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

Kristen E Elstner, MBBS1, Anita S Jacombs, MBBS, PhD2, John W Read, FRANZCR3, Anthony N Dardano, FACS4, Peter Cosman, FRACS1, Michael Edye, FRACS5, Omar Rodriguez, MBBS6, Nabeel Ibrahim, FRACS6. 1Macquarie University Hospital, Sydney, Australia, 2Faculty of Medicine & Health Sciences, Macquarie University, Australia, 3Castlereagh Imaging, St Leonards, Australia, 4Boca Raton Regional Hospital, Boca Raton, Florida USA, 5Professor of Surgery and Chair, University of Western Sydney, 6Hernia Institute Australia, Edgecliff, Australia

Introduction: The operative management of large, complex ventral hernia is a significant challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. We report initial outcomes of preoperative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce prolonged flaccid paralysis, in order to facilitate laparoscopic repair of complex ventral hernia.

Methods: This was a prospective evaluation of 27 patients presenting with complex incisional or traumatic ventral hernia, with minimum linear defects (or sum of multiple defects) measuring 5cm or greater, as measured on abdominal CT imaging. Patients were administered ultrasound-guided BTA injections bilaterally to all three layers of the lateral abdominal wall musculature prior to elective hernia repair. Injections were performed in a single outpatient session, 1-4 weeks preoperatively, according to pre-determined positions on the antero-lateral abdominal wall. Serial non-contrast abdominal CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size, and abdominal wall muscle belly thickness and length. All hernias were successfully repaired between January 2013 and August 2015.

Results: 27 patients received preoperative BTA injections, which were well tolerated with no complications. Mean age was 58 years (range 36 – 84 years), with a mean BMI of 31 kg/m2 (range 22 – 46). Hernia defects ranged from 5 x 9 cm to 24 x 27cm. Comparison of pre-BTA and post-BTA abdominal CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7cm pre-BTA to 19.9cm post-BTA (p<0.0001), with a mean unstretched length gain of 4.2 cm/side (range 0 – 11.7 cm/side). All hernias were repaired laparoscopically or laparoscopic-assisted using mesh, with no post-operative complications arising from raised intra-abdominal pressure, wound dehiscence, or early recurrence. Median length of hospital stay was 10 days.

Conclusion: Chemical component relaxation using BTA is a safe and effective technique in the preoperative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes laterally retracted abdominal muscles and enables laparoscopic closure of large fascial defects. The prolonged duration of action of BTA reduces lateral traction forces on the healing wound, thereby minimizing risk of early post-operative complications such as early hernia recurrence. Further long term follow-up is required, but early data is encouraging.

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