ORIGINAL ARTICLE Progressive preoperative pneumoperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: volumetric, respiratory and clinical impacts. A prospective study C. Sabbagh • F. Dumont • D. Fuks • T. Yzet • P. Verhaeghe • J.-M. Regimbeau Received: 18 February 2011 / Accepted: 24 June 2011 / Published online: 20 July 2011 Ó Springer-Verlag 2011 Abstract Introduction Progressive preoperative pneumoperito- neum (PPP) is used to prepare incisional hernias with loss of domain (IHLD) operations. The aim of the present study was to analyze the effect of PPP on peritoneal volume [measured using a new computed tomography (CT)-based method] and respiratory function. Methods From July 2004 to July 2008, 19 patients were included in a prospective, observational study. The vol- umes of the incisional hernia (VIH), the abdominal cavity (VAC), the total peritoneal content (VP) and the VIH/VP ratio were measured before and after PPP using abdominal CT scan data. Spirometric parameters were measured before and after PPP, and postoperative clinical data were evaluated. Results Before and after PPP, the mean VIH was 1,420 cc and 2,110 cc (P \ 0.01), and the mean VAC was 9,083 cc and 11,104 cc (P \ 0.01). The VAC increased by 2,021 cc (P \ 0.01) and was greater than the mean VIH before PPP. After PPP, the spirometric measurements revealed a restrictive syndrome. The overall postoperative morbidity rate was 37%. Conclusions PPP increased the hernia and abdominal volumes. PPP induced a progressive, restrictive syndrome. Keywords Large incisional hernia Á Volumetry Á Surgery Introduction Some incisional hernias are considered to be complex and dangerous to treat (regardless of the hernia site and any co- morbidities). These are large incisional hernias (defined as having a diameter greater than 10 cm) [1] and incisional hernias with loss of domain (IHLD). In the latter case, the hernia contents are held in place by adhesions and cannot be reintegrated into the abdominal cavity (i.e., the herni- ated organs have lost their ‘‘right of domain’’ in the abdomen) [2]. The incidence of incisional hernia has increased over recent years, and a report published in 1999 revealed that large median incisional hernias accounted for nearly 21% of all incisional hernias treated in our depart- ment [3, 4]. Treatment of large incisional hernias and IHLD is considered to be dangerous because fascia closure under tension not only constitutes a risk factor for recur- rence [5] but is also life threatening (due to intra-abdominal hypertension, also known as abdominal compartment syn- drome) [6, 7] with the risk of respiratory compliance dis- orders and intestinal ischemia [6–9]. To prevent this postoperative risk, progressive preop- erative pneumoperitoneum (PPP) (also known as the Goni Moreno protocol) [10, 11] has been suggested as a prepa- ratory procedure for the treatment of IHLD [12, 13] and other hernias [14]. In our department, Stoppa et al. [15] reported the use of PPP in 18.5% of 247 cases. To the best of our knowledge, there are no literature data on the vol- umetric and respiratory effects of PPP. Kingsnorth et al. [16] considered that a hernia sac (or second abdomen) volume [ 15–20% of the natural abdominal compartment volume would require respiratory adaptation. However, this figure was based on anecdotal experience, rather than a quantitative analysis. We recently reported that in the management of IHLD, PPP increased the length of the C. Sabbagh Á F. Dumont Á D. Fuks Á P. Verhaeghe Á J.-M. Regimbeau (&) Department of Digestive Surgery, Amiens University Medical Center, Place Victor Pauchet, 80054 Amiens Cedex 01, France e-mail: regimbeau.jean-marc@chu-amiens.fr T. Yzet Department of Radiology, Amiens University Medical Center, Place Victor Pauchet, 80054 Amiens Cedex 01, France 123 Hernia (2012) 16:33–40 DOI 10.1007/s10029-011-0849-2