Botulinum Toxin A Facilitated Laparoscopic Repair of Complex Ventral Hernia

Preoperative Image-guided Botulinum Toxin A Injection in Complex Abdominal Wall Hernia Repair

Purpose: This study aimed to examine the effectiveness of preoperative image guided botulinum toxin A injection in achieving fascial closure and reducing recurrence rates after repair of complex incisional abdominal wall hernias. Material and Methods: A total of 32 patients, consisting of 14 males and 18 females, with complex incisional hernias who underwent image guided botulinum toxin A injection at a median 33 [28-38.3] days before surgery were included in this retrospective study. Their mean age was 59.4 ± 11.2 years. Abdominal computed tomography imaging was obtained prior to botulinum toxin A administration to characterize the hernia defects of 26 patients (81.3%, 26/32). The transverse and vertical abdominal wall defects were measured and recorded. Three-dimensional objects of the hernia sac and peritoneal cavity were created based on the delineated borders, and volumes were calculated. The loss of domain was determined using the following formula: where x represents the hernia sac volume and y represents the peritoneal volume. Under ultrasound guidance, the abdominal wall musculature was injected with 300 units of botulinum toxin A across six sites. The fascial closure rate and rate of hernia recurrence were the principal outcomes investigated. Results: Fascial closure was achieved in 29 patients (90.6%, 29/32). Recurrence was observed in two patients (6.3%, 2/32) over an average followup of 2.5 ± 1.5 years (maximum 6.5). Fascial closure was obtained in 12 out of 14 patients with previous hernia repairs (85.7%, 12/14). One botulinum toxin A related complication was observed-a weakened cough that resolved without further treatment. Conclusions: Botulinum toxin A is safe and effective in improving rates of fascial closure and reducing instances of reoccurrence in patients with complex incisional hernias.

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.

The use of botulinum toxin type a to prepare patients with large ventral hernias for laparoscopic hernioplasty: Our experience

OBJECTIVE

Aim: To study the effectiveness of BTA in a total dose of 100 IU as the preparation for patients with primary and incisional ventral hernias (VH).

PATIENTS AND METHODS

Materials and Methods: The prospective study included 59 patients with large VH (defect ³10 cm). All patients received 100 IU of BTA in abdominal wall muscles 4-5 weeks before surgery from June 2017 to December 2022. An average age of the patients was 59.13 ± 9.07 years, body mass index - 32.20 ± 4.95 kg/m2.

RESULTS

Results: An average width of the hernia defect after BTA decreased by 4.5 ± 1.11 cm (p<0.001). An average length of the hernia defect after BTA also decreased, without clinical significance. A significant increase in the length of the abdominal wall and a decrease in its thickness were observed. The abdominal cavity volume after BTA increased by 4.04 ± 4.55% (p=0.008) and the hernial sac volume decreased by 21.43 ± 16.57% (p=0.005). All patients underwent surgery with hernia defect suturing and without component separation: laparoscopic IPOM hernioplasty - 50 (84.7%) patients, open IPOM hernia repair - 7 (11.9%) patients, open sublay hernioplasty - 2 (3.4%) patients. There was no recurrence of hernia during 12 months after surgery.

CONCLUSION

Conclusions: The administration of 100 IU BTA allows to increase the length of the abdominal wall muscles and to perform laparoscopic IPOM hernioplasty for patients with large VH.

Preoperative Optimization for Abdominal Wall Reconstruction

Patients requiring abdominal wall reconstruction may have medical comorbidities and/or complex defects. Comorbidities such as smoking, diabetes, obesity, cirrhosis, and frailty have been associated with an increased risk of postoperative complications. Prehabilitation strategies are variably associated with improved outcomes. Large hernia defects and loss of domain may present challenges in achieving fascial closure, an important part of restoring abdominal wall function. Prehabilitation of the abdominal wall can be achieved with the use of botulinum toxin A, and preoperative progressive pneumoperitoneum.

Preoperative Abdominal Muscle Elongation Facilitated Laparoscopic Intraperitoneal Onlay Mesh Repair of Complex Ventral Hernia

Background: Complex ventral hernia remains a challenging situation for any surgeon. In this study, our aim was to analyze the effect of laparoscopic intraperitoneal onlay mesh (IPOM) repair in the treatment of complex abdominal wall hernia, with the assistance of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA). Methods: In this retrospective study, we included 13 patients with complex ventral hernia between May 2021 and December 2022. All patients undergoing PPP and BTA protocol before hernia repair. The length of abdominal wall muscles and abdominal circumference were measured from CT scan. All hernias were repaired with laparoscopic or laparoscopic-assisted IPOM. Results: Thirteen patients received PPP and BTA injections. PPP and BTA administration time was over 8.8 ± 2.5 days. Before and after PPP and BTA, imaging showed that the length of lateral muscle on each side increased from 14.3 to 17.4 cm (P < .05). The abdominal circumference increased from 81.8 to 87.9 cm (P < .05). Complete fascial closure was obtained in 13 patients (100%), and no patient experienced postoperative abdominal hypertension and ventilatory support. No patient suffered from recurrent hernia to date. Conclusions: Preoperative PPP combined with BTA injection plays a role similar to component separation technique, avoids the abdominal hypertension after laparoscopic IPOM repair of complex ventral hernia.