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Pous-Serrano S, Bueno-Lledó J, García-Pastor P, Carreño-Sáenz O, Pareja-Ibars V, Bonafé-Diana S, Gea-Moreno AM, Martínez-Hoed J. Use of botulinum toxin type A in the prehabilitation of abdominal wall musculature for hernia repair: a consensus proposal. Cir Esp 2024; 102:391-399. [PMID: 38342140 DOI: 10.1016/j.cireng.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/03/2023] [Indexed: 02/13/2024]
Abstract
The prehabilitation of the abdominal wall through the infiltration of botulinum toxin type A, which induces temporary chemical denervation ("chemical component separation") in the lateral abdominal musculature, is a common practice in units specialized in abdominal wall surgery. However, its use for this indication is currently off-label. The main objective of this article is to describe a consensus proposal regarding indications, contraindications, dosages employed, potential side effects, administration method, and measurement of possible outcomes. Additionally, a proposal for an informed consent document endorsed by the Abdominal Wall Section of the Spanish Association of Surgeons is attached.
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Affiliation(s)
- Salvador Pous-Serrano
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - José Bueno-Lledó
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Providencia García-Pastor
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Omar Carreño-Sáenz
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Victoria Pareja-Ibars
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Santiago Bonafé-Diana
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Alba Maria Gea-Moreno
- Unidad de Cirugía de Pared y Corta Estancia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Jesús Martínez-Hoed
- Grupo Integrado de Trabajo en Hernia Compleja, Servicio de Cirugía General, Hospital R. A. Calderón Guardia, San José, Costa Rica
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Van Hoef S, Dries P, Allaeys M, Eker HH, Berrevoet F. Intra-abdominal hypertension and compartment syndrome after complex hernia repair. Hernia 2024; 28:701-709. [PMID: 38568348 DOI: 10.1007/s10029-024-02992-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/10/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE Abdominal compartment syndrome (ACS) is a well-known concept after trauma surgery or after major abdominal surgery in critically ill patients. However, ACS as a complication after complex hernia repair is considered rare and supporting literature is scarce. As complexity in abdominal wall repair increases, with the introduction of new tools and advanced techniques, ACS incidence might rise and should be carefully considered when dealing with complex abdominal wall hernias. In this narrative review, a summary of the current literature will highlight several key features in the diagnosis and management of ACS in complex abdominal wall repair and discuss several treatment options during the different steps of complex AWR. METHODS We performed a literature search across PubMed using the search terms: "Abdominal Compartment syndrome," "Intra-abdominal pressure," "Complex abdominal hernia," and "Ventral hernia." Articles corresponding to these search terms were individually reviewed by primary author and selected on relevance. CONCLUSION Intra-abdominal hypertension (IAH) and ACS require imperative attention and should be carefully considered when dealing with complex abdominal wall hernias, even without significant loss of domain. Development of a true abdominal compartment syndrome is relatively rare, but is a devastating complication and should be prevented at all cost. Current evidence on surgical treatment of ACS after hernia repair is scarce, but conservative management might be an option in the early phase and low grades of IAH. However, life-saving treatment by relaparotomy and open abdomen management should be initiated when ACS starts setting in.
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Affiliation(s)
- S Van Hoef
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium.
