Abstract:Background and Aims Incisional hernia is one of the common postoperative complications of abdominal surgery. Patients undergoing abdominal surgery will usually develop intra-abdominal adhesions of varying degrees, and adhesion separation is an unavoidable and relatively difficult task during incisional hernia repair. Preoperative progressive pneumoperitoneum (PPP) is an important component of laparoscopic incisional hernia repair, and the authors previously found that comparison of the imaging data before and after PPP can assess the intra-abdominal status of patients with incisional hernia, thereby is helpful for surgical predetermination, improving surgical precision and reducing surgical risk. Therefore, this study was conducted to further evaluate the application value of PPP combined with abdominal wall CT imaging in laparoscopic repair for patients with incisional hernia and concomitant intra-abdominal adhesions, and summarize the types of intra-abdominal adhesions and surgical skills of adhesion separation.Methods The clinical data and surgical videos of patients meeting the inclusion criteria and undergoing laparoscopic incisional hernia repair in the Department of Gastrointestinal, Hernia and Abdominal Wall Surgery of the Sixth Affiliated Hospital of Sun Yat-sen University from April 2019 to May 2020 were retrospectively collected. The presence or absence of intra-abdominal adhesions was determined by comparison of the abdominal CT before and after PPP. Through the operation video review, the classification of intra-abdominal adhesions was observed, the techniques of adhesion separation were summarized, and the time and complications of intraoperative adhesion separation were recorded. The associated injuries during puncture, and postoperative complications and recovery were also documented.Results A total of 72 cases of laparoscopic incisional hernia repair were collected, of whom, 15 cases with no preoperative artificial pneumoperitoneum, 7 cases with no preoperative abdominal CT review after the establishment of artificial pneumoperitoneum, and 15 cases with no three-dimensional CT reconstruction of the hernia sac before or after pneumoperitoneum were excluded. A total of 35 patients were included finally. All of them were type II abdominal wall defect including recurrent hernia in 5 cases. Of the patients, 16 were males and 19 were females, with an age of (63.26±11.11) years; body mass index was 25.04 (23.03-27.34) kg/m2; 4 cases had intra-abdominal infection with incision infection and 7 cases had incision infection after previous operation; the maximum number of operations that a single patient experienced was 5. By comparing the abdominal CT before and after PPP, 33 patients (94.29%) were diagnosed with adhesions between the abdominal contents and the abdominal wall, and 2 patients (5.71%) had no adhesions. Among them, the dominant findings were intestinal adhesions in 20 cases (60.61%), and omental adhesions in 13 cases (39.39%). According to the morphological characteristics, the adhesions were classified as point-like adhesions, linear adhesions, sheet-like adhesions, and mixed adhesions. According to the texture of adhesions, the adhesions were categorized into membranous adhesions, cicatricial adhesions, and complex adhesions. The adhesion separation was performed by a procedural approach of changing the plane to the peak plane, transforming the plane to the line and point, blunt-sharp separation of the membranous adhesions, and sharp separation of the cicatricial adhesions. Adhesion separation was successfully completed in the whole group. The separation time was 32 (4.50-46.50) min. Small intestinal wall seromuscular injury occurred in 5 patients, which was repaired with a 3-0 absorbable suture. No intra-abdominal organ injury occurred during observation port puncture. One patient developed pulmonary infection after operation, and the time to anal gas passage was 3 (2-4) d.Conclusion PPP combined with abdominal CT imaging is helpful for determining the presence or absence of intra-abdominal adhesions as well as the location of the adhesions, and also helpful for the selection of the layout of the observation port. A procedural approach based on the morphology and nature of adhesion is beneficial for simplifying the dissection of intraperitoneal adhesions.