Effects of botulinum toxin in two indicators of loss of domain and hernia size among patients with large ventral hernias

BACKGROUND

In patients with large ventral hernias, botulinum toxin to external and internal oblique muscles decreases thickness and increases length. We examined the impact of botulinum toxin in the amount of loss of domain according to two ratios and in hernia size.

METHODS

Between October 2021 and November 2023, 20 patients with ventral hernias measuring 10 cm or more on the horizontal size underwent the administration of 50 units of botulinum toxin to each external and each internal oblique muscle 4 weeks before their surgery. Incisional hernia volume to peritoneal volume ratio, volume ratio, and hernia size were compared before and 4 weeks after the injection of botulinum toxin. Comparisons between all variables obtained before and after the administration of botulinum toxin were performed using either the paired t-test or the Wilcoxon signed-rank test. Pearson correlation coefficient was used to analyze associations between initial conditions and further changes observed after botulinum toxin injection.

RESULTS

We observed a 42% reduction in muscle amplitude, 16% increase in intra-abdominal volume, 28% decrease in herniated volume, decreases of 6% in IHV/PV ratio and of 11% in V ratio, 11% reduction of hernia width, and decrease of 10% in rectangular and elliptical hernia areas.

CONCLUSIONS

In patients with large ventral hernias, botulinum toxin is associated with reduction of hernia size and decrease in loss of domain, the latter not being significant when less than 10% of the visceral block is herniated.

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.

[Surgical treatment of complex incisional hernia]

There is no generally accepted incisional hernia classification. To categorize incisional hernias, the European Hernia Society (EHS) proposed their classification based on the measurement of three parameters - location, dimension of hernia gate and recurrence. Unfortunately, this classification does not consider the «loss of the domain» of 20% or more, local complications including trophic ulcer or fistula of anterior abdominal wall. Moreover, implantation of mesh after previous hernia repair, obesity and other clinical factors are also not considered. Thus, surgeons have recently allocated patients with complex incisional hernia in a separate group. There is no clear definition of this term. There are no clinical guidelines on the management of patients with these hernias, and the choice of optimal surgical treatment remains individual. The authors present a patient with complex incisional hernia. Surgical strategy is described.

Preoperative Progressive Pneumoperitoneum Revisited

Incisional hernia represents a common and potentially serious complication of open abdominal surgery, with up to 20% of all patients undergoing laparotomy subsequently developing an incisional hernia. This incidence increases to as much as 35% for laparotomies performed in high-risk patients and emergency procedures. A rarely used technique for enabling closure of large ventral hernias with loss of domain is preoperative progressive pneumoperitoneum (PPP), which uses intermittent insufflation to gradually stretch the contracted abdominal wall muscles, increasing the capacity of the abdominal cavity and allowing viscera to re-establish right of domain. This assists in tension-free closure of giant hernias which may otherwise be considered inoperable. This technique may be used on its own, or in conjunction with preoperative Botulinum Toxin A to confer paralysis to the lateral oblique muscles. These two complementary techniques, are changing the way complex hernias are managed.

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

Background: The combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BTA) in adjuvant treatment of large parastomal hernia (LPH) has not been reported in the previous literature.

Methods: From February 2018 to June 2019, 16 patients were diagnosed with LPH in our hospital were included in this study. All patients received PPP and BTA treatment to expand abdominal volume and extend abdominal muscle before surgery. The laparoscopic Sugarbaker method was preferred for defect close.

Results: Before and after PPP and BTA, the mean volume of the parastomal hernia (VPH) was 1,522 and 1,644 cc, respectively (P < 0.01), and the mean volume of the abdominal cavity (VAC) was 5,847 and 9,408 cc, respectively (P < 0.01). The VPH/VAC ratio was decreased by an average of 8.4% after the combination management. And the lateral abdominal muscle length was increased by an average of 4.8 cm/side (P < 0.01). These patients underwent surgery successfully, and no hernia recurrence after (17.6 ± 2.4) months of follow-up.

Conclusions: The combination of PPP and BTA effectively expand the abdominal volume, decrease the risk of abdominal compartment syndrome (ACS) postoperatively, and beneficial to laparoscopic repair of LPH.

Intraoperative Fascia Tension as an Alternative to Component Separation. A Prospective Observational Study

Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods. Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods.

Repair of a Giant Inguinal Hernia

We report a case of a giant inguinal hernia (GIH) that underwent open surgical repair with mesh. The patient had a massive transcompartmental redistribution of abdominal contents from the abdominopelvic cavity to the hernia sac in the scrotum, with subsequent effects on the mechanical nature of the abdominal wall muscles. Repair of this type of giant hernia is challenging as it can raise the intra-abdominal pressure, therefore increasing the risk of abdominal compartment syndrome (ACS). The large size and chronicity of the hernia, associated with deranged mechanical forces/properties of the abdominal wall, made the management of this complex case unique and interesting. In similar cases of massive incisional or ventral hernias, the term “loss of domain” (LOD) is used. In such types of massive hernias, it is important to carefully plan and monitor for adverse physiological effects associated with increased abdominal pressure.

Preoperative treatment with botulinum toxin A: a tool for giant groin hernia repair? Case report

&lt;b&gt;Introduction:&lt;/b&gt; Giant groin hernia is an unusual disease nowadays and its management can be a challenge for surgeons. The application of botulinum toxin A as a preoperative therapy could decrease the thickness of the lateral wall muscles, increase their length and increase the volume of the abdominal cavity facilitating the surgical repair. Morbidity and mortality due to high intra-abdominal pressure would decrease, allowing a minimal tension closure after reduction of the herniated viscera. &lt;br&gt;&lt;b&gt;Case report:&lt;/b&gt; We present the repair of two cases of massive inguinal hernia with loss of domain using preoperative abdominal wall injection of botulinum toxin.

Role of tissue expanders in patients with loss of abdominal domain awaiting intestinal transplantation

Abdominal closure is a complex surgical problem in intestinal transplant recipients with loss of abdominal domain, as graft exposure results in profound morbidity. Although intraoperative coverage techniques have been described, this is the first report of preoperative abdominal wall augmentation using tissue expanders in patients awaiting intestinal transplantation. We report on five patients who received a total of twelve tissue expanders as a means to increase abdominal surface area. Each patient had a compromised abdominal wall (multiple prior operations, enterocutaneous fistulae, subcutaneous abscesses, stomas) with loss of domain and was identified as high risk for an open abdomen post-transplant. Cross-sectional imaging and dimensional analysis were performed to quantify the effect of the expanders on total abdominal and intraperitoneal cavity volumes. The overall mean increase in total abdominal volume was 958 cm(3) with a mean expander volume of 896.5 cc. Two expanders were removed in the first patient due to infection, but after protocol modification, there were no further infections. Three patients eventually underwent small bowel transplantation with complete graft coverage. In our preliminary experience, abdominal tissue expander placement is a safe, feasible, and well-tolerated method to increase subcutaneous domain and facilitate graft coverage in patients undergoing intestinal transplantation.