JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2019.0669

Combination of Preoperative Progressive

Pneumoperitoneum and Botulinum Toxin A Enables
the Laparoscopic Transabdominal Preperitoneal Approach
for Repairing Giant Inguinoscrotal Hernias

Fu-Xin Tang, MD,1,* Zhen Zong, MD,2,* Jian-Bo Xu, MD,3,* Ning Ma, MD, PhD,1
Tai-Cheng Zhou, MD, PhD,1 and Shuang Chen, MD, PhD1
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Abstract

Background: Reports on preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) for
managing giant inguinoscrotal hernias are limited. Hence, we report our experience with these preoperative
techniques in patients with this condition.
Materials and Methods: Observational study of 8 consecutive patients with giant inguinoscrotal hernias be-
tween January 2018 and December 2018. All patients were treated preoperatively with BTA injection to the
lateral abdominal wall muscles and PPP for passive abdominal cavity expansion. Length of abdominal wall
muscles, volume of inguinal hernia (VIH), volume of the abdominal cavity (VAC), and VIH/VAC ratio were
measured before and after PPP and BTA using abdominal computed tomography. All hernias were repaired
laparoscopically using transabdominal preperitoneal (TAPP) repair techniques.
Results: The mean insufflated volume of air for PPP was 5625 – 845 mL for 15.4 – 1.6 days. An average
reduction of 5.3% of the VIH/VAC ratio after PPP and BTA was obtained (P < .01). The length of lateral
abdominal muscles with a mean gain of 3.3 cm/side (P < .01) and complications associated with PPP were
12.5% and with surgical technique, 25%. Laparoscopic TAPP repair was achieved in all cases, with no clinical
evidence of postoperative abdominal hypertension. The mean follow-up was 22 months; no hernia recurrences
have been reported.
Conclusions: Combination of PPP and BTA is feasible and useful for surgically managing giant inguinoscrotal
hernias, which can avoid abdominal compartment syndrome after laparoscopic TAPP repair of giant in-
guinoscrotal hernias.

Keywords: Inguinoscrotal hernias, giant inguinoscrotal hernias, preoperative progressive pneumoperitoneum,

botulinum toxin A, TAPP

Introduction
G iant inguinoscrotal hernias rarely occur in devel-
oped regions because of early intervention; it is often
associated with the rural region.1,2 A giant inguinal hernia
is characterized by the following: the inguinal hernia ex-
tends below the midpoint of the inner thigh of a patient in a
standing position, the front and rear diameters exceed 30 cm,
the left and right diameters exceed 50 cm, and it is difficult to
return it to the abdominal cavity for >10 years.3,4 This con-
dition can hinder patients’ daily life activities, such as
walking, sitting, and voiding. A so-called loss of domain
hernia (LODH) occurs when it persists for a long time and is
impossible to be repaired by a simple technique of fascial

1
Department of Gastrointestinal Surgery and Hernia Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangdong
Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.
2
Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China.
3
Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Colorectal
and Pelvic Floor Diseases, Guangzhou, China.
*These authors contributed equally to this work.

