Kristen E Elstner, MBBS, MS1, John W Read, FRANZCR2, Peter H Cosman, FRACS2, Anita Jacombs, MBBS, PhD1, Omar Rodriguez-Acevedo, MBBS1, Nabeel Ibrahim, FRACS, FACS1. 1Hernia Institute Australia, Edgecliff, Australia, 2Macquarie University Hospital, Sydney, Australia
INTRODUCTION: Despite recent advances in the operative management of complex ventral hernia, these remain a significant challenge for surgeons. Closure of large defects in the unprepared abdomen can have serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 50 consecutive patients who were administered preoperative Botulinum Toxin A (BTA) injections to provide flaccid paralysis of the abdominal wall muscles, facilitating closure and repair.
METHODS: This was a prospective observational study of 50 patients who underwent ultrasound guided intramuscular injections of BTA to the lateral abdominal oblique muscles prior to elective laparoscopic ventral hernia repair between January 2013 and September 2016. Ventral hernias were either incisional or traumatic in origin. BTA was injected under ultrasound guidance into all 3 layers of the lateral abdominal wall muscles 1 – 4 weeks preoperatively. Serial non-contrast abdominal CT imaging was performed pre- and post-BTA injection to evaluate changes in fascial defect size, loss of domain, and length and thickness of the lateral abdominal wall musculature. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) between January 2013 and September 2016.
RESULTS: 50 patients received BTA injections at predetermined sites in the lateral abdominal muscles, which were well tolerated. Mean age was 58 years, with a mean BMI 32 kg/m2 (range 22 – 54). Maximum defect size was 24 x 27cm. A comparison of baseline imaging (pre-BTA) to preoperative (post-BTA) imaging demonstrated an increase in mean lateral abdominal wall length from 16.7cm to 20.4cm per side, a mean gain of 3.7cm/side (range 0-11.7cm/side) (p<0.0001). This corresponds to an unstretched mean gain of 7.4cm of lateral abdominal wall length, as measured on resting CT images. Laparoscopic/LOL repair and fascial closure was achieved in all cases, with no post-operative sequelae of raised intra-abdominal pressures. There have no hernia recurrences to date.
CONCLUSION: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. The flaccid paralysis imparted by BTA relaxes, elongates and thins the chronically contracted abdominal musculature and reduces lateral traction forces, and by doing so, facilitates laparoscopic repair and fascial closure of large defects under minimal tension.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80071
Program Number: S052
Presentation Session: Ventral Hernias
Presentation Type: Podium