A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction

Minimally Invasive Stapled Abdominal Wall Repair: A New Surgical Technique

Background: Diastasis recti (DR) is a common condition, especially in women after pregnancy, often associated with concomitant hernia defects and defined as a rupture of the midline and a separation of the rectus muscle more than 2 cm. Symptoms related to this are low back pain, urinary incontinence and pelvic prolapse, as well as abdominal bulging and core instability. We analyzed clinical and functional outcomes after treatment of DR alone or associated with midline hernias in 219 patients who underwent a midline reconstruction using miSAR® technique (minimally invasive stapled abdominal wall reconstruction). Methods: Between April 2019 and April 2022, 219 patients were treated with miSAR®. All patients were requested to quantify preoperative and postoperative functional symptoms (urinary incontinence, low back pain, abdominal swelling, and respiratory distress). Results: Twenty-seven men and 192 women underwent the miSAR® technique. The mean body mass index was 23.9 kg/m2. We performed the miSAR® technique in patients affected by incisional midline hernia and umbilical hernia alone or associated with DR. Composite mesh was used in 91.8% of cases. The average operating time was 90 minutes. Seven percent of the patients had postoperative complications, including two retromuscular hematomas, two retromuscular seromas, and one postoperative bleeding event. Two patients were readmitted for bowel obstruction. After surgery, there was symptomatic improvement in urinary incontinence, low back pain, respiratory symptoms, and abdominal swelling; this improvement was confirmed at 6 months and at 1- and 2-year follow-up. At the 1-year follow-up, the overall recurrence rate was 2.83%. Conclusion: miSAR® is a feasible and effective technique and shows promising results in the treatment of DR and ventral hernia. Possible enhancements include use of preoperative Botox to treat defects larger than 6 cm. Multicentric analysis is needed to validate the technique, and longer follow-up is required to assess the recurrence rate.

Use of botulinum toxin type A in the prehabilitation of abdominal wall musculature for hernia repair: a consensus proposal

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.

[The use of botulinum toxin in hernia surgery: results of a survey in certified hernia centers]

BACKGROUND

Botulinum toxin application into the abdominal wall prior to major hernia repair can reduce the complexity of surgery and has been increasingly used in recent years, even if it is an off-label use.

OBJECTIVE

To what extent is botulinum toxin used in hernia surgery in German-speaking countries and what is the current evidence in the literature?

MATERIAL AND METHODS

In a voluntary online survey of German Society for General and Visceral Surgery (DGAV)-certified competence centers and reference centers for hernia surgery, aspects of botulinum toxin application were surveyed and the results analyzed.

RESULTS

A total of 57 centers took part in the survey, of which 27 (47%) use botulinum toxin. The main reasons for not using it were lack of experience and reimbursement. Of the centers 85% have treated less than 50 patients with botulinum toxin. The main indications were midline hernias (M2-4 according to the EHS classification) with a hernia gap > 10 cm (W3 according to EHS classification) and loss of domain situations. The application was predominantly ultrasound-guided by designated hernia surgeons with 100-200 Allergan or 500 Speywood units 4-6 weeks preoperatively and without complications related to the botulinum toxin application.

CONCLUSION

Botulinum toxin injections in hernia surgery appear to be safe and effective. Ultrasound-guided preoperative bilateral administration is supported by the available data. Specific course and information formats should be offered by the hernia surgery institutions.

The effect of preoperative botulinum toxin a injection on traction force during hernia repair: a prospective, single-blind study, intra-patient comparison using contralateral side as a control

PURPOSE

Ventral hernias are a common complication of laparotomy, posing challenges particularly when primary fascial closure is unattainable. Although chemical component separation using preoperative botulinum toxin A (BTX) injections has emerged as a promising adjunct, objective evidence of its efficacy remains limited. This study aimed to objectively assess the effect of preoperative BTX on traction force during ventral hernia repair.

