Progressive pneumoperitoneum: Where do we stand in 2021?

Progressive pneumoperitoneum (PPP) is a technique in which the abdomen is artificially and gradually insufflated over a period of time. The technique was first applied in hernia repair in the 1940s and is now regarded as a useful adjunct in the treatment of complex or giant hernias and those associated with “loss of domain” (LOD). With gradual insufflation, the abdomen becomes progressively distended, promoting soft tissue elongation and preparing it for the post-repair surplus volume of the herniated content. PPP also helps with preoperative pulmonary stabilization and preparation, and it induces pneumatic lysis of intestinal adhesions. In contrast to the longevity of the technique, the heterogeneity in indications and technical variations is remarkable. Indications vary greatly in literature, being either based on clinical judgment or different volumetric cut-off values. Neither is there any consensus on which gas should be used, what volume should be injected, in what frequency, and for how long the pneumoperitoneum should be maintained. There is a clear need for an international consensus concerning LOD hernias and how they are defined. As setting up randomized controlled trials on PPP is not feasible, further research should rely on high-quality observational studies. For reviews and meta-analysis to have any meaningful conclusions, these studies should follow, and adhere to, clear guidelines on the manner of reporting. However, PPP remains a very powerful adjunct in the treatment of large and complex hernias with LOD and has proven its value over time.