1
 2 TANG ET AL.
closure. If preoperative preparation is inadequate, complete
reduction of the herniated viscera can be dangerous because
the abdominal pressure may suddenly increase, causing re-
spiratory disorders and sometimes, abdominal compartment
syndrome (ACS).5,6 Therefore, adequate preparation before
surgery is vital.
Preoperative progressive pneumoperitoneum (PPP), which
was introduced by Goñi Moreno,7 can cause passive ab-
dominal cavity expansion, allowing the viscera to reestablish
the right domain and improve the respiratory adaptation.
Thus, the risk of ACS, which is a major problem in LODH,
can be reduced.8 Pneumoperitoneum also improves dia-
phragmatic function,9 diminishes chronic edema of the her-
niated intestine and mesentery,9,10 and results in lysis of
adhesions.9–11
Muscle relaxation with botulinum toxin A (BTA) injection
has recently been reported. BTA is a neurotoxin that blocks
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the acetylcholine receptor at the neuromuscular junction,
resulting in temporary flaccid paralysis of the abdominal
muscles and facilitating surgical closure and repair.12,13
The combined use of PPP and BTA has been described in the
literature for large incisional hernias; successful out-
comes were achieved.14,15 However, there have been few
related case reports for giant inguinoscrotal hernias.16,17
Furthermore, the cases of giant inguinoscrotal hernia that
have been reported in the literature were mostly treated with
an open repair, and endoscopic treatment has been rarely
reported.3,18
Thus, the purpose of this observational study was to dis-
cuss our experience in preparing patients with giant in-
guinoscrotal hernias for the combined use of PPP and BTA
before endoscopic repair.
Materials and Methods
This single-center prospective study included patients with
giant inguinoscrotal hernias who underwent PPP and preop-
erative BTA abdominal wall injections before elective sur-
gical repair of endoscopic hernia from January 2018 to
December 2018. Informed consent was obtained from each
patient for inclusion in the study.
Before and after the treatment, the volume of the inguinal
hernia (VIH) and volume of the abdominal cavity (VAC) as
well as the length and thickness of abdominal wall muscles
were calculated from noncontrast 64-slice multidetector
computed tomography (CT) using a specific software
(Fig. 1). A radiologist, who specialized in abdominal wall
scanning, calculated the diameters and volumes according to
the abdominal CT findings and the modified index of Tana-
ka.19 The axial length of muscles was measured along the
deep surface of the abdominal muscle complex from the
lateral edge of the quadratus lumborum to the medial edge of
rectus abdominis muscle on each side at the same spinal
level. Meanwhile, the thickness of the muscle was measured
along the midaxillary line from the deep surface of the
transversus muscle to the superficial surface of the external
oblique muscle. All cases were radiologically assessed by the
same radiologist. If the VIH/VAC ratio was higher than or
equal to 20%, regardless of the size of the hernia defect, he
was included in the protocol of preoperative techniques.
All patients underwent preanesthetic evaluation and pul-
monary function tests. In the preoperative assessment, we
emphasized on the importance of smoking abstinence and
pulmonary function exercise.
For preoperative preparation of the patients, two consec-
utive techniques, namely intraperitoneal catheter placement
and BTA injection administration, were used 2–3 weeks
preoperatively and performed simultaneously under ultra-
sound guidance. Initially, the patient was administered the
abdominal wall BTA (Botulinum Toxin Type for Injection;
BOTOX, Allergan, Ireland) injection as an inpatient pro-
cedure. All patients received a total dose of 100 units of BTA,
which was diluted to 2 units/mL with 0.9% saline and divided
into six equal amounts to obtain a volume of 8 mL in each
aliquot. Using ultrasound guidance, we placed the patient in a
lateral position and identified three sites on each side of the
abdomen, that is, along the anterior axillary line equidistant
between the costal margin at the level of the ninth rib and a
point anterior to the anterior superior iliac spine, according to
the positions identified by Smoot et al.20 Then, 8 mL of the
diluted BTA was injected at the three sites of the three lateral
oblique muscles (transversus abdominis, internal oblique,
and external oblique) at each of the six points (16 units/8 mL
at each injection site), and the patient was returned to a supine
position. Pneumoperitoneum was then introduced 2–3 weeks
before elective hernia repair. Under ultrasound guidance, we
established pneumoperitoneum by introducing a 14-Fr deep
venous catheter into the peritoneal space at a location distant
from the previous incisions. We initially insufflated 200 mL
of air via a syringe and then performed X-ray with the patient
in a standing position to check whether the PPP catheter was
appropriately placed. Subsequently, 300–400 mL of air was
introduced daily according to the patients’ tolerance. Ca-
theter placement and initial insufflation were performed as
inpatient procedures, and patients were discharged on the
following day. During the period of pneumoperitoneum in-
troduction, patients wore an abdominal binder and were en-
couraged to improve their respiratory function and to walk
for at least 2 hours a day. We tried our best to reduce the loss
of domain ratio, so that the increase in abdominal volume was
greater than that in the inguinal hernia volume before PPP.
PPP administration was temporarily terminated when the
following instances occurred: (1) intolerable subjective
symptoms such as abdominal pain, abdominal distension, and
shoulder pain; (2) dyspnea, hypoxemia, or CO2 retention; and
(3) serious subcutaneous emphysema.
Elective surgical repair was performed using the transab-
dominal preperitoneal (TAPP) approach.21 The patient was
placed in a supine position, and an indwelling urinary cath-
eter was routinely inserted after intubation. A 12 mm port was
placed 1 cm below the umbilicus for inserting a 10 mm, 30
telescope. Two 5 mm working ports were inserted at a two-
finger distance below the umbilicus in both lateral margins of
the rectus abdominis under direct vision. After the hernial sac
was completely reduced, the defect diameter was measured.
The peritoneum was transected 2 cm from the upper margin
of the defect and then dissociated from the medial Retzius’
space and the lateral Bogros’ space. The hernial sac was
incised in a ‘‘T’’ shape, and the spermatic cord was then
transversely severed and was fully separated up to 6 cm long.
The defect of the inner ring was stitched continuously with
barbed sutures (2–0) and was weaved into a network struc-
ture, avoiding excessive tension and injury to the inferior
epigastric vessel. We then inserted a single central venous
 MANAGEMENT INGUINAL HERNIAS WITH PPP AND BTA 3
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FIG. 1. Abdominal volumes (volume of the abdominal cavity and volume of inguinal hernia) were calculated from a 64-
slice multidetector CT using a specific software before and after the preoperative techniques. BTA, botulinum toxin A; CT,
computed tomography; PPP, preoperative progressive pneumoperitoneum.

