Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation

Use of botulinum toxin type A in the prehabilitation of abdominal wall musculature for hernia repair: a consensus proposal

The prehabilitation of the abdominal wall through the infiltration of botulinum toxin type A, which induces temporary chemical denervation ("chemical component separation") in the lateral abdominal musculature, is a common practice in units specialized in abdominal wall surgery. However, its use for this indication is currently off-label. The main objective of this article is to describe a consensus proposal regarding indications, contraindications, dosages employed, potential side effects, administration method, and measurement of possible outcomes. Additionally, a proposal for an informed consent document endorsed by the Abdominal Wall Section of the Spanish Association of Surgeons is attached.

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.

A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction

OBJECTIVE

To explore how intramuscular injection of botulinum toxin A (BTA) affects the lateral abdominal wall (LAW) musculature, abdominal- and hernia dimensions, and muscle structure on computed tomography (CT) in patients scheduled for complex abdominal wall reconstruction (CAWR).

METHODS

Retrospective analysis of prospectively registered patients who received bilateral intramuscular BTA injections into all three muscles of the LAW. Only patients for which a CT was available before and 3-6 weeks after BTA treatment prior to surgery were analyzed.

RESULTS

Fifty-two patients were analyzed. Median hernia width in all patients decreased with 0.4 cm (IQR - 2.1;0.6) (p = 0.023). Median intra-abdominal transverse diameter increased with 0.9 cm (IQR - 0.2;3.3) (p = 0.001) and the intra-abdominal anterior-posterior diameter decreased with 0.5 cm (IQR - 1.3;0.5) (p = 0.017), making the abdomen more oval. Median LAW muscle length increased with 0.9 cm (IQR 0.0;2.4) per side (p < 0.001), muscle thickness decreased with 0.5 cm (IQR - 0.8;- 0.2) (- 25.0%) per side (p < 0.001), and muscle mass decreased with 3.9 cm2 (IQR - 6.4;-1.5) (- 15.8%) per side (p < 0.001). Median HU of the psoas muscles (density) increased with 4.8 HU (IQR 0.4;9.7) (10.3%) per side (p < 0.001). Effects of BTA were more pronounced in patients with a loss of domain (LoD) ≥ 20%.

CONCLUSIONS

The main effect of BTA injections is elongation and thinning of the LAW muscles, more than a decrease in hernia width. Concomitantly, the abdomen becomes more oval. An increase of psoas muscles density is seen, associated with offloading of the LAW muscles. Patients with large LoD have a proportionally higher effect of BTA.

Is there a role for botulinum toxin A in the emergency setting for delayed abdominal wall closure in the management of the open abdomen? A systematic review

INTRODUCTION

Emergency laparotomy for either trauma or non-trauma indications is common and management is varied. Use of the open abdomen technique allowing for planned re-look is an option; however, performing delayed definitive fascial closure (DFC) following this can be a challenge. The use of botulinum toxin-A (BTX) infiltration into the lateral abdominal wall has been well documented within the elective setting; its use within the emergency setting is undecided. This systematic review assesses the efficacy and safety of BTX injection into the lateral abdominal wall muscles in the emergency setting. The primary outcome is DFC rate.

METHODS

Systematic review was performed according to the PROSPERO registered protocol (CRD42020205130). Papers were dual screened for eligibility, and included if they met pre-stated criteria where the primary outcome was DFC. Articles reporting fewer than five cases were excluded. Bias was assessed using the Cochrane Risk of Bias and Joanna Brigg's appraisal tools.

FINDINGS

Fourteen studies were screened for eligibility, twelve full texts were reviewed and two studies were included. Both studies showed evidence of bias due to confounding factors and lack of reporting. Both studies suggested significantly higher rates of DFC than reported in the literature against standard technique (90.7% vs 66%); however, these data are difficult to interpret due to strict study inclusion criteria or lack of a control population.

CONCLUSION

The use of BTX is deemed safe and its effects in the emergency situation may have great potential. Unfortunately, to date, there is insufficient evidence to facilitate opinion.

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.

