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

Follow-up of complex hernia repair with intraoperative fascial traction

BACKGROUND

Different techniques for complex abdominal wall repair are utilised including intraoperative fascial traction (IFT) as the latest development. Despite increasing case numbers for IFT across Europe, long-term data especially on recurrence rates are not available yet.

METHODS

Follow-up data from five different German hernia centers between 12/2019 and 9/2023 were assessed. All patients received Rives-Stoppa repair (RSR) and IFT intraoperatively with an additional transverse abdominis muscle release (TAR) in some cases. 30-day postoperative outcome data were retrospectively collected Standardized follow-up was performed after a minimum of 3 months including clinical examination and standardized ultrasound.

RESULTS

A total of 100 patients were included in the study. The mean age was 60.7 ± 14.3 years; the mean BMI was 31.3 ± 7.3 kg/m² with a mean follow-up of 19.7 ± 10.7 months. The mean defect width was 15.8 ± 5.2 cm. In 94% of the patients complete fascial closure was achieved; in 28% an additional TAR procedure was necessary During follow-up, 2 recurrences were found. The surgical site occurrence (SSO) rate was 33% including mainly seromas (54.5%) and surgical site infections (SSI) of 9% Comparing the groups of IFT + TAR and IFT + RSR a significantly higher incidence of SSO was found in the TAR group (50% vs. 26.4%, p<0.01).

CONCLUSIONS

This study, which is the first long-term follow-up, shows very promising results of the innovative IFT technique in terms of closure rate, wound morbidity, and recurrence rate.

Preoperative botulinum toxin for complex abdominal wall reconstruction: a meta-analysis of propensity-score matched studies with trial sequential analysis

PURPOSE

Large ventral hernias can be associated with significant loss of domain, and preoperative Botulinum Toxin A (BTA) has been suggested as an adjunct therapy to minimize the effects of ventral hernia repair and facilitate fascial closure. However, there is often bias in studies involving BTA and its use is associated with significant cost and its efficacy remains unclear.

METHODS

We systematically searched Medline, Embase, Cochrane, and ClinicalTrial.gov for propensity-score matched (PSM) studies comparing preoperative BTA and AWR with standard AWR for complex hernias. We pooled odds ratios (ORs) and mean differences with 95% confidence intervals (CIs) to assess outcomes, applying a random-effects model. We used R studio version 4.3.1 for statistical analyses.

RESULTS

We included six studies with PSM comprising 851 patients undergoing AWR. The mean age was 60.5 years, mean BMI was 31.8 kg/m2, and 46.5% of patients were male. There were no significant differences between groups regarding fascial closure rate (OR 1.54; 95% CI 0.78 to 3.05; p = 0.21), hernia recurrence (OR 0.81; 95% CI 0.33 to 2.01; p = 0.65), component separation (OR 1.50; 95% CI 0.54 to 4.14 p = 0.4), surgical site infections and occurrences (OR 1.31; 95% CI 0.34 to 5.00; p = 0.70), length of hospital stay, or operation time. The Trial Sequential Analysis (TSA) indicated that none of the outcomes reached the necessary sample size for a definitive conclusion.

CONCLUSIONS

Preoperative BTA did not offer significant benefits in AWR of complex incisional hernia repairs. However, TSA showed that the required sample size was not achieved.

Anaesthesiology and Ultrasound-Guided Injection of Botulinum Toxin in the Abdominal Wall: A State-of-the-Art and Technical Adaptation

Ventral incisional hernia represents a prevalent postoperative complication, characterized by high morbidity and significant healthcare burden. Surgical management can be technically demanding, with a notable risk of recurrence and perioperative complications. This report describes a patient scheduled for hernioplasty with posterior component separation and bilateral transversus abdominis release. As an adjuvant technique, she was proposed botulinum toxin A (BTA) injection under ultrasound guidance into the three lateral abdominal muscle layers (transversus abdominis, internal oblique, and external oblique), to minimize tension and facilitate fascial medialization. Owing to their expertise in regional anatomy and proficiency in ultrasound-guided interventions, anaesthesiologists were consulted to perform the procedure. After four weeks, the size of the hernia decreased by 1.5 cm (width). On the day of surgery, combined anaesthesia was performed, with bilateral transversus abdominis plane block, followed by balanced general anaesthesia. The surgery lasted about five hours. There were no surgical complications, and the patient remained hemodynamically stable. The patient was transferred to the ICU under invasive mechanical ventilation. Ventilatory weaning was achieved after approximately 12 hours. Postoperative pain control was achieved through conventional analgesia, enhanced by the preoperative injection of BTA to alleviate muscle tension, avoiding neuraxial analgesia or intravenous opioids.