catheter through an abdominal puncture for drainage and Results

placed the catheter tip in the lowest part of the scrotum
through the inner ring. Finally, we introduced a mesh to
complete the procedure without using fixation. We routinely
used a macroporous polypropylene mesh (BARD 3DMax,
10.8 · 16 cm; Davol, Inc.).
In the immediate postoperative period, we routinely as-
sessed the bladder pressure and elevated the scrotum. Patients
were asked to locally apply mirabilite to the groin area for 48
hours. Intravenous antibiotics were continued postopera-
tively for 72 hours. The drainage was removed 48 hours later.
The difference in the length and peritoneal volumes of the
lateral abdominal wall before and after the PPP and BTA
procedure was analyzed using the SPSS version 24.0 soft-
ware (IBM Corp., Armonk, NY); P < .05 indicates statistical
significance.
Eight male patients underwent our protocol using PPP and
BTA injections. Their mean age was 65 (58–73) years, and
the mean body mass index was 25.4 (21.6–29.3) kg/m2. Four
patients had right-sided inguinal hernia, 2 had left-sided in-
guinoscrotal hernia, and 2 had bilateral inguinoscrotal hernia.
The mean time since the occurrence of the inguinal hernia
was 119 (72–180) months. The smallest defect size was
4 · 5 cm, whereas the largest size was 6 · 7 cm (Table 1).
The mean duration of the preoperative techniques was
15.4 – 1.6 (13–18) days, and the mean volume of insufflated
air was 5625 – 845 (4000–6800) mL. A comparison of the
peritoneal volumes before and after the preoperative tech-
niques is shown in Table 1. Before and after PPP, the VIH
was 1894 – 500 (1023–2459) mL and 2020 – 482 (1191–
2617) mL (P < .05), the VAC was 6720 – 1281 (5054–8793) mL

