Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair

Abstract Aim the worldwide increase in morbidly obese patients with complex hernia raises controversies in the choice of the appropriate treatment timing: synchronous bariatric and abdominal wall surgery versus delayed abdominal wall surgery. We report an innovative tailored surgical treatment carried out at our Institution. Material and Methods the approach provided the injection, six weeks before surgery, of 500 international units of botulinum toxin A on either side of the large abdominal wall muscles. Four weeks before surgery pneumoperitoneum was inducted and out-patient daily sessions of progressive insufflation with ambient air were then carried out. Surgery was scheduled 48 days after botulinum injection. Sleeve gastrectomy and simultaneous posterior component separation with transversus abdominis release were performed. Two prosthetic meshes were placed sublay. Results Postoperative superficial surgical site infection was successfully treated with negative pressure wound therapy. At one year follow up no hernia recurrence was recorded while total body weight loss was 31%. Conclusions a delay in ventral hernia repair could worsen quality of life of morbidly obese patients. In such high risk patients, the choice of the best surgical strategy remains controversial. There is great concern in performing bariatric surgery simultaneously to hernia repair, although there is lack of evidence on which is the ideal treatment modality. Synchronous bariatric surgery and complex ventral hernia repair should be approached in high volume centres where a consolidated experience of multidisciplinary team-work is available. Combined botulinum toxin A and preoperative progressive pneumoperitoneum administration allow for a safe resolution of loss of domain.

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Botulinum Toxin A Facilitated Laparoscopic Repair of Complex Ventral Hernia

Frontiers in Surgery ◽

10.3389/fsurg.2021.803023 ◽

2022 ◽

Vol 8 ◽

Author(s):

Fu-Xin Tang ◽

Ning Ma ◽

Enmin Huang ◽

Tao Ma ◽

Chuang-Xiong Liu ◽

...

Keyword(s):

Botulinum Toxin ◽

Hernia Repair ◽

Ventral Hernia ◽

Botulinum Toxin A ◽

Abdominal Muscles ◽

Toxin A ◽

Complex Ventral Hernia ◽

Combined Use ◽

Before And After ◽

The Mean

Background: Complex ventral hernia repair can be challenging despite the recent advances in surgical techniques. Here, we aimed to examine the effectiveness of preoperative combined use of botulinum toxin A (BTA) and preoperative progressive pneumoperitoneum (PPP) for surgical preparation of patients with complex ventral hernia.Methods: In this prospective, observational study, we included 22 patients with complex ventral hernia between January 2018 and May 2021. All patients were treated with BTA injections into the lateral abdominal muscles and PPP before hernia repair. The lengths of abdominal wall muscles, the volumes of the incisional hernia (VIH), the volumes of the abdominal cavity (VAC), and the VIH/VAC ratio were measured before and after BTA and PPP using abdominal CT scan. All Hernias were repaired using laparoscopic intra-peritoneal onlay mesh (IPOM) or laparoscopic-open-laparoscopic (LOL) techniques.Results: Imaging showed a significant increase in the mean lateral abdominal muscle length from 13.1 to 17.2 cm/side (p < 0.01). Before and after BTA and PPP, the mean VIH was 894 cc and 1209 cc (P < 0.01), and the mean VAC was 6,692 cc and 9,183 cc (P < 0.01). The VAC increased by 2,491 cc (P < 0.01) and was greater than the mean VIH before PPP. An average reduction of 0.9% of the VIH/VAC ratio after BTA and PPP was obtained (p > 0.05). All hernias were surgically reduced with mesh, hernia recurrence occurred in only two patients.Conclusions: The preoperative combined use of PPP and BTA increased the abdominal volume, lengthened the laterally retracted abdominal muscles, and facilitated laparoscopic closure of large complex ventral hernia.

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Low-Dose Pre-Operative Botulinum Toxin A Effectively Facilitates Complex Ventral Hernia Repair: A Case Report and Review of the Literature

Medicina ◽

10.3390/medicina57010014 ◽

2020 ◽

Vol 57 (1) ◽

pp. 14

Author(s):

Ali P. Mourad ◽

Marie Shella De Robles ◽

Robert D. Winn

Keyword(s):