Preoperative botolinum toxin A (BTA) and intraoperative fascial traction (IFT) in the management of complex abdominal wall hernias

INTRODUCTION

Preoperative botolinum toxin A (BTA) administration to the lateral abdominal wall has been widely used since its introduction for treating complex abdominal wall defects and loss of domain (LOD) hernias. Intraoperative fascial traction (IFT) is an established technique for complex abdominal wall hernias exceeding a width of 10 cm and has also shown auspicious results. We present our single center data including 143 consecutive cases combining both techniques from 2019 to 2023. Aim of the study was to develop an algorithm for a tailored approach for very large and complex ventral abdominal wall hernias.

METHODS

Consecutive patients treated with preoperative BTA and IFT from August 2019 to December 2023 were identified in our prospectively maintained database and reviewed retrospectively. Metrics included intraoperative findings and short-term (30 days) postoperative outcomes.

RESULTS

143 patients were included in our retrospective analysis. The mean age was 58.9 years and 99% of all patients had an ASA Score of II or III with a mean body mass index of 32.4 kg/m2. The mean intraoperative reduction of fascia-to-fascia after BTA and IFT was 9.81 cm. 14 patients either had a lateral defect or a combination of a midline and lateral hernia. An additional uni- or bilateral transverse abdominis release (TAR) was necessary in 43 cases (30.1%). The overall surgical site occurrence rate (SSO) was 30.1% of which 13.8% were surgical site infections (SSI). Re-operation and SSO rates were significantly higher if an additional TAR was performed (both p = 0.001; α = 0.05).

CONCLUSIONS

IFT in combination with BTA is a transformative and clinically proven tool in the surgeons' toolbox. It might be an easier, and less invasive alternative to other available techniques in many cases, but it should not be looked at as an ultimate stand-alone method to treat all complex W3 hernias.

Exploring New and Potential Indications for Botulinum Toxin Treatment: An Updated Literature Review

Botulinum toxin (BoNT) has traditionally been utilized to relieve tension in muscular and connective tissue diseases (CTD). However, its usage has rapidly expanded and now encompasses usage for neurological, gastrointestinal, psychological, cardiovascular, ophthalmology, orthopedics, and more. More recently, its usage has been utilized for sequelae of CTDs such as Raynaud's disease and reduced oral aperture secondary to scleroderma/systemic sclerosis. Beyond its current applications, BoNT holds promise in various medical fields but is not FDA-approved in these conditions. Thus, the design and conduction of well-designed randomized controlled trials are essential in establishing the efficacy and safety of BoNT treatment which can help accelerate regulatory approval for new indications. The versatility of BoNT suggests that its therapeutic applications continue to expand, offering novel therapies for a wide range of conditions. This review aims to comprehensively evaluate the literature on BoNT's current FDA-approved indications and potential non-FDA uses in other medical conditions. Additionally, this review offers potential insights and future possibilities for BoNT treatment.

[The use of botulinum toxin in hernia surgery: results of a survey in certified hernia centers]

BACKGROUND

Botulinum toxin application into the abdominal wall prior to major hernia repair can reduce the complexity of surgery and has been increasingly used in recent years, even if it is an off-label use.

OBJECTIVE

To what extent is botulinum toxin used in hernia surgery in German-speaking countries and what is the current evidence in the literature?

MATERIAL AND METHODS

In a voluntary online survey of German Society for General and Visceral Surgery (DGAV)-certified competence centers and reference centers for hernia surgery, aspects of botulinum toxin application were surveyed and the results analyzed.

