A structured protocol for Preoperative Progressive Pneumoperitoneum (PPP) in Complex Abdominal Wall Reconstruction (CAWR): our York protocol

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Abstract
Background: Complex Abdominal Wall Reconstruction (CAWR) in patients with significant loss of domain poses substantial surgical and physiological challenges [1], [2]. Preoperative Progressive Pneumoperitoneum (PPP), involving incremental insufflation of gas into the abdominal cavity, enhances the likelihood of tension-free fascial closure [3]. However, there remains considerable variability and incompleteness in existing PPP protocols, especially concerning venous thromboembolism (VTE) prophylaxis, inferior vena cava (IVC) filter placement, respiratory prehabilitation, and multidisciplinary coordination. Methods: A structured literature review was conducted (MEDLINE® and Embase®, final search April 2025), yielding no comprehensive PPP protocols for CAWR. In response, we convened a multidisciplinary team at a tertiary UK referral centre—including specialists in general surgery, plastic and reconstructive surgery, vascular surgery, interventional radiology, and pharmacy—to develop an integrated, replicable protocol. Consensus development methods (CDMs) informed the iterative refinement process, incorporating clinical experience and best available evidence. Results: Our seven-week perioperative protocol systematically integrates key preoperative interventions: bilateral abdominal wall botulinum toxin injections, respiratory prehabilitation, abdominal binder use, VTE prophylaxis with low molecular weight heparin (LMWH), planned IVC filter insertion, peritoneal dialysis catheter placement, and scheduled PPP insufflation sessions. Final surgical planning is guided by crosssectional imaging obtained one week preoperatively. Postoperatively, a structured IVC filter removal strategy, including cavogram assessment, is implemented to manage thromboembolic risk. Conclusion: We present a comprehensive PPP protocol designed to optimise outcomes in CAWR. This structured, multidisciplinary approach represents an important step toward standardising care in complex abdominal wall reconstruction.

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