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Background and objective: Giant inguinoscrotal hernias with loss of domain (LOD) represent a major surgical challenge, especially in multimorbid elderly patients. We present a complex case of a 77-year-old high-risk patient successfully treated with a complementary preoperative strategy combining progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) without complications. This approach enabled safe enlargement of the abdominal cavity, reduction of chronically displaced viscera, and avoidance of more invasive reconstructive procedures.

Method: A 77-year-old man presented with a giant right-sided inguinoscrotal hernia present for over 10 years, extending nearly to his knees. He suffered from pain, buried penis, impaired mobility, and urinary leakage. Due to severe comorbidities, including ischemic cardiomyopathy, chronic renal failure, severe mitral insufficiency, and previous NSTEMI, surgery had previously been denied. CT imaging revealed a 33-cm hernial sac filled with small and large bowel. Under local anesthesia, a Foley catheter was inserted through a small subxiphoid incision to initiate PPP. After 10 days and 6.7 L of insufflation, abdominal wall expansion remained insufficient. Therefore, 300 IU of BTA was injected bilaterally between the external and internal oblique muscles at three sites per side. PPP was continued for a total of 20 days, with daily volumes of 600–1400 cc, reaching 20.7 L. Complete reduction of the hernia contents was achieved without bowel resection, followed by a Shouldice tissue repair. Operative time was 90 minutes, and recovery was uneventful, with discharge on postoperative day 10.

Result: LOD hernias are associated with increased intra-abdominal pressure and high perioperative risk, particularly in multimorbid patients. PPP serves as an effective prehabilitation technique, expanding the abdominal cavity and reducing the risk of abdominal compartment syndrome. In this case, PPP alone was insufficient, and patient discomfort occurred with volumes above 1,000 cc. The addition of BTA allowed progressive, well-tolerated expansion, facilitating atraumatic reduction and shorter operative time without major complications.

Summary: The combined use of PPP and BTA represents a safe and effective preoperative strategy in high-risk patients with giant LOD inguinoscrotal hernias. This approach enables gradual abdominal cavity expansion, reduces perioperative risk, and facilitates tension-free hernia reduction and repair, even in severely multimorbid patients.