| | - P Dries
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - M Allaeys
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - H H Eker
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
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Barretto VRD, de Oliveira JGR, Brim ACS, Araújo RBS, Barros RA, Romeo ALB. Botulinum toxin A in complex incisional hernia repair: a systematic review. Hernia 2024; 28:665-676. [PMID: 37801164 DOI: 10.1007/s10029-023-02892-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE To evaluate the safety, efficacy, and short and long-term postoperative results of using BTA. METHODS We conducted a systematic review following the recommendations of the PRISMA method. We systematically reviewed the MEDLINE/PubMed and SCOPUS electronic databases for studies published between January 2010 and September 2021. This systematic review was registered in PROSPERO, with registration number CRD42021252445. RESULTS After applying the selection criteria, 11 relevant articles were selected. The total sample size was 1058 patients. Most studies aimed to assess the rate of fascial closure, followed by the rate of recurrence and reporting of postoperative complications, as well as the need for the components separation technique (CST). None of the studies reported serious complications from using BTA. Regarding fascial closure, all articles had rates above 75%, except for one. Surgical site events ranged between 19% and 29.4%. No recurrence in the group that used BTA was recorded in five studies. The other articles reported recurrence rates ranging from 6.4 to 11.4% in the groups that received BTA. The studies had varying follow-up times ranging from 1 to 49 months, with a mean of 18.6 months (± 11.2). CONCLUSION This review described most of the key points about the preoperative use of BTA in hernia repair. It can be concluded that the use of BTA is a safe and effective practice that promotes good short and long-term results. However, the limitations of the current literature prevent more accurate conclusions on the subject.
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Affiliation(s)
- V R D Barretto
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil.
| | | | - A C S Brim
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - R B S Araújo
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - R A Barros
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - A L B Romeo
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
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Giuffrida M, Biolchini F, Capelli P, Banchini F, Perrone G. Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:12650. [PMID: 38572390 PMCID: PMC10990139 DOI: 10.3389/jaws.2024.12650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/06/2024] [Indexed: 04/05/2024]
Abstract
Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10 cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.
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Affiliation(s)
- Mario Giuffrida
- Department of General Surgery, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Federico Biolchini
- General Surgery Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Patrizio Capelli
- Department of General Surgery, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Filippo Banchini
- Department of General Surgery, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Gennaro Perrone
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
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Amaral PHF, Macret JZ, Dias ERM, Carvalho JPV, Pivetta LGA, Ribeiro HB, Franciss MY, Silva RA, Malheiros CA, Roll S. Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure. Hernia 2024; 28:53-61. [PMID: 37563426 DOI: 10.1007/s10029-023-02848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/23/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. METHOD A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. RESULTS Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. CONCLUSION BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.
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Affiliation(s)
- P H F Amaral
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil.
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil.
| | - J Z Macret
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - E R M Dias
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - J P V Carvalho
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - L G A Pivetta
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - H B Ribeiro
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - M Y Franciss
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - R A Silva
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - C A Malheiros
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - S Roll
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
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Tarasiuk TV, Ioffe OY, Chukanov OM, Kryvopustov MS, Stetsenko OP. The use of botulinum toxin type a to prepare patients with large ventral hernias for laparoscopic hernioplasty: Our experience. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:1188-1197. [PMID: 39106379 DOI: 10.36740/wlek202406112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Aim: To study the effectiveness of BTA in a total dose of 100 IU as the preparation for patients with primary and incisional ventral hernias (VH). PATIENTS AND METHODS Materials and Methods: The prospective study included 59 patients with large VH (defect ³10 cm). All patients received 100 IU of BTA in abdominal wall muscles 4-5 weeks before surgery from June 2017 to December 2022. An average age of the patients was 59.13 ± 9.07 years, body mass index - 32.20 ± 4.95 kg/m2. RESULTS Results: An average width of the hernia defect after BTA decreased by 4.5 ± 1.11 cm (p<0.001). An average length of the hernia defect after BTA also decreased, without clinical significance. A significant increase in the length of the abdominal wall and a decrease in its thickness were observed. The abdominal cavity volume after BTA increased by 4.04 ± 4.55% (p=0.008) and the hernial sac volume decreased by 21.43 ± 16.57% (p=0.005). All patients underwent surgery with hernia defect suturing and without component separation: laparoscopic IPOM hernioplasty - 50 (84.7%) patients, open IPOM hernia repair - 7 (11.9%) patients, open sublay hernioplasty - 2 (3.4%) patients. There was no recurrence of hernia during 12 months after surgery. CONCLUSION Conclusions: The administration of 100 IU BTA allows to increase the length of the abdominal wall muscles and to perform laparoscopic IPOM hernioplasty for patients with large VH.