RESULTS

A total of 57 centers took part in the survey, of which 27 (47%) use botulinum toxin. The main reasons for not using it were lack of experience and reimbursement. Of the centers 85% have treated less than 50 patients with botulinum toxin. The main indications were midline hernias (M2-4 according to the EHS classification) with a hernia gap > 10 cm (W3 according to EHS classification) and loss of domain situations. The application was predominantly ultrasound-guided by designated hernia surgeons with 100-200 Allergan or 500 Speywood units 4-6 weeks preoperatively and without complications related to the botulinum toxin application.

CONCLUSION

Botulinum toxin injections in hernia surgery appear to be safe and effective. Ultrasound-guided preoperative bilateral administration is supported by the available data. Specific course and information formats should be offered by the hernia surgery institutions.

Giant Inguino-Scrotal Hernia With Loss of Domain: Surgical Report and Literature Review

The surgical repair of giant inguinal hernias with loss of domain, defined as the relocation of the majority of the intestine into the hernia sac, poses a significant challenge. In the majority of cases, a combination of different surgical techniques with the placement of multiple meshes is necessary to achieve reduction of such complex hernias. The reduction of chronic giant hernias can increase the risk of abdominal compartment syndrome or cardiopulmonary complications. This case study presents a rare and complex case of a patient with a chronic giant inguinal hernia, in which almost the entire intestine was herniated, involving the scrotum and reaching mid thigh. The reduction of the hernia was achieved by a combined open transabdominal and inguinal approach, utilizing the abdominal component separation technique and multiple preperitoneal mesh placements. This multimodal approach resulted in optimal outcomes in terms of cosmesis, functionality, and abdominal wall integrity.

Area of Focus in 3D Volumetry and Botulinum Toxin A Injection for Giant Diaphragmatic Hernia with Loss of Domain: A Case Report with Video Illustration

Background

Chronic giant diaphragmatic hernia is a severe disease with challenging diagnosis and treatment. Given the risk of loss of domain, the use of botulinum toxin A is an option but has been minimally studied in diaphragmatic hernia surgery.

Case Report

We present a case of a giant diaphragmatic hernia in a 66-years-old patient who showed a 12-year history of progressive chronic respiratory insufficiency. There were not notion of traumatic injuries. The CT-scan showed a giant diaphragmatic hernia with herniation of small bowel, right liver, omentum and transverse colon.

Method

We assessed the risk of loss of domain using a 3D volumetry based on the Sabbagh score and decided to use Botox injection before laparoscopic reduction of the hernia due to the high risk of complications related to the loss of domain. A computed tomography was performed 24 months after surgery and showed no evidence of recurrence. The patient presented an excellent functional result with a normal physical activity.

Conclusion

This report is among the first to highlight the utility of 3D reconstruction in assessing the risk associated with loss of domain and in preparing the abdominal wall with botulinum toxin A for diaphragmatic hernia repair.

A New Ultrasound-Guided, One-Point, Single Interfascial Plane Botulinum Toxin A Injection Technique for the Repair of Ventral Abdominal Wall Hernias Before Surgery: A Case Report

Patients presenting with large ventral abdominal wall hernias require pretreatment with injection botulinum toxin A before surgery. Currently, multipoint and multilayered botulinum injection techniques are practiced. We are describing a new ultrasound-guided, 1-point, single interfascial plane botulinum toxin A injection technique for the closure of big hernial defects.

Image guided preoperative abdominal wall botox injection for large ventral hernia repair: A case series

This case series aims to explore the application of preoperative CT guided Botox injections in three different cases of abdominal wall reconstructions. Each of the three cases highlights the role of chemical component separation in achieving myofascial release and contributing to a successful surgical repair. The use of Botox in the preoperative planning of abdominal wall repair aims at creating a tension-free environment for midline closure and promoting an overall positive postoperative course for the patient. This case series presents as a valuable contribution to the different surgical approaches in abdominal wall reconstruction and the collaboration between Interventional Radiology and Surgery in treating such patients.

