P008 SYNCHRONOUS SURGICAL TREATMENT OF MORBID OBESITY AND COMPLEX VENTRAL HERNIA AFTER PROGRESSIVE PNEUMOPERITONEUM AND BOTULINUM TOXIN A INJECTION

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.

Download Full-text

Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair

Hernia ◽

10.1007/s10029-019-01939-3 ◽

2019 ◽

Vol 24 (2) ◽

pp. 287-293 ◽

Cited By ~ 5

Author(s):

K. E. Elstner ◽

J. W. Read ◽

J. Saunders ◽

P. H. Cosman ◽

O. Rodriguez-Acevedo ◽

...

Keyword(s):

Botulinum Toxin ◽

Hernia Repair ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

Botulinum Toxin A ◽

Toxin A ◽

Complex Ventral Hernia

Download Full-text

Preoperative abdominal muscle elongation with botulinum toxin A for complex incisional ventral hernia repair

ANZ Journal of Surgery ◽

10.1111/ans.13258 ◽

2015 ◽

Vol 86 (1-2) ◽

pp. 79-83 ◽

Cited By ~ 36

Author(s):

Faisal Farooque ◽

Anita S. W. Jacombs ◽

Emmanouel Roussos ◽

John W. Read ◽

Anthony N. Dardano ◽

...

Keyword(s):

Botulinum Toxin ◽

Hernia Repair ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

Botulinum Toxin A ◽

Abdominal Muscle ◽

Toxin A ◽

Incisional Ventral Hernia

Download Full-text

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

Hernia ◽

10.1007/s10029-020-02226-2 ◽

2020 ◽

Cited By ~ 2

Author(s):

Y. Yurtkap ◽

M. M. J. van Rooijen ◽

S. Roels ◽

J. M. L. Bosmans ◽

O. Uyttebroek ◽

...

Keyword(s):

Botulinum Toxin ◽

Hernia Repair ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

Botulinum Toxin A ◽

Toxin A ◽

Giant Ventral Hernia

Download Full-text

The Effect of Bariatric Surgery Volume on General Surgery Outcomes for Morbidly Obese Patients

Journal of Obesity ◽

10.1155/2021/8945091 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Katheryn Hope Wilkinson ◽

Ruizhe Wu ◽

Aniko Szabo ◽

Rana Higgins ◽

Jon Gould ◽

...

Keyword(s):

Bariatric Surgery ◽

Morbid Obesity ◽

Hernia Repair ◽

Ventral Hernia ◽

General Surgery ◽

Ventral Hernia Repair ◽

High Volume ◽

Morbidly Obese ◽

Obese Patients ◽

Procedure Volume

Introduction. Bariatric surgery performed at high volume centers decreases length of stay, cost, and morbidity and mortality. The effect of a high volume of bariatric surgery procedures on outcomes may extend not just to bariatric surgery but to any general surgical procedure in morbidly obese patients. We hypothesized that patients with morbid obesity (body mass index >40 kg/m2) undergoing common, nonbariatric general surgery would have decreased morbidity and mortality at centers performing high volumes of bariatric surgery. Methods. The 2016 National Inpatient Sample (NIS) was used to identify the number of laparoscopic gastric bypass and sleeve gastrectomy performed at each hospital. Hospitals were classified as high volume bariatric hospitals (HVBH) ≥10 reported cases (50 actual)/year or low volume bariatric hospitals (LVBH) <10 reported cases (50 actual)/year, as NIS reports a 20% sample of actual cases. Patients with morbid obesity undergoing laparoscopic or open appendectomy, cholecystectomy, or ventral hernia repair were included for analysis. Propensity scores were developed based on available demographics, comorbidities, and hospital procedure volume. Postoperative complications during the index hospital admission, determined by ICD-10 code, were compared using inverse propensity weights. Differences were considered significant with a p value of <0.05. Results. The total number of general surgery patient cases analyzed was 14,028 from 2,482 hospitals, representing 70,140 admissions. The cohort of patients undergoing operations treated at HVBH were younger ( p = 0.03 ) with higher rates of COPD ( p = 0.04 ). Patients at LVBH had higher rates of nicotine dependence ( p = 0.0001 ) and obstructive sleep apnea ( p < 0.001 ). On propensity-weighted analysis adjusting for preoperative comorbidities and hospital procedure volume, there were significantly higher rates of multiple postprocedure complications at LVBH, specifically, postprocedure respiratory failure for patients undergoing elective laparoscopic cholecystectomy, elective ventral hernia repair with mesh and appendectomy. Conclusion. Patients with morbid obesity may have an advantage in having general surgery procedures at HVBH. HVBH may have a volume-outcomes relationship where the hospital and staff familiarity with the management principles required to minimize the postoperative risk associated with morbid obesity and improve patient outcomes.

Download Full-text

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.

Download Full-text

Laparoscopic Ventral Hernia Repair Combined with Sleeve Gastrectomy in Morbidly Obese Patients: Early Outcomes

The Surgery Journal ◽

10.1055/s-0039-1694979 ◽

2019 ◽

Vol 05 (03) ◽

pp. e87-e91 ◽

Cited By ~ 2

Author(s):

Ahmed M.S.M. Marzouk ◽

Heba O.E. Ali

Keyword(s):

Sleeve Gastrectomy ◽

Hernia Repair ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

Mesh Size ◽

Laparoscopic Ventral Hernia Repair ◽

Abdominal Pressure ◽

Morbidly Obese ◽

Obese Patients ◽

The Mean

Background Morbid obesity is a serious chronic condition with, among other symptoms, increased intra-abdominal pressure and subsequent abdominal wall hernias. The optimal management of these manifestations is still controversial. The objective of this study was to assess the early postoperative outcomes of a surgical approach combining laparoscopic ventral hernia repair (LVHR) with sleeve gastrectomy in morbidly obese patients. Methods In this retrospective study, we reviewed the files of patients who are obese with a primary ventral hernia of less than 10 cm in diameter who received simultaneous laparoscopic sleeve gastrectomy and LVHR at our institution between February 2016 and July 2018. LVHR was performed using an intraperitoneal only mesh. The individual mesh size was chosen based on the number and size of the defects. Clinical and radiological follow-ups were performed between 9 and 15 months. Results A total of 15 patients were included. Five of them were males. The mean body mass index was 45.2 kg/m2 (range: 38.7–56.2 kg/m2). The mean hernia defect size was 2.6 cm (range: 1.3–4.2 cm). Mesh size was 10 × 15 cm in five, 20 × 15 cm in seven, and 25 cm× 20 cm in three patients. All patients were discharged without complications on the second postoperative day. Mean follow-up was at 12 months. One patient presented with hernia recurrence 14 months after surgery and four patients presented with self-limited seroma. Conclusion Despite ambiguous guidelines and ongoing debate regarding simultaneous bariatric surgery and ventral hernia repair, the short-term outcomes of this approach appeared promising, provided that patients are carefully selected and receive an individually tailored approach.

Download Full-text