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Karkhaneh Yousefi AA, Pierrat B, Le Ruyet A, Avril S. Patient-specific computational simulations of wound healing following midline laparotomy closure. Biomech Model Mechanobiol 2023; 22:1589-1605. [PMID: 37024600 DOI: 10.1007/s10237-023-01708-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/01/2023] [Indexed: 04/08/2023]
Abstract
In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue recovers partially its mechanical strength and stiffness by gradually increasing the volume fraction of collagen fibers. Following the principles of the constrained mixture theory, we assumed that new collagen fibers are deposited at homeostatic tension while the already existing tissue undergoes a permanent deformation due to the effects of remodeling. The model was implemented in the finite-element software Abaqus® through a VUMAT subroutine and applied to a complex and realistic case: simulating wound healing following midline laparotomy closure. The incidence of incisional hernia is still quite significant clinically, and our goal was to investigate different conditions hampering the success of these procedures. We simulated wound healing over periods of 6 months on a patient-specific geometry. One of the outcomes of the finite-element simulations was the width of the wound tissue, which was found to be clinically correlated with the development of incisional hernia after midline laparotomy closure. We studied the impact of different suturing modalities and the effects of situations inducing increased intra-abdominal pressure or its intermittent variations such as coughing. Eventually, the results showed that the main risks of developing an incisional hernia mostly depend on the elastic strains reached in the wound tissue after degradation of the suturing wires. Despite the need for clinical validation, these results are promising for establishing a digital twin of wound healing in midline laparotomy incision.
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Affiliation(s)
| | - Baptiste Pierrat
- Mines Saint-Étienne, Université Jean Monnet, INSERM, U1059 SAINBIOSE, 42023, Saint-Étienne, France
| | | | - Stéphane Avril
- Mines Saint-Étienne, Université Jean Monnet, INSERM, U1059 SAINBIOSE, 42023, Saint-Étienne, France.
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Bueno-Lledó J, Martínez-Hoed J, Bonafé-Diana S, García-Pastor P, Torregrosa-Gallud A, Pareja-Ibars V, Carreño-Sáenz O, Pous-Serrano S. Complications related to the prehabilitation with preoperative pneumoperitoneum in loss of domain hernias: our experience in 180 consecutive cases. Hernia 2023:10.1007/s10029-023-02836-6. [PMID: 37432512 DOI: 10.1007/s10029-023-02836-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Progressive pneumoperitoneum (PPP) is useful tool in the preparation of patients with loss of domain hernias (LODH). The purpose of this observational retrospective study was to report our experience in the management of complications associated with the PPP procedure after treating 180 patients with LODH and to report preventive measures to avoid them. METHODS Of the 971 patients with a ventral incisional hernia operated on between June 2012 and July 2022, 180 consecutive patients with LODH were retrospectively analysed. Diameters of abdominal cavity, and volumes of incisional hernia and abdominal cavity were calculated from CT scan, based on the modified index of Tanaka. Complications related to the PPP procedure (catheter placement and following insufflations of air) were recorded by Clavien-Dindo classification. RESULTS Complications associated to PPP were 26.6%. No complications occurred during the administration of botulinum toxin (BT). Eighteen patients (10% of 180 patients) developed subcutaneous emphysema during the last days of the insufflations; there were 2 accidental perforations of the small bowel and four punctures with liver and splenic hematomas, detected during catheter placement; a laparotomy, however, was not needed because it was solved with conservative treatment. We diagnosed it as a peritoneum-cutaneous fistula due to the cutaneous atrophy secondary to chronic eventration. CONCLUSION PPP is a safe technique well tolerated by patients, although at the cost of some specific complications. Hernia surgeons must understand these complications to prevent them and to inform the LODH patient about their existence.