Ultrasound-Guided Lateral Abdominal Wall Botulinum Toxin Injection Before Ventral Hernia Repair: A Review for Radiologists

Preoperative ultrasound-guided lateral abdominal wall botulinum toxin injection is a promising method for improving patient outcomes and reducing recurrence rates after ventral hernia repair. A review of the literature demonstrates variability in the procedural technique, without current standardization of protocols. As radiologists may be increasingly asked to perform ultrasound-guided botulinum toxin injections of the lateral abdominal wall, familiarity with the procedure and current literature is necessary.

A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction

Purpose

To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome.

Methods

PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients.

Results

We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport^® or 200–300 units of Botox^® are injected at 3–5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0–4.3, I² = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2–6.8, I² = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02–1.16, I² = 0%, p = 0.02)].

Conclusion

The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely.

Study registration

A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02499-1.

Image-guided botulinum toxin injection in the lateral abdominal wall prior to abdominal wall reconstruction surgery: review of techniques and results

Ventral hernias represent the most common complication after abdominal surgery. Loss of domain and/or large ventral hernias in patients are especially challenging for surgeons to manage, but preoperative image-guided botulinum toxin injection has emerged as an effective adjunct to abdominal wall surgery. Loss of domain is caused by chronic muscle retraction of the lateral abdominal wall and leads to an irreducible protrusion of abdominal viscera into the hernia sac. Botulinum toxin can be used in the oblique muscles as a chemical component relaxation technique to aid abdominal wall reconstruction. Intramuscular botulinum toxin injection causes functional denervation by blocking neurotransmitter acetylcholine release resulting in flaccid paralysis and elongation of lateral abdominal wall muscles, increasing the rate of fascial closure during abdominal wall reconstruction, and decreasing recurrence rates. In total, 200-300 units of onabotulinumtoxinA (Botox®) or 500 units of abobotulinumtoxinA (Dypsort®) in a 2:1 dilution with normal saline is most commonly used. Botulinum toxin can be injected with ultrasonographic, EMG, or CT guidance. Injection should be performed at least 2 weeks prior to abdominal wall reconstruction, for maximal effect during surgery. At minimum, botulinum toxin should be injected into the external and internal oblique muscles at three separate sites bilaterally for a total of six injections. Although botulinum toxin use for abdominal wall reconstruction is currently not indicated by the Food and Drug Administration, it is safe with only minor complications reported in literature.

The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction

BACKGROUND

Fascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias.

METHODS

A prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias.

RESULTS

A total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm³) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up. Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P = 0.002) than patients who did not require CST.

CONCLUSIONS

In patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.

Prehabilitation of complex ventral hernia patients with Botulinum: a systematic review of the quantifiable effects of Botulinum

PURPOSE

Complex ventral hernia repair (CVHR) encompasses patient optimization, primary fascial closure (PFC), mesh reinforcement and component separation technique (CST), if needed. High rates of complications after CST are still reported. Prehabilitation by managing pre-operative modifiable risk factors, like abdominal wall compliance, possibly reduces these rates. Compliance can be modified by intramuscular injection of Botulinum in the lateral abdominal wall muscles (LAWM). Paralysis leads to elongation of these muscles, which may facilitate PFC and/or prevent CST. Evidence to use Botulinum in hernia patients is scarce and fragmented. An update of evidence for the effect of Botulinum is presented.

METHODS

A multi-database search was conducted for Botulinum studies in ventral hernia patients. A systematic review was performed to describe its primary effect on compliance (LAWM elongation) and secondary effects like PFC ± CST rate, complications and recurrence.

RESULTS

14 studies were included (377 patients) with a HDW of median 12 (10-15) cm. A typical intervention consisted of 200-300 U Botulinum in 3 points per hemi-abdomen under US guidance, > 2 weeks pre-operatively and evaluated by CT just before the operation. The primary effect was a median LAWM elongation of 4.0 cm per side without complications of the injection (four studies, 107 patients). The median PFC rate was 100%, CST rate 38%, wound-related complications 19%, medical complications 18% and recurrence 0% (14 studies).

CONCLUSION

Botulinum safely elongates the abdominal wall muscles, but the level of evidence available remains low. Any patient in whom PFC is expected to be difficult, could be a candidate for prehabilitation with Botulinum.