METHODS

A prospective, single-blind study was conducted on patients with midline incisional hernias following liver transplantation. BTX was administered unilaterally, and the traction force required to medially advance the anterior rectus sheath was measured intraoperatively. Pre- and post-injection CT scans were analyzed for changes in hernia size and LAW muscle measurements. Statistical analyses were performed to evaluate traction force differences between BTX-injected and uninjected sides.

RESULTS

Ten patients underwent hernia repair with primary fascial closure achieved in all cases. Comparison of pre- and post-injection CT scans showed no significant changes in hernia size. LAW muscle length increased by 1.8 cm, while thickness decreased by 0.2 cm. Intraoperative traction force measurements revealed a significant reduction on the BTX-injected side compared to the uninjected side (p < 0.0001). The traction force ratio on the BTX-injected to the uninjected side averaged 57%, indicating the efficacy of BTX in reducing tension.

CONCLUSION

Preoperative BTX significantly reduces traction force during ventral hernia repair, highlighting its potential as an adjunctive therapy in complex cases. While challenges remain in patient selection and outcome assessment, BTX offers a promising avenue for enhancing abdominal wall reconstruction outcomes and reducing surgical complications.

Quantifying postoperative recovery using wearable activity monitors following abdominal wall surgery: The AbTech trial

PURPOSE

This work aimed to investigate the validity of wearable activity monitors (WAMs) as an objective tool to measure the return toward normal functional mobility following abdominal wall surgery. This was achieved by quantifying and comparing pre- and postoperative physical activity (PA).

METHODS

A multicenter, prospective, observational cohort study was designed. Patients undergoing abdominal wall surgery were assessed for eligibility and consent for study participation was obtained. Participants were asked to wear a WAM (AX3, Axivity) on the wrist of their dominant hand at least 48 hours pre-operatively, for up to 2 weeks postop, and again after 6 months postop for 48 hours.

RESULTS

A cohort of 20 patients were recruited in this validation study with a mean age of 47.3 ± 13.0 years. Postoperation, the percentage median PA (±IQR) dropped to 32.6% (20.1), whereas on day 14, PA had reached 64.6% (22.7) of the preoperative value providing construct validity. Activity levels at >6 months postop increased by 16.4% on an average when compared to baseline preoperative PA (p = 0.046).

CONCLUSION

This study demonstrates that WAMs are valid markers of postoperative recovery following abdominal wall surgery. This was achieved by quantifying the reduction in PA postoperation, which has not been previously shown. In addition, this study suggests that abdominal wall surgery may improve the patient's quality of life via increased functional mobility at 6 months postop. In the future, this technology could be used to identify the patient and surgical factors that are predictors of outcome following abdominal wall surgery.

Prevention of component separation in complex abdominal wall surgery by Botox prehabilitation: a propensity-matched study

AIM

To facilitate midline fascial closure in complex abdominal wall surgery, component separation techniques (CST) are usually required. However, CST is associated with an enlarged morbidity. Prehabilitation could increase the compliance of the abdominal wall and thereby decrease the necessity of myofascial release. This can be accomplished by administration of botulinum toxin type A (BTA) in the lateral abdominal wall musculature. The aim of this study was to determine the effect of BTA on the subsequent necessity to perform CST in patients with complex abdominal wall hernias.

METHODS

Patients with a complex abdominal wall hernia, planned to undergo CST between July 2020 and November 2022 were included. Outcome of procedures with 300U of BTA 4 (2-6) weeks prior to surgery, were retrospectively analyzed by comparison with propensity matched subjects of an historical group. Hernia width difference was assessed by CT and operative details were included.

RESULTS

A total of 13 patients with a median hernia width of 12 cm (IQR 9-14, range 24) were prehabilitated with BTA between July 2020 and November 2022. A CST was planned for all, however not required in 6/13 patients (46%) to accomplish midline fascial closure. A mean elongation of lateral abdominal wall musculature of 4.01 cm was seen in patients not requiring CST. Compared to the propensity score matched control group, a 27% reduction (p = 0.08) in the need for CST was observed.

