Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia

Preoperative Botulinum Toxin A (BTA) injection in abdominal wall reconstruction for subxiphoid (M1) hernias

INTRODUCTION

Preoperative BTA assists with fascial closure during abdominal wall reconstruction. Its efficacy in subxiphoid (M1) hernias has been questioned with high rates of component separation techniques (CST) despite BTA. To assess the role of BTA in these hernias, we compared fascial closure and recurrence rates in patients with M1 hernias requiring CST with or without preoperative BTA.

METHODS

A prospectively maintained database at a tertiary hernia center was reviewed for M1 hernias who underwent CST, and grouped based on use of preoperative BTA. Standard univariate analysis was performed.

RESULTS

Of 67 patients, 30 (44.8%) received preoperative BTA. BTA versus non-BTA groups had similar mean ages (56.0 ± 14.1vs.61.5 ± 11.8 years, p = 0.087), ASA score (p = 0.345), rate of diabetes (p = 0.421), and very large defect size (499.2 ± 185.5vs.416.1 ± 238.6 cm2,p = 0.144). In the BTA group, BMI was lower (28.9 ± 5.1vs.32.7 ± 7.2 kg/m2,p = 0.018), with fewer current smokers (0%vs.10.8%,p = 0.006), and more contaminated (20.0%vs.5.4%) and dirty cases (33.3%vs.13.5%) (p = 0.008). External oblique release was performed in 24 (80.0%) BTA patients versus 23 (62.2%) non-BTA (p = 0.179), posterior CST in 6 (20.0%) versus 14 (37.8%) (p = 0.133). Rates of bilateral CST (90.0%vs.94.6% p = 0.394), fascial closure (90.0%vs.94.6%,p = 0.650), overall wound complications (33.3%vs.43.2%,p = 0.458), and recurrence (6.7%vs.2.7%,p = 0.583) were similar with average follow up of 12.7 ± 18.8 versus 24.1 ± 28.2 months (p = 0.062).

CONCLUSION

Repair of very large M1 hernias requires high rates of CST despite preoperative BTA injection. When CST is needed, BTA as a preoperative adjunct does not appear to offer benefit in terms of fascial closure rates, frequency of bilateral CST, or risk of recurrence.

Total Thickness Bilateral Rupture of the Rectus Abdominis: A Case Report and Literature Review

Rupture of the rectus abdominis is a rare condition. We describe the case of a young male trainee paratrooper who presented with sudden onset severe lower abdominal pain that occurred during military training. Magnetic resonance imaging revealed full-thickness bilateral rupture of the rectus abdominis. Our management involved injecting botulinum toxin into the rectus muscles preoperatively, reconstructing the rectus muscles, and placing a supportive biosynthetic mesh. Postoperatively, our patient could walk pain-free at 3 weeks, jog pain-free at 10 weeks, and run up to 2 miles at 25 weeks. As there is no consensus on the management of this rare injury, we conducted a literature review on all cases reporting rupture of the rectus abdominis from the year 2000. After comparing the outcomes of conservatively versus surgically managed patients, we can conclude that generally, management of such defects is dependent on size, severity, and patient factors; however, surgical treatment yields comparable results to conservative treatment.

Prevention of component separation in complex abdominal wall surgery by Botox prehabilitation: a propensity-matched study

AIM

To facilitate midline fascial closure in complex abdominal wall surgery, component separation techniques (CST) are usually required. However, CST is associated with an enlarged morbidity. Prehabilitation could increase the compliance of the abdominal wall and thereby decrease the necessity of myofascial release. This can be accomplished by administration of botulinum toxin type A (BTA) in the lateral abdominal wall musculature. The aim of this study was to determine the effect of BTA on the subsequent necessity to perform CST in patients with complex abdominal wall hernias.

METHODS

Patients with a complex abdominal wall hernia, planned to undergo CST between July 2020 and November 2022 were included. Outcome of procedures with 300U of BTA 4 (2-6) weeks prior to surgery, were retrospectively analyzed by comparison with propensity matched subjects of an historical group. Hernia width difference was assessed by CT and operative details were included.

RESULTS

A total of 13 patients with a median hernia width of 12 cm (IQR 9-14, range 24) were prehabilitated with BTA between July 2020 and November 2022. A CST was planned for all, however not required in 6/13 patients (46%) to accomplish midline fascial closure. A mean elongation of lateral abdominal wall musculature of 4.01 cm was seen in patients not requiring CST. Compared to the propensity score matched control group, a 27% reduction (p = 0.08) in the need for CST was observed.