Case Report ◽

Botulinum Toxin ◽

Incisional Hernia ◽

Hernia Repair ◽

Abdominal Wall ◽

Ventral Hernia ◽

Low Dose ◽

Botulinum Toxin A ◽

Anatomical Landmarks ◽

Toxin A

Background: Complex ventral hernias following laparotomy present a unique challenge in that repair is hindered by the lateral tension of the abdominal wall. A novel approach to overcome this is the “chemical component separation” technique. Here, botulinum toxin A (BTA) is instilled into the muscles of the abdominal wall. This induces flaccid paralysis and effectively reduces tension in the wall, allowing the muscles to be successfully joined in the midline during surgery. We describe a method where a large incisional hernia was repaired using this technique and review the variations in methodology. Case report: A woman in her mid-40s developed a ventral hernia in the setting of a previous laparotomy for a small bowel perforation. Computed tomography (CT) of the abdomen demonstrated an 85 (Width) × 95 mm (Length) ventral hernia containing loops of the bowel. Pre-operative botulinum toxin A administration was arranged at the local interventional radiology department. A total of 100 units of BTA were instilled at four sites into the muscular layers of the abdominal wall under CT-fluoroscopic guidance. She underwent an open incisional hernia repair 4 weeks later, where the contents were reduced and the abdominal wall layers were successfully joined in the midline. There was no clinical evidence of hernia recurrence at 3-months follow-up. Conclusion: Low-dose BTA effectively facilitates the surgical management of large ventral incisional hernias. There is, however, significant variation in the dosage, concentration and anatomical landmarks in which BTA is administered as described in the literature. Further studies are needed to assess and optimise these variables.

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Patient experiences following botulinum toxin A injection for complex abdominal wall hernia repair

Journal of Clinical Anesthesia ◽

10.1016/j.jclinane.2020.109956 ◽

2020 ◽

Vol 66 ◽

pp. 109956

Author(s):

Oluwatobi O. Hunter ◽

Janey S.A. Pratt ◽

Jesse Bandle ◽

Jody Leng ◽

Edward R. Mariano

Keyword(s):

Botulinum Toxin ◽

Hernia Repair ◽

Abdominal Wall ◽

Botulinum Toxin A ◽

Abdominal Wall Hernia ◽

Patient Experiences ◽

Toxin A ◽

Abdominal Wall Hernia Repair

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Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia

Surgical Endoscopy ◽

10.1007/s00464-016-5030-7 ◽

2016 ◽

Vol 31 (2) ◽

pp. 761-768 ◽

Cited By ~ 23

Author(s):

Kristen E. Elstner ◽

John W. Read ◽

Omar Rodriguez-Acevedo ◽

Peter H. Cosman ◽

Anthony N. Dardano ◽

...

Keyword(s):

Botulinum Toxin ◽

Ventral Hernia ◽

Laparoscopic Repair ◽

Botulinum Toxin A ◽

Chemical Component ◽

Toxin A ◽

Complex Ventral Hernia

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Chemical components separation with the use of Botulinum toxin A

Revista de Medicina ◽

10.11606/issn.1679-9836.v97i6p569-573 ◽

2018 ◽

Vol 97 (6) ◽

pp. 569-573

Author(s):

Gustavo Heluani Antunes de Mesquita ◽

Yuri Justi Jardim ◽

Diego Ramos Martines ◽

Leando Ryuchi Iuamoto ◽

Fernanda Nii ◽

...

Keyword(s):

Botulinum Toxin ◽

Ventral Hernia ◽

Botulinum Toxin A ◽

Chemical Components ◽

Toxin A ◽

Components Separation ◽

Para Determinar

Introdução: Hérnias ventrais são um resultado prevalente de cirurgias abdominais que podem representar um desafio cirúrgico em casos complexos, principalmente devido à tensão na musculatura da parede abdominal. A falha na correção cirúrgica pode levar a necessidade de um tratamento mais mórbido, além de um considerável impacto socioeconômico. Para que o risco de complicações seja menor, o uso da toxina botulínica A (TBA) pode ser uma alternativa pré-operatória para reduzir a tensão da parede abdominal, através de uma paralisia sustentada e reversível. Esta revisão crítica da literatura propõe avaliar o uso adjacente de TBA em correções de hérnias ventrais cirúrgicas. Métodos: Usando o banco de dados PubMed, as palavras-chave “ventral hernia” e “botullinum toxin” foram pesquisadas usando o operador “AND”. Os artigos foram selecionados com base em sua relevância e informações atualizadas. Os desfechos de interesse incluíram a mudança na largura do defeito da hérnia ventral e no comprimento do músculo da parede abdominal lateral, dor, recidiva de hérnia e complicações. Resultados: Foram encontrados 20 artigos de 2009 a 2018. Foram excluídos artigos devido à técnica irrelevante, uso de modelos animais e falta de dados sobre resultados. Redução da espessura da parede abdominal aumentando seu comprimento, menos dor perioperatória, redução de hérnia e correção com menos tensão foram observados após o uso da injeção de BTA. Nenhuma complicação ocorreu durante as aplicações. Conclusão: O uso de TBA parece ser uma alternativa promissora no manejo de hérnias ventrais devido à sua capacidade de reduzir a tensão na parede abdominal. No entanto, mais estudos são necessários para determinar a eficácia deste método.

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