CONCLUSION

There is a tendency for decrease of necessity for CST by preoperatively administered BTA in patients with complex abdominal wall defects. Although small, as this study used propensity matched comparison, further exploration of BTA should be encouraged.

Intra-abdominal hypertension and compartment syndrome after complex hernia repair

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.

Botulinum toxin A in complex incisional hernia repair: a systematic review

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.

Exploring Variable Approaches in Complex Hernia Repair: A Comprehensive Literature Review

Surgeons have long grappled with categorizing complex hernias, leading to varied interpretations and fluctuating incidence rates. Complex Abdominal Wall Reconstruction (CAWR) addresses repairs for large hernias, with defined factors including size, previous repairs, mesh placement, infections, and comorbidities. This review explores pivotal surgical techniques for complex hernia repair, starting with Preoperative Progressive Pneumoperitoneum (PPP) and progressing to innovative methods like Botulinum Toxin Type A. Mesh fixation, both open and laparoscopic, plays a crucial role, with synthetic and biological mesh options discussed. Hybrid techniques and the "sandwich" approach are proposed for intricate cases. Each technique presents advantages and limitations, emphasizing the ongoing quest for optimal outcomes.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations

Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure

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.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

Botox in below knee amputation for the management of post-operative contracture: a systematic review

During the 1970s, scientists first used botulinum toxin to treat strabismus. While testing on monkeys, they noticed that the toxin could also reduce wrinkles in the glabella area. This led to its widespread use in both medical and cosmetic fields. The objective of the study was to evaluate the potential use of Botox in managing post-operative contracture after below-knee amputation. We conducted a systematic review In Pubmed, Cochrane Library, Embase, and Google Scholar using the MESH terms Botox, botulinum toxin, post-operative contracture, amputation, and below knee amputation. Our goal was to evaluate the potential use of Botox to manage post-operative contracture in patients who have undergone below-knee amputation. Our findings show evidence in the literature that Botox can effectively manage stump hyperhidrosis, phantom pain, and jumping stump, but no clinical trial has been found that discusses the use of Botox for post-operative contracture. Botox has been used in different ways to manage spasticity. Further studies and clinical trials are needed to support the use of Botox to manage this complication.

[Loss of domain and reduction in median suture tension]

BACKGROUND

Abdominal wall reconstruction in large incisional hernia/laparostoma poses a particular challenge. A loss of domain is the extreme form of intestinal volume displacement. The challenge lies in overcoming retraction of the lateral abdominal muscles.

OBJECTIVE

Experienced surgeons have access to a variety of techniques aimed at gaining lateral length along the abdominal wall or reducing suture tension at the midline. These techniques are intended to facilitate reconstruction even in complex cases and are outlined in this article from a practical perspective.

MATERIAL AND METHODS

The application of botulinum toxin A (BTA) and progressive pneumoperitoneum (PPP) are described as preoperative methods to gain abdominal wall length. Peritoneal flaps, intraoperative fascial traction (IFT) and component separation including transversus abdominis muscle release (TAR) are available for the surgical reconstruction of the abdominal wall. Bridging and the intraperitoneal onlay mesh approach are fallback techniques. All these techniques were integrated into a practical algorithm for complex abdominal wall reconstruction including preoperative and postoperative care and assessed by the authors with respect to effort, effectiveness and complexity.

RESULTS AND CONCLUSION

In the opinion of the authors, the status of complex abdominal wall reconstruction is currently best described by a combination of the most effective and proven techniques in terms of a "categorical algorithm". The combination of BTA, IFT and TAR presently appears to be the most effective method; however, experience and expertise are a prerequisite.

The use of botulinum toxin type a to prepare patients with large ventral hernias for laparoscopic hernioplasty: Our experience

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.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin

INTRODUCTION

Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience.

METHODS

patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect.

RESULTS

while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects.