Table 1. Comparison of Peritoneal Volumes Before and After the Preoperative Techniques
Before PPP+BTA After PPP+BTA
Hernia size Loss of Domain Loss of Domain
Patient (horizontal · vertical, cm) VIH VAC (%) VIH VAC (%)
1 4·5 1878 6789 28 2083 8657 24
2 5·6 2458 5916 42 2275 7271 31
3 6·6 2182 7717 28 2475 9837 25
4 5·6 1392 5187 27 1488 7052 21
5 6·7 2459 8793 28 2617 11,250 23
6 6·5 1023 5054 20 1191 7617 16
7 6·6 1786 7023 25 1913 9584 20
8 5·5 1972 7284 27 2118 9643 22
Results for the first 8 patients undergoing preoperative PPP and BTA therapy.
BTA, botulinum toxin A; PPP, preoperative progressive pneumoperitoneum; VAC, volume of the abdominal cavity; VIH, volume of the
inguinal hernia.
 4 TANG ET AL.

FIG. 2. Comparison of preoperative axial CT images before and after the preoperative techniques; significant elongation
and thinning of the lateral abdominal oblique muscles were observed (patient 2). BTA, botulinum toxin A; PPP, preop-
erative progressive pneumoperitoneum.

and 8864 – 1473 (7052–11,250) (P < .01), and the VIH/VAC operatively, seroma developed in 2 patients but was resolved
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ratio (LODH ratio) was 28.1% – 6.0% (20.2%–41.5%) and
22.8% – 4.5% (15.6%–31.3%) (P < .01), respectively. The
LODH ratio was significantly reduced by 5.3% on CT after the
combination of PPP and BTA (Fig. 1). As expected, the mean
length of lateral abdominal muscles significantly increased,
and the mean thickness of lateral abdominal muscles decreased
(Fig. 2). A statistically significant increase was found in the
length of mean abdominal muscles from 16.8 – 2.8 (14.2–21.5)
cm/side before the combination approach to 20.1 – 3.4 (16.3–
25.5) cm/side after the combination approach (P < .01), indi-
cating a gain in the mean transverse length of the lateral
abdominal muscles of 3.3 (1.3–4.1) cm/side. In all cases, the
thickness of lateral abdominal wall muscles decreased by a
mean of 6.3 (0.4–13.5) mm. Intestinal segments at the level of
the femur on CT before and after the preoperative techniques
are shown in Figure 3.
Only 1 patient (12.5%) experienced PPP-related compli-
cations. This patient experienced shoulder pain, but required
no intervention. No bowel perforations or instances of air
embolism, peritonitis, or venous thrombosis occurred.
Moreover, no complications occurred during BTA adminis-
tration. All patients had a successful laparoscopic repair of
their giant inguinal hernias (Fig. 4). The closure of the inner
ring was feasible in all patients. The mean operation time was
93.1 – 16.2 (70–120) minutes, and the mean duration of
postoperative hospitalization was 7.6 – 0.7 (7–9) days. Post-
within 1 week after local application of mirabilite. No patient
suffered from abdominal hypertension or required prolonged
ventilatory support. To date, no hernia recurrences have been
reported, and the mean follow-up was 15 (9–20) months.
Discussion
Despite recent advances in surgical techniques and ap-
proaches, the repair of giant inguinoscrotal hernias is partic-
ularly challenging for surgeons. Considering that the herniated
viscera progressively lose their ‘‘right of domain’’ in the
peritoneal cavity, this type of hernia cannot be repaired with a
simple technique of fascial closure. The forced reduction of
the herniated viscera into an unprepared abdomen can increase
the postoperative risk of elevated intra-abdominal pressure
and its associated ventilatory complications because of an
abrupt rise in abdominal pressure.5,6 Hence, adequate preop-
erative preparation of these patients is crucial.
For preventing life-threatening ACS after the repair of a
large hernia, PPP has been suggested as a preparatory pro-
cedure.7,11 PPP increases VAC, results in a pneumatic lysis of
intestinal adhesions, facilitates visceral reintroduction during
surgery, and minimizes the involvement of respiratory
function.22 Hence, PPP is also recommended for the repair
of giant inguinoscrotal hernias.17,23,24 Meanwhile, in 2009,
Ibarra-Hurtado et al.12 first reported the benefits of BTA

