Preoperative Paralysis of Abdominal Musculature using Botox and Progressive Pneumoperitoneum - An Alternate Approach for Giant Inguinal Hernia Repair

Giant hernias are uncommon and rarely encountered hence there are no clear guidelines on the management of such cases. However, Giant Inguinal Hernias (GIH) are mostly asymptomatic apart from the obvious swelling in the inguinoscrotal region. Sometimes, they might have skin excoriation, urinary disturbances due to the penis being buried completely thereby obstructing the urethral meatus. Operating such patients with GIH does pose a significant risk of postop abdominal compartment syndrome due to intraabdominal hypertension leading upto death. It is advisable to prepare such patients pre-operatively in order to mitigate such dreaded complications. The combined efforts of a Multi-Disciplinary Team consisting of a General Surgeon, Urologist, Interventional Radiologist, Anesthetist may prove beneficial to reduce the morbidity associated. Steps taken to increase the abdominal cavity volume in order to accommodate the herniated contents include Preoperative Progressive Pneumoperitoneum (PPP), weakening/ temporarily paralyzing the abdominal muscles, resection of herniated contents, splenectomy, omentectomy, etc. We present a case of a 63-year-old male chef of lower economic strata residing in Gowliguda, Hyderabad. The patient presented with a large inguinoscrotal swelling in the right groin region with mild dragging type of pain. He has no significant comorbidities. On preop CT, Tanaka Index was measured to be 55%, i.e loss of domain hernia. We planned to infiltrate botulinum toxin into the lateral abdominal muscles initially followed by progressive pneumoperitoneum and then later perform hernioplasty, with an interval of 15 days between each procedure. The toxin would serve to paralyze the muscles in order for the abdomen to accommodate the hernial contents. After 15 days, the abdomen was insufflated with air of 750cc daily for the next 2 weeks. CT Abdomen at this point revealed the decrease in Tanaka index to 55%. The patient then underwentLichtenstein tension free meshplasty, following which he was discharged with a Tanaka index score was 20% with an uneventful postoperative period.