CONCLUSION

There is a tendency for decrease of necessity for CST by preoperatively administered BTA in patients with complex abdominal wall defects. Although small, as this study used propensity matched comparison, further exploration of BTA should be encouraged.

A Review of Advanced Abdominal Wall Hernia Patch Materials

Tension-free abdominal wall hernia patch materials (AWHPMs) play an important role in the repair of abdominal wall defects (AWDs), which have a recurrence rate of <1%. Nevertheless, there are still significant challenges in the development of tailored, biomimetic, and extracellular matrix (ECM)-like AWHPMs that satisfy the clinical demands of abdominal wall repair (AWR) while effectively handling post-operative complications associated with abdominal hernias, such as intra-abdominal visceral adhesion and abnormal healing. This extensive review presents a comprehensive guide to the high-end fabrication and the precise selection of these advanced AWHPMs. The review begins by briefly introducing the structures, sources, and properties of AWHPMs, and critically evaluates the advantages and disadvantages of different types of AWHPMs for AWR applications. The review subsequently summarizes and elaborates upon state-of-the-art AWHPM fabrication methods and their key characteristics (e.g., mechanical, physicochemical, and biological properties in vitro/vivo). This review uses compelling examples to demonstrate that advanced AWHPMs with multiple functionalities (e.g., anti-deformation, anti-inflammation, anti-adhesion, pro-healing properties, etc.) can meet the fundamental clinical demands required to successfully repair AWDs. In particular, there have been several developments in the enhancement of biomimetic AWHPMs with multiple properties, and additional breakthroughs are expected in the near future.

Systematic review and meta-analysis of the pre-operative application of botulinum toxin for ventral hernia repair

PURPOSE

Surgical repair of large hernia defects requires detailed pre-operative planning, particularly in cases with loss of domain. This situation often hampers mid-line reconstruction, even after component separation, when the size of the hernia is disproportional to the volume of the abdominal area. In this case, other strategies may be needed to place the viscera back into the abdominal cavity after reducing the hernia sac. The administration of botulinum toxin prior to the surgical procedure has been indicated as an adjunct for more complex cases. This results in stretching of the lateral musculature of the abdomen, allowing midline approximation. In addition, the application of botulinum toxin alone has been investigated as a means of downstaging in the management of ventral hernias, thereby precluding component separation and enabling primary closure of the midline by placement of mesh within the retromuscular space using the Rives Stoppa technique.

METHODS

Systematic review of the literature for observational studies involving patients undergoing pre-operative application of botulinum toxin for ventral hernia repair was conducted according to the PRISMA guidelines.

RESULTS

Advance of the lateral musculature of the abdomen by an average of 4.11 cm with low heterogeneity, as well as low rates of surgical site infection (SSI), surgical site occurrences (SSO) and recurrence, was shown.

CONCLUSION

Pre-operative application of botulinum toxin for ventral hernia repair promoted an increase in the length of the lateral musculature of the abdomen which can help improve the outcomes of morbidity and recurrence.

Imaging Insights Into Abdominal Wall Function

Purpose

The successful repair of any complex ventral hernia requires a thorough understanding of the underlying anatomical defect and its functional context. We describe an improved “functional” approach to CT imaging of the abdominal wall that can facilitate this understanding and assist surgical planning.

Methods

This invited article reports the observational experience gained from the functional abdominal wall CT examinations of 88 patients who underwent complex ventral hernia repair using pre-operative Botulinum toxin A (BTA) infiltration of the lateral oblique abdominal muscles as well as a further eight patients with diastasis rectus abdominis who were examined to exclude ventral hernia.

Results

The use of a functional CT protocol which supplements resting images with additional “crunching” images (acquired with the abdominal wall muscles all strongly contracted) can significantly improve the demonstration of ventral hernia defects. Crunching acquisitions can also help differentiate true hernias from dysfunctional bulges, identify muscle denervation or atrophic changes, reveal otherwise occult hernias that may be missed on resting or Valsalva images alone, and assist the pre-operative assessment of BTA effect.

Conclusion

A more functional approach to pre-operative CT imaging of the abdominal wall can significantly improve the understanding of complex ventral hernia defects and help formulate effective surgical plans that achieve low recurrence rates and good functional outcomes.

The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure

Abdominal wall surgeons have developed a host of tools to help facilitate fascial closure. Botulinum toxin A is one of the most recently identified treatments and has grown in popularity over recent years; showing great promise in a number of case series and cohort studies. The toxin paralyses lateral abdominal wall muscles in order to increase laxity of the tissues—facilitating medialisation of the rectus muscles. Several research groups around the world are developing expertise with its use-uncovering its potential. We present a review of the relevant literature over the last two decades, summarising the key evidence behind its indications, dosing and effects.