FIG. 3. Intestinal segments at the femur level on CT before and after the preoperative techniques (patient 2). BTA,
botulinum toxin A; PPP, preoperative progressive pneumoperitoneum.
 MANAGEMENT INGUINAL HERNIAS WITH PPP AND BTA
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FIG. 4. Comparison of before and after the preoperative techniques and day 7 postoperative coronal views with the patient
in an active crunching maneuver (patients 2 and 3). BTA, botulinum toxin A; PPP, preoperative progressive pneumoper-
itoneum.
injection in patients with abdominal wall hernias after an
open abdomen management. Since then, the number of re-
ports regarding BTA being used preoperatively to facilitate
surgical reconstruction of abdominal wall hernia has been
limited because of its effect on lengthening and relaxing the
laterally retracted abdominal muscles and decreasing lateral
traction.25–28 Furthermore, the advantages of preoperative
BTA therapy in conjunction with PPP, which facilitates pri-
mary closure of large complex ventral hernia, have been
described.14,15,29
The scrotum is not covered by muscles; most of the in-
sufflated gas can spread into the hernial sac, leading to an
insufficient increase in abdominal volume.30 Hence, preop-
erative BTA injections were also administered as an adjunct
procedure to PPP for expanding the abdominal space. In our
series, the VIH increased by 126 mL after PPP (P < .05). The
VAC increased by 2144 mL (P < .01) and was slightly greater
than that in the inguinal hernia volume (1894 mL), and
roughly equal to the mean volume (2020 cc) of the VIH after
PPP. However, this degree of increase in abdominal volume
basically ensures safety of the operation. Furthermore, only 1
patient had a specific complication that required intervention.
During BTA administration, no complications occurred.
Combined with PPP, this approach allowed us to obtain re-
duction in the LODH rate in all patients. Such reductions are
important for reconstruction in patients with LODH. Other
common methods to enlarge the abdominal space include
5
component separation technique31 and transversus abdominis
muscle release.32 However, these methods increase the rate
of surgical wound morbidity, and recurrence rates remain
high. Another approach is to reduce the contents of the ab-
dominal cavity by resecting the bowel, omentum, ovary, or
spleen.33,34 This approach, however, is associated with the
risks of intraperitoneal infection, partial loss of physical
function, and infection of the mesh grafts.
During open repair of giant inguinoscrotal hernias, a long
surgical incision close to the scrotum skin is performed; thus,
incisional infection or even mesh infection can most likely
occur. To benefit from the advantages of minimally invasive
surgery, researchers suggest a laparoscopic approach with
TAPP repair.35 In our study, all patients were treated by the
TAPP approach. We found no significant increase in the
operation time, postoperative hospital stay, chronic pain in-
cidence, or recurrence compared with that with open repair.
Endoscopic TAPP repair has its advantages. First, the hernial
contents can be easily observed from the abdominal cavity,
and the blood supply and adhesion of the hernia contents can
be completely and comprehensively evaluated. Second, un-
der the combined action of general anesthesia and pneumo-
peritoneum, the hernial contents can be easily returned to the
abdominal cavity and the operation time can be reduced.
Third, the mesh can completely cover the myopectineal ori-
fice and reduce the chance of recurrence. Finally, TAPP re-
pair can lessen incision and mesh infection incidences.
 6 TANG ET AL.
Piskin et al.17 reported 2 patients with giant inguinal her-
nias who were prepared for hernia repair with PPP therapy. In
the first patient, the volume of insufflated air for PPP was
7400 mL over 18 days. The intra-abdominal pressure in-
creased over time, but the waist circumference at the um-
bilical level stayed at 11 cm at that time and on day 4. Thus,