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Affiliation(s)
- J Bueno-Lledó
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain.
| | | | - S Bonafé-Diana
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
| | - P García-Pastor
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
| | - A Torregrosa-Gallud
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
| | - V Pareja-Ibars
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
| | - O Carreño-Sáenz
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
| | - S Pous-Serrano
- Unit of Abdominal Wall Surgery. Department of Digestive Surgery, Hospital Universitari i Politecnic "La Fe". University of Valencia, Calle Gabriel Miró 28, puerta 12, 46008, Valencia, Spain
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Dias ERM, Rondini GZ, Amaral PHF, Macret JZ, Carvalho JPV, Pivetta LGA, Malheiros CA, Roll S. Systematic review and meta-analysis of the pre-operative application of botulinum toxin for ventral hernia repair. Hernia 2023:10.1007/s10029-023-02816-w. [PMID: 37329437 DOI: 10.1007/s10029-023-02816-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/28/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE Surgical repair of large hernia defects requires detailed pre-operative planning, particularly in cases with loss of domain. This situation often hampers mid-line reconstruction, even after component separation, when the size of the hernia is disproportional to the volume of the abdominal area. In this case, other strategies may be needed to place the viscera back into the abdominal cavity after reducing the hernia sac. The administration of botulinum toxin prior to the surgical procedure has been indicated as an adjunct for more complex cases. This results in stretching of the lateral musculature of the abdomen, allowing midline approximation. In addition, the application of botulinum toxin alone has been investigated as a means of downstaging in the management of ventral hernias, thereby precluding component separation and enabling primary closure of the midline by placement of mesh within the retromuscular space using the Rives Stoppa technique. METHODS Systematic review of the literature for observational studies involving patients undergoing pre-operative application of botulinum toxin for ventral hernia repair was conducted according to the PRISMA guidelines. RESULTS Advance of the lateral musculature of the abdomen by an average of 4.11 cm with low heterogeneity, as well as low rates of surgical site infection (SSI), surgical site occurrences (SSO) and recurrence, was shown. CONCLUSION Pre-operative application of botulinum toxin for ventral hernia repair promoted an increase in the length of the lateral musculature of the abdomen which can help improve the outcomes of morbidity and recurrence.
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Affiliation(s)
- E R M Dias
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil.
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil.
| | - G Z Rondini
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
| | - P H F Amaral
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - J Z Macret
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - J P V Carvalho
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - L G A Pivetta
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - C A Malheiros
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
| | - S Roll
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Júnior, 61, Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
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Claessen JJM, Timmer AS, Hemke R, Atema JJ, Hompes R, Boermeester MA, Rutten MVH. A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction. Hernia 2023; 27:281-291. [PMID: 36239824 PMCID: PMC10126041 DOI: 10.1007/s10029-022-02692-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore how intramuscular injection of botulinum toxin A (BTA) affects the lateral abdominal wall (LAW) musculature, abdominal- and hernia dimensions, and muscle structure on computed tomography (CT) in patients scheduled for complex abdominal wall reconstruction (CAWR). METHODS Retrospective analysis of prospectively registered patients who received bilateral intramuscular BTA injections into all three muscles of the LAW. Only patients for which a CT was available before and 3-6 weeks after BTA treatment prior to surgery were analyzed. RESULTS Fifty-two patients were analyzed. Median hernia width in all patients decreased with 0.4 cm (IQR - 2.1;0.6) (p = 0.023). Median intra-abdominal transverse diameter increased with 0.9 cm (IQR - 0.2;3.3) (p = 0.001) and the intra-abdominal anterior-posterior diameter decreased with 0.5 cm (IQR - 1.3;0.5) (p = 0.017), making the abdomen more oval. Median LAW muscle length increased with 0.9 cm (IQR 0.0;2.4) per side (p < 0.001), muscle thickness decreased with 0.5 cm (IQR - 0.8;- 0.2) (- 25.0%) per side (p < 0.001), and muscle mass decreased with 3.9 cm2 (IQR - 6.4;-1.5) (- 15.8%) per side (p < 0.001). Median HU of the psoas muscles (density) increased with 4.8 HU (IQR 0.4;9.7) (10.3%) per side (p < 0.001). Effects of BTA were more pronounced in patients with a loss of domain (LoD) ≥ 20%. CONCLUSIONS The main effect of BTA injections is elongation and thinning of the LAW muscles, more than a decrease in hernia width. Concomitantly, the abdomen becomes more oval. An increase of psoas muscles density is seen, associated with offloading of the LAW muscles. Patients with large LoD have a proportionally higher effect of BTA.
