Giant inguinoscrotal hernias are rare entities that present significant surgical and physiological challenges due to loss of domain and associated risks. An inguinoscrotal hernia is termed “giant” if it descends below the midpoint of the inner thigh in an upright position. We describe the case of a 50-year-old male with a 20-year history of progressively enlarging right inguinoscrotal hernia, treated successfully with open hernioplasty following a 14-day preoperative progressive pneumoperitoneum (PPP) regimen using filtered medical-grade room air. Daily monitoring included vital signs, abdominal girth, and SpO2, along with respiratory physiotherapy to optimize diaphragmatic adaptation. Adequacy of PPP was confirmed clinically by tolerance of insufflation, reduced scrotal bulging, improved abdominal compliance, and intraoperative ease of reduction. The patient had an uneventful postoperative recovery with no recurrence at the 3-month follow-up. PPP with room air is a practical, safe, and cost-effective adjunct in managing giant inguinoscrotal hernias, particularly in resource-constrained settings, provided structured monitoring and supportive care protocols are followed.