they insufflated their second patient with 3000 mL of gas for
4 days, and the expansion length of the waist circumference
at the umbilical level was 11 cm on day 4. These 2 patients
underwent successful hernia repair without recurrence, in-
dicating that abdominal expansion correlated with the in-
flated volume and pressure during the first 4 days of PPP.
More recently, a case report on the combination of PPP and
preoperative BTA injection for repairing LODH in the in-
guinal area has been documented.16 This patient received
BTA injection in the abdominal wall. Four weeks after BTA
administration, the hernia had shrunk markedly. Then, the
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surgeons continued with a PPP technique, insufflated 1 L of
ambient air per day into the peritoneal cavity for 2 weeks, and
performed the Lichtenstein technique. Two years after the
surgery, this patient is doing well without hernia recurrence.
The giant inguinoscrotal hernia recurrence rate can be as
high as 30%.4 To prevent hernia recurrence, surgeons should
ensure that the mesh covers the entire myopectineal orifice
and at least 3 cm over the edge. In our study, the defect of the
inner ring orifice was closed horizontally with a barbed suture
to weave a loose ‘‘net,’’ providing support for the mesh and
reducing hernia recurrence. However, the inner ring orifice
should not be closed forcibly to prevent postoperative pain
due to excessive tension. At the same time, a loose network
structure is conducive for draining of the fluid in the scrotum.
To reduce postoperative seroma incidence, surgeons incised
the hernial sac in a ‘‘T’’ shape and then transversely severed.
Savoie et al.36 also concluded that leaving the distal hernial
sac in the scrotum can limit the occurrence of complications
in patients after repair of giant inguinoscrotal hernias. The
patient should also elevate the scrotum and apply mirabilite
to the groin area to reduce the formation of scrotal effusion.
The present study has some limitations. First, the sample
size is relatively small (n = 8), although it is one of the longest
series previously reported in the literature. Second, the mean
follow-up duration is limited. Further inclusion of more pa-
tients in this study and long-term follow-up of these cases are
required to more convincingly demonstrate the advantages of
this method.
In conclusion, the combined use of PPP and preoperative
BTA is a safe and easy method for preventing ACS after
laparoscopic TAPP repair of giant inguinoscrotal hernias. In
our limited experience, we observed that the combination
approach induces an insignificant increase in VAC and in the
length of lateral abdominal muscles before surgery, thereby
eliminating the need for expanding the abdominal space with
a surgical technique and allowing total reintegration of the
bowel into the abdomen.
Acknowledgments
We thank all the participants included in this study. We
acknowledge the kind assistance of Z.Z., MD, in designing
the study and J.-B.X., MD, and N.M., MD, PhD, in editing the
article. Furthermore, we acknowledge Prof. T.-C.Z. and Prof.
S.C. for their critical reading of the article.
Disclosure Statement
No competing financial interests exist.
Funding Information
This work was funded by the Science and Technology
Planning Project of Guangdong Province (Grant No.
2017A020215036), the National Natural Science Foundation
of China (Grant No. 81860433), and the Natural Science
Youth Foundation of Jiangxi Province (Grant No. 20192BAB
215036).
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Address correspondence to:
Tai-Cheng Zhou, MD, PhD
Department of Gastrointestinal Surgery
and Hernia Center
The Sixth Affiliated Hospital of Sun Yat-sen University
26 Yuancun Erheng Road
Guangzhou 510655
TianHe District
China
E-mail: zhoutaicheng@126.com
Shuang Chen, MD, PhD
Department of Gastrointestinal Surgery
and Hernia Center
The Sixth Affiliated Hospital of Sun Yat-sen University
26 Yuancun Erheng Road
Guangzhou 510655
TianHe District
China
E-mail: chensh2@mail.sysu.edu.cn