i iE i i i i f i f lli i f i f llEpigastricEpigastric pain, sensation of gastric fullness.pain, sensation of gastric fullness.Hematoma formation.Hematoma formation.Spontaneous dissection of the gallbladder from the Spontaneous dissection of the gallbladder from the hepatic bed. hepatic bed. ppAir emboli.Air emboli.Failure to establishFailure to establish pneumoperitoneumpneumoperitoneumFailure to establish Failure to establish pneumoperitoneumpneumoperitoneum((intraabdominalintraabdominal adhesions from previous surgery)adhesions from previous surgery) 66


ConclusionConclusion

Progressive preoperative pneumoperitoneum is a Progressive preoperative pneumoperitoneum is a f l dj t i th r p ir f m i i i l h r if l dj t i th r p ir f m i i i l h r iuseful adjunct in the repair of massive inguinal hernias useful adjunct in the repair of massive inguinal hernias

with loss of domain. with loss of domain. d ll d h bd l dd ll d h bd l dIt gradually expands the abdominal cavity and It gradually expands the abdominal cavity and

increases in intraabdominal and thoracic pressures, increases in intraabdominal and thoracic pressures, h bd i l dh bd i l dthat may prevent abdominal compartment syndrome that may prevent abdominal compartment syndrome

and acute respiratory distress upon hernia reduction.and acute respiratory distress upon hernia reduction.Complications similar to those of pneumoperitoneum Complications similar to those of pneumoperitoneum for laparoscopic surgery. for laparoscopic surgery.


ReferencesReferencesAli SD C lh T K t LH (1975) Th U f P it i th T t t fAli SD C lh T K t LH (1975) Th U f P it i th T t t f M h iM h i JJ1.1. Ali SD, Calhoun T, Kurtz LH (1975) The Use of Pneumoperitoneum in the Treatment of Ali SD, Calhoun T, Kurtz LH (1975) The Use of Pneumoperitoneum in the Treatment of MegaherniaeMegaherniae. J . J NMA 67:16NMA 67:16--18.18.

2.2. Rodriguez M, Rodriguez M, GarauletGaraulet P, Rios R, Jimenez V, P, Rios R, Jimenez V, LimonesLimones E (2006) Pneumoperitoneum in the Treatment of E (2006) Pneumoperitoneum in the Treatment of Giant Hernias. Cir Giant Hernias. Cir EspEsp 80: 22080: 220--223. 223.

3.3. Winfield R, Del Winfield R, Del GuercioGuercio L (1989) The Place for Pneumoperitoneum in the Repair of Massive Hernia. L (1989) The Place for Pneumoperitoneum in the Repair of Massive Hernia. World J World J SurgSurg 13: 58113: 581--585.585.

4.4. Koontz AR, Graves JW (1954) Preoperative Pneumoperitoneum as an Aid in the Handling of Gigantic Koontz AR, Graves JW (1954) Preoperative Pneumoperitoneum as an Aid in the Handling of Gigantic Hernias. Annals Hernias. Annals SurgSurg 140: 759140: 759--762.762.gg

5.5. Moreno IG (1947) Chronic Moreno IG (1947) Chronic EventrationsEventrations and Large Hernias: Preoperative Treatments by Progressive and Large Hernias: Preoperative Treatments by Progressive Pneumoperitoneum: Original Procedure. Surgery 22: 945Pneumoperitoneum: Original Procedure. Surgery 22: 945--953.953.

6.6. MayagoitiaMayagoitia JC, Suarez D, Arenas JC, Diaz de Leon V (2005) Preoperative Progressive Pneumoperitoneum JC, Suarez D, Arenas JC, Diaz de Leon V (2005) Preoperative Progressive Pneumoperitoneum in Patients ith Abdominal Wall Hernias World J Herniain Patients ith Abdominal Wall Hernias World J Hernia AbdAbd WallWall S rgS rg Oct 2005Oct 2005in Patients with Abdominal Wall Hernias. World J Hernia in Patients with Abdominal Wall Hernias. World J Hernia AbdAbd Wall Wall SurgSurg Oct 2005Oct 2005

7.7. Connolly DP, Connolly DP, PerriPerri FR Giant Hernias Managed by Pneumoperitoneum (1969) JAMA 209: 71FR Giant Hernias Managed by Pneumoperitoneum (1969) JAMA 209: 71--74 74 8.8. CoopwoodCoopwood RW, Smith RJ (1988) Treatment of Large Ventral and Scrotal Hernias Using Preoperative RW, Smith RJ (1988) Treatment of Large Ventral and Scrotal Hernias Using Preoperative

Pneumoperitoneum. J NMA 81: 402Pneumoperitoneum. J NMA 81: 402--404.404.9.9. ValliattuValliattu AJ, AJ, KingsnorthKingsnorth (2008) Single(2008) Single--stage repair of giant stage repair of giant inguinoscrotalinguinoscrotal hernias using the abdominal wall hernias using the abdominal wall

component separation technique. Hernia 12: 329component separation technique. Hernia 12: 329--330.330.10.10. BeitlerBeitler JC, Gomes SM, Coelho ACJ, JC, Gomes SM, Coelho ACJ, MansoManso JEF (2009) Complex inguinal hernia repairs. JEF (2009) Complex inguinal hernia repairs.