CONCLUSION

this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Effective Management of Giant Ventral Hernias: A Comprehensive Approach Combining Preoperative Botulinum Toxin Application, Modified Ramírez's Component Separation, and Rives-Stoppa Hernioplasty

Introduction  Giant ventral hernias are a surgical challenge due to their size and the need for a specialized approach during repair. Over the decades, abdominal wall surgery has evolved into a sophisticated field with a wide range of techniques aimed at improving patient outcomes. However, there is no universally accepted method suitable for repairing all giant ventral hernias. Surgeons must rely on a combination of techniques, choosing the approach that best matches their expertise, available resources, and the individual patient's specific needs. This article explores the effective use of a combination of techniques, including preoperative botulinum toxin application, modified Ramírez's component separation, and Rives-Stoppa hernioplasty, yielding excellent results and minimizing recurrences. Objective  This study aims to provide a comprehensive literature review of giant ventral hernias. Additionally, we aim to share our experience in managing and repairing giant ventral hernias using a multi-modal approach, combining various surgical techniques with a focus on patient safety, reduced recurrence rates, and improved quality of life. Methods Between October 1, 2019, and October 1, 2021, six patients with giant ventral hernias were enrolled at our department of surgery. They received preoperative botulinum toxin A (BT) application, underwent corrective surgery involving modified component separation following the Ramírez method, and received Rives-Stoppa hernioplasty. Follow-up was conducted for at least six months. Results Six patients were included in the study: three women and three men. They had an average age of 53.6 years and an average body mass index of 31.8 kg/m2. The most common location of the hernia defect was supra and infraumbilical, among 66% of cases. The primary adverse effect associated with BT application was abdominal distension, reported in 33% of patients. No postoperative complications, such as abscesses or seromas, were observed. After the surgical procedure, the average hospital stay was 2.6 days, and no recurrences were noted within six months post-surgery. Conclusion  The proposed method, which involves a combination of techniques, has demonstrated promising results based on our experience. However, to solidify these findings and better understand the full scope of this approach, further comprehensive statistical studies involving larger populations are essential. These studies will not only validate our results but also provide valuable insights for optimizing the management of giant ventral hernias.

Open Complex Abdominal Wall Reconstruction

This article provides an approach to open complex abdominal wall reconstruction. Herein, the authors discuss the purpose of component separation as well as its relevant indications. The techniques and anatomical considerations of both anterior and posterior component separation are described. In addition, patient selection criteria, preoperative adjuncts that may assist with fascial or soft tissue closure, and complications of component separation will be discussed.

Preoperative Optimization for Abdominal Wall Reconstruction

Patients requiring abdominal wall reconstruction may have medical comorbidities and/or complex defects. Comorbidities such as smoking, diabetes, obesity, cirrhosis, and frailty have been associated with an increased risk of postoperative complications. Prehabilitation strategies are variably associated with improved outcomes. Large hernia defects and loss of domain may present challenges in achieving fascial closure, an important part of restoring abdominal wall function. Prehabilitation of the abdominal wall can be achieved with the use of botulinum toxin A, and preoperative progressive pneumoperitoneum.

Systematic review and meta-analysis of the pre-operative application of botulinum toxin for ventral hernia repair

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.

Comparison of Two Versus Three Bilateral Botulinum Toxin Injections Prior to Abdominal Wall Reconstruction

