15 Jul 2025 PPP in Giant Hernias

PPP is a useful method for preparing patients with complex hernias accompanied by loss of domain. It is adjunct to these type of hernias. When used especially in combination with retromuscular repair techniques, it provides successful outcomes.

PPP is an acronym and it stands for Progressive PneumoPeritoneum. I will refer to it as PPP throughout this blog post. PPP is a technique used to gradually expand the abdominal cavity by controlled air insufflation before hernia repair in complex abdominal wall hernias with loss of domain, aiming to increase intra-abdominal volume.

The first surgeon to apply this technique was Argentine surgeon Iván Goñi Moreno (1905–1976). In 1940, he used PPP to increase intra-abdominal volume as a preoperative preparation for large hernias. The technique is still known by his name.

In practice, the technique involves inserting a catheter into the patient’s abdomen and injecting increasing amounts of air daily to expand the abdominal cavity. This progressive insufflation relaxes the abdominal wall while maintaining the patient’s hemodynamic and respiratory stability. The air pushes the abdominal wall outward and increases its compliance. The abdominal wall muscles stretch, especially the lateral muscle group. It also dissects the fascial planes. It stretches the fibrotic and scar tissues in the hernia. After hernia repair, this helps minimise complications related to increased intra-abdominal pressure.

A notable advantage of the technique is that it facilitates adhesiolysis. The injected air performs a pneumo-dissection, separating the herniated organs from the hernia sac. It helps return the organs to their original anatomical position. In many cases, the hernia sac appears empty when opened during surgery.

Performing PPP can lower the complexity level of the hernia repair; component separation techniques may no longer be necessary. Especially in midline incisional hernias, the elongation of the lateral muscle group significantly reduces the defect width, allowing a Rives-Stoppa repair.

Catheter Placement
This can be done in several ways: percutaneously on an outpatient basis, under ultrasound guidance, or laparoscopically. Central venous catheters are suitable for this purpose. When performed percutaneously with ultrasound, bowel injury is rare but possible. The safest approach is the laparoscopic method under direct vision. If the hernia allows, the Palmer’s point is the most suitable entry site. Otherwise, other areas of the abdomen can be used. After catheter placement, we begin the procedure with an initial dose of 500 mL of air. CO₂ gas used in laparoscopy should not be used, as it is rapidly absorbed by the peritoneum and eliminated via the lungs. Ambient air stays longer.

Insufflation
The intra-abdominal volume is gradually increased by injecting increasing amounts of air daily. The volume increase depends on the patient’s tolerance. The most important factor is the effect of increased intra-abdominal pressure on the diaphragm and respiratory function. This is assessed through patient feedback.

Volume
The volume varies depending on patient tolerance and the duration of application but typically reaches a daily maximum of 1500–1800 mL.

Duration
Usually 7–10 days, although in cases of giant hernias with large defects, some centers apply it for up to two weeks.

Outpatient or Inpatient?
This remains a matter of debate. Some centers prefer outpatient application. The patient comes in daily for insufflation, which takes about 5 minutes. We prefer inpatient application. As I will discuss below, the potential complications of PPP can be serious, and the best way to reduce risk is through close monitoring. The safest way to ensure this is hospitalisation.

These patients have limited mobility, making daily visits difficult. Some complications require early detection and intervention, which is quicker in an inpatient setting. However, long hospital stays come at a high cost. This patient group is special, and cost should not be the primary concern. For low-risk patients without comorbidities, if a short-term (3–5 days) PPP is planned, and patient compliance and daily follow-ups can be ensured, it may be done on an outpatient basis.

With Botox
Botox-assisted chemical component separation has become routine in large incisional hernias. It should also be routinely applied in patients with loss of domain requiring PPP.

Complications
The potential complications of this procedure are important and must be considered.

Pulmonary – Due to increased intra-abdominal pressure, atelectasis and even pneumothorax (rare) can occur. In patients with COPD, respiratory distress may develop in relation to the volume of air injected.

Vascular – Increased intra-abdominal pressure (IAP) can compress the vena cava, reducing venous return. As thromboembolic events are more likely in these patients, prophylactic low molecular weight heparin injections should be administered!

Gastrointestinal – There is a rare risk of gastric or bowel perforation during catheter placement, though cases have been reported. Early detection is crucial. Temporary bowel motility disorders and ileus may occur due to gas pressure.

Infectious – Port site infection may occur. If sterile technique is breached, peritonitis may develop. Since room air is used, passing the air through a filter adds another layer of safety.

Other – Subcutaneous emphysema, shoulder pain, etc.

Volume expansion should be performed slowly, always prioritising patient comfort. The patient’s respiratory rate, oxygen saturation, and hemodynamic status must be continuously monitored; if signs of overdistension or diaphragmatic pressure (shortness of breath, hypotension) occur, the volume should be reduced. Lower volumes should be preferred in patients with comorbidities such as COPD or heart failure.

This technique is not limited to incisional hernias. It is also used in giant inguinal hernias with loss of domain. Neglected inguinal hernias may extend into the scrotum and even reach below the knee. These also result in loss of domain. The European Hernia Society (EHS) has added a specific classification for scrotal hernias in its inguinal hernia classification. According to this classification, if the hernia reaches the upper thigh, it is classified as S1; if it reaches the mid-thigh, it is S2; and if it reaches the knee, it is S3. If the hernia is irreducible (IR), it should be noted. Many S2 and most S3 hernias involve loss of domain. Almost all S3 hernias are irreducible. I explained this in detail in my blog post about scrotal hernias.

PPP is an important preparatory method that facilitates the repair of large, complex abdominal hernias accompanied by loss of domain. When applied correctly, it safely relaxes the abdominal wall and increases surgical success while always prioritising patient comfort and safety. Awareness of potential complications, careful patient selection, close monitoring, and an experienced team are key to success.

Click here to watch a short video of the procedure!