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Affiliation(s)
- J J M Claessen
- Department of Surgery (Suite J1A-228), Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - A S Timmer
- Department of Surgery (Suite J1A-228), Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - R Hemke
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Atema
- Department of Surgery (Suite J1A-228), Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery (Suite J1A-228), Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery (Suite J1A-228), Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands.
| | - M V H Rutten
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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Malaussena Z, Pittala K, Diab ARF, Docimo S. Prediction models in hernia repair: a systematic review. Surg Endosc 2023; 37:3364-3379. [PMID: 36595065 DOI: 10.1007/s00464-022-09842-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hernias can present with unique challenges when it comes to management and repair. Prediction models can be a useful tool for clinicians to better anticipate and understand the severity of a hernia, the type of surgical technique, or presurgical planning that may be required to treat the patient, and the risk of complications. Our goal is to evaluate and consolidate prediction models in hernia repair present in the literature for which physicians can reference to best improve patient outcomes and postoperative management. METHODS We performed a literature search in PubMed using keywords, "rectus width to defect width ratio," "predicting myofascial release," "computed tomography hernia repair prediction," "component separation radiology prediction hernia," "fat volume and hernia repair," "body morphometrics and Query hernia repair," "body morphometrics and reherniation," "computed tomography findings and risk of emergency hernia repair," "loss of domain and hernia radiology," and "volumetry and hernia repair." We searched for publications that used radiographic parameters to predict hernia severity, interventions, and outcomes. RESULTS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found twenty-three studies related to prediction models in hernia repair published between 2000 and 2021. We summarized studies pertaining to predicting acute care, predicting operative planning with loss of domain and component separation, predicting complications, paraesophageal hernia predictions, and predicting postoperative respiratory complications. CONCLUSION Radiographic prediction models can be an objective and efficient way for surgeons to analyze hernias and better understand a patient's situation so that they can inform patients about the best treatment options and the risk of complications.
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Affiliation(s)
- Zachary Malaussena
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA.
| | - Karthik Pittala
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Abdul-Rahman F Diab
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Salvatore Docimo
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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12
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Timmer AS, Claessen JJM, Boermeester MA. Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2022; 1:10722. [PMID: 38314165 PMCID: PMC10831687 DOI: 10.3389/jaws.2022.10722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/31/2022] [Indexed: 02/06/2024]
Abstract
All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.
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Affiliation(s)
- Allard S. Timmer
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Jeroen J. M. Claessen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam, Netherlands
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13
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Whitehead-Clarke T, Windsor A. The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure. Front Surg 2021; 8:753889. [PMID: 34660688 PMCID: PMC8517326 DOI: 10.3389/fsurg.2021.753889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 01/10/2023] Open
Abstract
Abdominal wall surgeons have developed a host of tools to help facilitate fascial closure. Botulinum toxin A is one of the most recently identified treatments and has grown in popularity over recent years; showing great promise in a number of case series and cohort studies. The toxin paralyses lateral abdominal wall muscles in order to increase laxity of the tissues—facilitating medialisation of the rectus muscles. Several research groups around the world are developing expertise with its use-uncovering its potential. We present a review of the relevant literature over the last two decades, summarising the key evidence behind its indications, dosing and effects.
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Affiliation(s)
- Thomas Whitehead-Clarke
- Centre for 3D Models of Health and Disease, Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Alastair Windsor
- Alastair Windsor, Princess Grace Hospital, HCA Healthcare, London, United Kingdom
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14
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Timmer AS, Claessen JJM, Atema JJ, Rutten MVH, Hompes R, Boermeester MA. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction. Hernia 2021; 25:1413-1425. [PMID: 34546475 PMCID: PMC8613151 DOI: 10.1007/s10029-021-02499-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/31/2021] [Indexed: 01/15/2023]
Abstract
Purpose To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome. Methods PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients. Results We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200–300 units of Botox® are injected at 3–5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0–4.3, I2 = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2–6.8, I2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02–1.16, I2 = 0%, p = 0.02)]. Conclusion The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246). Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02499-1.