Background: Intramuscular injection of botulinum toxin A (BTA) induces a temporary muscle paralysis. In patients with a ventral hernia, preoperative injection of BTA in the muscles of the lateral abdominal wall (LAW) leads to thinning and lengthening of these muscles, making fascial closure more likely. In many hernia centres, treatment with BTA prior to abdominal wall reconstruction has therefore become standard care. However, evidence on the optimal BTA strategy is lacking. Methods: In this single-centre retrospective study, we analysed a consecutive cohort of ventral hernia patients that underwent bilateral BTA injections prior to abdominal wall reconstruction with available CT before and after BTA. We only included patients that were treated with exactly 600 units of Dysport®, diluted into 120 mL of saline, via either two- or three injections on each side into all three LAW muscle layers. The primary outcome was the change in LAW muscle length and thickness, comparing CT measures from before BTA and 4-6 weeks after the injections. Results: We analysed 67 patients; 30 had received two injections bilaterally and 37 had received three injections bilaterally. Baseline data showed no significant differences in LAW muscle thickness or length between groups. In both groups, the median LAW muscle thickness decreased with 0.5 cm (p < 0.001). The LAW muscle length increased with 0.9 cm (p = 0.001) and 1.2 cm (p < 0.001) in the two- and three bilateral injection group, respectively. The BTA-induced changes in LAW thickness and length were not significantly different between both groups (p = 0.809 and p = 0.654, respectively). Discussion: When using the exact same dosage and distribution volume of BTA in patients with a complex abdominal wall defect, two injections bilaterally in the lateral abdominal wall muscles are as effective as three injections bilaterally.

A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction

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.

State-of-the-art abdominal wall reconstruction and closure

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

The use of botulinum toxin in the acute management of symptomatic complex incisional hernia: a case series

PURPOSE

Complications of incisional hernia are amongst the commonest presentations to the emergency surgical take. Outcomes from emergency hernia repair are poor, particularly for those with complex defects and for the growing population of comorbid, high-risk patients. Attempts to avoid emergency surgery by improving success rates of non-operative management could prove hugely beneficial. Botulinum toxin A (Botox) is already used in the elective management of incisional hernia and this study evaluates if the relaxation produced could be used to augment the outcomes of conservative management of acutely presenting incisional hernia.

METHODS

Patients presenting between October 2020 and April 2022 without evidence of visceral ischaemia, who had been selected for a non-operative approach, were given 300 units of Botox under image guidance to the abdominal wall in addition to standard conservative measures.

RESULTS

Twelve patients were eligible for Botox administration. Median age was 75 years and median BMI was 36.45 kg/m². All patients were high risk; minimum ASA score was 3, and median frailty score was 5. In ten patients, symptoms resolved following Botox allowing for discharge without further complication. Seven subsequently referred on to the abdominal wall team. Symptoms did not settle in the two remaining patients; one required emergency laparotomy and the second was palliated.

CONCLUSION

Botox may be a useful adjunct to established non-operative measures in patients with acute presentations of incisional hernia. It may improve the acute symptoms, eliminate the need for high-risk emergency surgery, or provide a bridge to abdominal wall reconstruction.

Comparison of two-dimensional measurement with three-dimensional volume rendering for the assessment of loss of domain in incisional hernia patients

PURPOSE

We aimed to compare simple two-dimensional (2D) measurement with comprehensive three-dimensional (3D) volume rendering to determine loss of domain (LOD), a clinically important decision-making feature for incisional hernia repair.

METHODS

In this single-center retrospective study, we analyzed the CT scans of a consecutive cohort of adult patients with a midline incisional hernia. The hernia sac- and abdominal cavity volumes were obtained by two different methods. The 2D method estimated the volumes using the corresponding height, width, and depth. The 3D method comprised of a volume rendering tool. For both methods, LOD was calculated according to the Sabbagh ratio (hernia sac volume / (hernia sac volume + abdominal cavity volume)). Taking the 3D method as the reference standard, the performance of the 2D method was expressed as positive predictive value (PPV) and negative predictive value (NPV) for LOD of more than- and less than 20%. The agreement between both methods was expressed as Cohen's kappa coefficient (kappa).

RESULTS

We analyzed 92 CT scans. Agreement between both methods was high (kappa = 0.854, p = 0.0001); all 67 measurements for which the 2D method assessed LOD to be less than 20% were correctly classified (NPV = 100%), and 20 of 25 measurements for which the 2D method assessed LOD to be more than 20% were correctly classified (PPV = 80%).

CONCLUSIONS

The 2D method can exclude patients from perioperative actions needed for a more complex hernia. Since this method is easy to use and less time-consuming, it seems useful for the routine radiological assessment of LOD in clinical practice.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review

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.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.