A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.

INTRODUCTION: Preoperative progressive pneumoperitoneum (PPP) is a technique that has been used since 1947 to expand the abdominal cavity volume, for presurgical preparation of patients with large hernias. This systematic review attempts to answer some unresolved questions about PPP, while using the evidence to clarify the different forms that the procedure has taken over time.

PURPOSE: The purpose of the paper was to analyze the literature about PPP and gather information about the procedure and its indications, advantages, and disadvantages.

METHODS: A systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The database searches, in English and Spanish, were made using the terms "preoperative pneumoperitoneum," "progressive pneumoperitoneum," "preoperative pneumoperitoneum," and "progressive pneumoperitoneum," for the period between 1 January 1940 and 31 May 2019. Indications, techniques, results, and complications were registered. The statistical analysis was based on means, standard deviations, medians, mode, and interquartile ranges for quantitative variables, and frequencies and percentages for categories.

RESULTS: The qualitative synthesis was made on the basis of 53 articles that reported the treatment of a total of 1216 patients. The most frequent indication for PPP was a large incisional hernia with loss of domain. The most common technique employed a spinal needle or multipurpose catheter by the anatomical method in the left hypochondrium. In spite of the heterogeneity of the data and the management of different volumes of air and daily insufflations, 99.6% of visceral reintroduction and 86% of primary fascial closure was achieved. Complications had an incidence of 12%, mostly minor, and there were five mortalities.

CONCLUSION: Preoperative progressive pneumoperitoneum (PPP) is a beneficial and safe technique to use in preparing patients with large hernias, but the procedure is not free of complications. The technique has evolved through the years and, although many variations exist, it is possible to establish an algorithm for its application.