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Affiliation(s)
- A S Timmer
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, Location AMC, Suite J1A-228, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - J J M Claessen
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, Location AMC, Suite J1A-228, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - J J Atema
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, Location AMC, Suite J1A-228, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - M V H Rutten
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, Location AMC, Suite J1A-228, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, Location AMC, Suite J1A-228, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
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15
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Eucker D, Rüedi N, Luedtke C, Stern O, Niebuhr H, Zerz A, Rosenberg R. Abdominal Wall Expanding System. Intraoperative Abdominal Wall Expansion as a Technique to Repair Giant Incisional Hernia and Laparostoma. New and Long-Term Results From a Three-Center Feasibility Study. Surg Innov 2021; 29:169-182. [PMID: 34530655 DOI: 10.1177/15533506211041477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The abdominal wall expanding system (AWEX) was first applied in 2012 and published in 2017. This novel technique was developed to reconstruct complex incisional hernias and residual skin-grafted laparostoma after treatment of an open abdomen, when primary midline closure was impossible. The main aim was the anatomical reconstruction of the abdominal wall and the avoidance of dissecting techniques (component separation). METHODS Between 2012 and 2019, 33 patients underwent AWEX hernia repair in three certified hernia centers. The retracted abdominal wall was stretched with the AWEX system intraoperatively for approximately 30 min. Hernia size was measured preoperatively, on CT, and intraoperatively. The gain in length on the lateral abdominal wall (decrease in width of the defect) after stretching and any residual midline gap were determined in the OR. RESULTS 33 patients underwent AWEX procedures. Six cases were evaluated separately because of additional procedures (TAR, four cases) and preoperative application of botulinum toxin (two cases). The median (95% confidence interval) measured width of hernia defects was 13 (12-16) cm, the median gain in length on the lateral abdominal wall was 12 (10-15) cm. After median follow-up of 29 (12-54) months, one recurrence from the broken mesh was observed. No method-related complications occurred. CONCLUSION Based on the 2017 and current results, the AWEX system represents an alternative or supplemental procedure to current techniques for complex abdominal wall reconstruction. The system proved again to be time-saving, safe, effective, and easy to learn. Further studies with enhanced technology are in progress.
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Affiliation(s)
| | - Nadine Rüedi
- 367307Kantonsspital Baselland, Liestal, Switzerland
| | | | | | | | - Andreas Zerz
- 273720Clinic Stephanshorn, St Gallen, Switzerland
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16
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Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia. Hernia 2021; 26:109-121. [PMID: 34184138 DOI: 10.1007/s10029-021-02428-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess 7-year outcomes after complex ventral hernia (CVH) repair using pre-operative Botulinum toxin A (BTA) injection and the Macquarie System of management. METHODS Clinical examination and functional non-contrast abdominal CT scans were used to assess complications and recurrences encountered in a prospective series of 88 consecutive CVH repairs using pre-operative BTA injection (200 or 300 units) between November 2012 and December 2019. Pre-operative progressive pneumoperitoneum (PPP) and/or component separation (CS) were also used in some cases. RESULTS All hernia defects (mean transverse width 12.9 ± 5.2 cm) were successfully closed using either laparoscopic or laparoscopic-assisted open techniques facilitated by pre-operative BTA injection. The mean pre-operative post-BTA lateral oblique length gain was 4.7 ± 2.2 cm/side (p < 0.001). In 43 patients with defects < 12 cm wide, closure was achieved using BTA-only in 33 (76.7%), BTA + PPP in 2 (4.7%), BTA + CS in 5 (11.6%) and BTA + PPP + CS in 3 (7.0%). In the remaining 45 patients with defects [Formula: see text] 12 cm wide, closure was achieved using BTA-only in 9 (20.0%), BTA + PPP in 11 (24.4%), BTA + CS in 5 (11.1%) and BTA + PPP + CS in 20 (44.4%). There was a significant correlation between increasing defect size and the need for 2 or more CVH closure procedures (χ2 = 25.28, p < 0.0005). There were no BTA complications. Two patients developed midline hernia recurrences. CONCLUSION Pre-operative BTA injection of the abdominal wall is a safe procedure that facilitates hernia defect closure and reduces the need for CS, especially when defect size is less than 12 cm. BTA may also decrease the rate of hernia recurrence.
