Preoperative Progressive Pneumoperitoneum and Botulinum Toxin Type A in Patients With Large Parastomal Hernia

Limitations of Transversus Abdominis Release (TAR)-Additional Bridging of the Posterior Layer And/Or Anterior Fascia Is the Preferred Solution in Our Clinical Routine If Primary Closure is Not Possible

Background: By separating the abdominal wall, transversus abdominis release (TAR) permits reconstruction of the abdominal wall and the placement of large mesh for many types of hernias. However, in borderline cases, the mobility of the layers is inadequate, and additional bridging techniques may be required for tension-free closure. We now present our own data in this regard. Patients and Methods: In 2023, we performed transversus abdominis release on 50 patients as part of hernia repair. The procedures were carried out using open (n = 25), robotic (n = 24), and laparoscopic (n = 1) techniques. The hernia sac was always integrated into the anterior suture and, in the case of medial hernias, was used for linea alba reconstruction. Results: For medial hernias, open TAR was performed in 22 cases. Additional posterior bridging was performed in 7 of these cases. The ratio of mesh size in the TAR plane to the defect area (median in cm) was 1200cm2/177 cm2 = 6.8 in patients without bridging, and 1750cm2/452 cm2 = 3.8 in those with bridging. The duration of surgery (median in min) was 139 and 222 min and the hospital stay was 6 and 10 days, respectively. Robotic TAR was performed predominantly for lateral and parastomal hernias. These procedures took a median of 143 and 242 min, and the hospital stay was 2 and 3 days, respectively. For robotic repair, posterior bridging was performed in 3 cases. Discussion: Using the TAR technique, even complex hernias can be safely repaired. Additional posterior bridging provides a reliable separation of the posterior plane from the intestines. Therefore, the hernia sac is always available for anterior reconstruction of the linea alba. The technique can be implemented as an open or minimally invasive procedure.

Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10 cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.