Abstract
Background
Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair.
Methods
This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh.
Results
Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0–11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date.
Conclusions
Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects.
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Kristen E. Elstner, Omar Rodriguez-Acevedo, Peter H. Cosman, Anita S. W. Jacombs, Michael Edye, Aaron Zea, Tillman Boesel, Dean J. Mikami, and Nabeel Ibrahim declare no conflict of interest or financial ties to disclose. John W. Read declares conflict of interest related to the submitted work as he receives financial remuneration from Medicare as a radiologist. Anthony N. Dardano declares conflict of interest not directly related to the submitted work in the form of Honorarium from biomedical companies Cook, Synthes, and KCI.
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Elstner, K.E., Read, J.W., Rodriguez-Acevedo, O. et al. Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia. Surg Endosc 31, 761–768 (2017). https://doi.org/10.1007/s00464-016-5030-7
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DOI: https://doi.org/10.1007/s00464-016-5030-7