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Adjunct botox to preoperative progressive pneumoperitoneum for incisional hernia with loss of domain: no additional effect but may improve outcomes. Hernia 2021; 25:1507-1517. [PMID: 33686553 DOI: 10.1007/s10029-021-02387-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/26/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Incisional hernia with loss of domain (IHLD) remains a surgical challenge. Its management requires complex approaches including specific preoperative and intra-operative techniques. This study focuses on the interest of adding preoperative botulinum toxin A (BTA) injection to preoperative progressive pneumoperitoneum (PPP), compared to PPP alone. MATERIAL Patients between January 2015 and March 2020 with IHLD who underwent pre-operative preparation were included. Their baseline characteristics were retrospectively analyzed, along with the characteristics of their incisional hernia before and after preparation including CT-scan volumetry. Intra-operative data, early post-operative outcomes, surgical site occurrences (SSOs) including surgical site infection (SSI) were recorded. RESULTS Four hundred and fifty (450) patients with incisional hernia were operated, including 41 patients (9.1%) with IHLD, 13 of which had both BTA and PPP, while 28 had PPP only. Both groups were comparable in term of patients and IHLD characteristics. Median increase in the volume of the abdominal cavity (VAbC) was + 55% for the entire population (+ 58.3% for the BTA-PPP group, p < 0.0001 and + 52.8% for the PPP-alone group, p < 0.0001) although the increase in volume was not different between the two groups (p = 0.99). Complete fascial closure was achieved in all patients. SSOs were more frequent in the PPP-alone group than in the BTA-PPP group (17 (60.7%) versus 3 (23.1%) patients, respectively, p = 0.043). CONCLUSION BTA and PPP are both useful in pre-operative preparation for IHLD. Combining both significantly increases the volume of abdominal cavity but associating BTA to PPP does not add any volumetric benefit but may decrease the post-operative SSO rate.
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Prehabilitation of complex ventral hernia patients with Botulinum: a systematic review of the quantifiable effects of Botulinum. Hernia 2020; 25:1427-1442. [PMID: 33215244 DOI: 10.1007/s10029-020-02333-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Complex ventral hernia repair (CVHR) encompasses patient optimization, primary fascial closure (PFC), mesh reinforcement and component separation technique (CST), if needed. High rates of complications after CST are still reported. Prehabilitation by managing pre-operative modifiable risk factors, like abdominal wall compliance, possibly reduces these rates. Compliance can be modified by intramuscular injection of Botulinum in the lateral abdominal wall muscles (LAWM). Paralysis leads to elongation of these muscles, which may facilitate PFC and/or prevent CST. Evidence to use Botulinum in hernia patients is scarce and fragmented. An update of evidence for the effect of Botulinum is presented. METHODS A multi-database search was conducted for Botulinum studies in ventral hernia patients. A systematic review was performed to describe its primary effect on compliance (LAWM elongation) and secondary effects like PFC ± CST rate, complications and recurrence. RESULTS 14 studies were included (377 patients) with a HDW of median 12 (10-15) cm. A typical intervention consisted of 200-300 U Botulinum in 3 points per hemi-abdomen under US guidance, > 2 weeks pre-operatively and evaluated by CT just before the operation. The primary effect was a median LAWM elongation of 4.0 cm per side without complications of the injection (four studies, 107 patients). The median PFC rate was 100%, CST rate 38%, wound-related complications 19%, medical complications 18% and recurrence 0% (14 studies). CONCLUSION Botulinum safely elongates the abdominal wall muscles, but the level of evidence available remains low. Any patient in whom PFC is expected to be difficult, could be a candidate for prehabilitation with Botulinum.
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