Hernia 2009:13Hernia 2009:13--6161--6666Hernia 2009:13Hernia 2009:13 6161 66 66 11.11. EkEk EW, EW, EkEk ET, Bingham R, Wilson J, Mooney B, ET, Bingham R, Wilson J, Mooney B, BantingBanting SW, Burt J (2006) Component Separation in the SW, Burt J (2006) Component Separation in the

Repair of a Giant Repair of a Giant InguinoscrotalInguinoscrotal Hernia. ANZ J Hernia. ANZ J SurgSurg 76: 95076: 950--952. 952.


QuestionsQuestionsQuestionsQuestions

1 Indications for preoperative progressive1. Indications for preoperative progressive pneumoperitoneum include:

a) Patient with giant inguinal hernia and poor generala) Patient with giant inguinal hernia and poor general medical condition.

b)b) Massive abdominal wall hernias with loss ofMassive abdominal wall hernias with loss ofb)b) Massive abdominal wall hernias with loss of Massive abdominal wall hernias with loss of intraabdominal domain.intraabdominal domain.

c)c) Strangulated inguinal hernia with evidence ofStrangulated inguinal hernia with evidence ofc)c) Strangulated inguinal hernia with evidence of Strangulated inguinal hernia with evidence of ischemic bowel.ischemic bowel.

d)d) Small reducible inguinal hernias. Small reducible inguinal hernias. )) gg


QuestionsQuestionsQuestionsQuestions

2 Loss of intraabdominal domain induces all of2. Loss of intraabdominal domain induces all of the following except:

a)a) Impaired venous and lymphatic return fromImpaired venous and lymphatic return froma)a) Impaired venous and lymphatic return from Impaired venous and lymphatic return from viscera due to compression from the hernia defect viscera due to compression from the hernia defect causing dilation of mesentery and bowel wall causing dilation of mesentery and bowel wall g yg yedema. edema.

b)b) Decrease in intraabdominal pressure.Decrease in intraabdominal pressure.ppc)c) Decrease capacity of the abdominal cavity.Decrease capacity of the abdominal cavity.d)d) Elevation of the diaphragm.Elevation of the diaphragm.)) p gp g


QuestionsQuestions

3 Possible complications of reduction of massivePossible complications of reduction of massive3. Possible complications of reduction of massive Possible complications of reduction of massive inguinal hernias include:inguinal hernias include:

a)a) Increased abdominal pressure and decreasedIncreased abdominal pressure and decreaseda)a) Increased abdominal pressure and decreased Increased abdominal pressure and decreased venous return leading abdominal compartment venous return leading abdominal compartment syndrome.syndrome.yy

b)b) Elevation of diaphragm leading to increased Elevation of diaphragm leading to increased thoracic pressure causing respiratory distress.thoracic pressure causing respiratory distress.p g p yp g p y

c)c) Dehiscence with hernia recurrence.Dehiscence with hernia recurrence.d)d) All of the above.All of the above.))


QuestionsQuestions

4. Regarding establishment of pneumoperitoneum4. Regarding establishment of pneumoperitoneum all are correct except:

a)a) Injection of airInjection of air is done via indwelling catheter.)) jj gb)b) Injection of air is stopped when patient complaints Injection of air is stopped when patient complaints

of diffuse abdominal pain, lumbar or shoulder of diffuse abdominal pain, lumbar or shoulder i d l i ii d l i ipain, dyspnea or palpitations.pain, dyspnea or palpitations.

c)c) Injection of air is done on an inInjection of air is done on an in--patient basis.patient basis.P i b ff i lP i b ff i ld)d) Pneumoperitoneum can be effectively Pneumoperitoneum can be effectively instituted from ten days to three weeks prior to instituted from ten days to three weeks prior to surgery. surgery. g yg y


Questions

5. The advantages of Preoperative Progressive 5. The advantages of Preoperative Progressive Pneumoperitoneum include:Pneumoperitoneum include:Pneumoperitoneum include: Pneumoperitoneum include:

a)a) Stretching of the abdominal wall, creating a larger cavity Stretching of the abdominal wall, creating a larger cavity for operative reduction of herniated viscerafor operative reduction of herniated viscerafor operative reduction of herniated viscera.for operative reduction of herniated viscera.

b)b) Stretching of the hernia sac causing elongation of Stretching of the hernia sac causing elongation of adhesions for an easier dissection or reduction.adhesions for an easier dissection or reduction.adhesions, for an easier dissection or reduction. adhesions, for an easier dissection or reduction.

c)c) Increased tone of diaphragm.Increased tone of diaphragm.d)d) Preoperative respiratory and circulatory adjustments toPreoperative respiratory and circulatory adjustments tod)d) Preoperative respiratory and circulatory adjustments to Preoperative respiratory and circulatory adjustments to

the elevation of the diaphragm.the elevation of the diaphragm.e)e) All of the above.All of the above.e)e) All of the above.All of the above.


Thank you !Thank you !Thank you !Thank you !


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