The Impact of Botulinum Toxin A Application on Reducing the Necessity for "Component Separation Techniques" in Giant Incisional Hernias: A Dual-Center, Polish-Ukrainian, Retrospective Cohort Study

<b>Introduction:</b> Incisional hernias are prevalent complications, with significant recurrence rates and associated surgical wound complications. Giant hernias, classified by the European Hernia Society (EHS) as exceeding 10 cm (width dimension), pose a challenge due to the "loss of domain" effect. Component separation techniques (CST), including anterior component separation (ACS) and transversus abdominis release (TAR), are established interventions but have drawbacks related to the irreversible alteration of abdominal wall anatomy and associated risks. An alternative approach involves the preoperative application of Botulinum Toxin A (BTA) to reduce lateral abdominal muscle tension, facilitating hernial defect closure.<b>Aim:</b> The aim was to assess the impact of BTA on reducing the necessity for CST, the occurrence of surgical site complications,and the need for further interventions.<b>Materials and methods:</b> A retrospective cohort study was conducted across two reference centers specializing in hernia treatment in Poland and Ukraine. The study compared outcomes between patients undergoing elective abdominal wall reconstruction surgery for giant hernias, specifically looking at the requirement for CST following preoperative BTA application. Patients were divided into two groups - those who received BTA injections 3-4 weeks prior to surgery (BOTOX group) and those who did not (NON-BOTOX group).<b>Results:</b> The study found that in the BOTOX group, a significantly lower proportion of patients required CST compared to the NON-BOTOX group (46 <i>vs</i> 84%, P-value = 0.000124). Additionally, the BOTOX group experienced fewer postoperative complications, suggesting a beneficial effect of BTA in simplifying surgical procedures and enhancing patient outcomes.<b>Conclusions:</b> The findings support the use of preoperative BTA injections as a valuable adjunct in the management of giant abdominal hernias. This approach not only facilitates fascial closure without the need for extensive CST but also potentially reduces perioperative trauma and postoperative complications. Preoperative BTA injections significantly reduce the need for CST in giant incisional abdominal hernia repairs, offering a less invasive and more effective approach to fascial closure. The most important role of BTA is "downstaging" the hernia before surgery. This study highlights the importance of considering BTA injections in preoperative protocols, advocating for broader acceptance and reimbursement to improve surgical outcomes and patient care in hernia surgery.

Botulinum Toxin A as an Adjunct for the Repair Giant Inguinal Hernias: Case Reports and a Review of the Literature

The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin

INTRODUCTION

Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience.

METHODS

patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect.

RESULTS

while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects.

CONCLUSION

this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Effective Management of Giant Ventral Hernias: A Comprehensive Approach Combining Preoperative Botulinum Toxin Application, Modified Ramírez's Component Separation, and Rives-Stoppa Hernioplasty

Introduction  Giant ventral hernias are a surgical challenge due to their size and the need for a specialized approach during repair. Over the decades, abdominal wall surgery has evolved into a sophisticated field with a wide range of techniques aimed at improving patient outcomes. However, there is no universally accepted method suitable for repairing all giant ventral hernias. Surgeons must rely on a combination of techniques, choosing the approach that best matches their expertise, available resources, and the individual patient's specific needs. This article explores the effective use of a combination of techniques, including preoperative botulinum toxin application, modified Ramírez's component separation, and Rives-Stoppa hernioplasty, yielding excellent results and minimizing recurrences. Objective  This study aims to provide a comprehensive literature review of giant ventral hernias. Additionally, we aim to share our experience in managing and repairing giant ventral hernias using a multi-modal approach, combining various surgical techniques with a focus on patient safety, reduced recurrence rates, and improved quality of life. Methods Between October 1, 2019, and October 1, 2021, six patients with giant ventral hernias were enrolled at our department of surgery. They received preoperative botulinum toxin A (BT) application, underwent corrective surgery involving modified component separation following the Ramírez method, and received Rives-Stoppa hernioplasty. Follow-up was conducted for at least six months. Results Six patients were included in the study: three women and three men. They had an average age of 53.6 years and an average body mass index of 31.8 kg/m2. The most common location of the hernia defect was supra and infraumbilical, among 66% of cases. The primary adverse effect associated with BT application was abdominal distension, reported in 33% of patients. No postoperative complications, such as abscesses or seromas, were observed. After the surgical procedure, the average hospital stay was 2.6 days, and no recurrences were noted within six months post-surgery. Conclusion  The proposed method, which involves a combination of techniques, has demonstrated promising results based on our experience. However, to solidify these findings and better understand the full scope of this approach, further comprehensive statistical studies involving larger populations are essential. These studies will not only validate our results but also provide valuable insights for optimizing the management of giant ventral hernias.