Abstract
BackgroundPost-omphalocele ventral hernias (POVH) are common after giant omphaloceles. Abdominal wall botulinum toxin injections (BTI) are useful to treat complex incisional hernias (CIH) in adults, which may also apply to POVH. We review BTI data in the treatment of CIH and POVH and propose an algorithm applicable to POVH.ResultsSixteen papers which described the treatment of CIH on the treatment of POVH in adults (n = 15) and children (n = 1) were reviewed. BTI elongates the lateral abdominal wall and reduces the hernia defect, with a lower incidence of compartment syndrome and respiratory complications. Doses and injection volumes vary. Effects start after 3 days, peak after 10–15 days, stabilize for 2–3 months, and decline after 4–6 months, disappearing after 6–9 months. Patients should be operated on 3–4 weeks after injection. Post-operative complications are uncommon. BTI may be associated with pre-operative pneumoperitoneum (PPP). Children presenting POVH differ from adults presenting CIH. Associated congenital cardiac malformations, genetically determined syndromes, pulmonary hypoplasia, abdominal wall hypoplasia, and thoracic dysmorphism, are common; children need sedation for any procedures; non-absorbable reinforcing meshes are not indicated; and POVH limits are frequently near to the costal margin.ConclusionBTI to induce preoperative muscular relaxation in preparation of CIH repair in adults is effective and safe. Experience with the method in children with POVH is limited, but the proposal is logical and probably safe. POVH differs from CIH in some aspects, especially abdominal wall hypoplasia, proximity to the rib cage, and diaphragmatic biomechanics.
Highlights
Post-omphalocele ventral hernias (POVH) are common after giant omphaloceles
Other authors inferred that this could be useful in the treatment of complex incisional hernias (CIH), hypothesizing that planned relaxation of the abdominal musculature around the hernia defect could facilitate closure
botulinum toxin injections (BTI) has been proved to counteract the tension of the abdominal wall and to reduce hernia size
Summary
Post-omphalocele ventral hernias (POVH) are common after giant omphaloceles. Abdominal wall botulinum toxin injections (BTI) are useful to treat complex incisional hernias (CIH) in adults, which may apply to POVH. Patients presenting big ventral hernias characteristically show lateral retraction of the abdominal muscles, relative hypertonia of those muscles [1], and an abnormal posture (hyperlordosis) Their treatment shows high recurrence (12-56%), morbidity (mainly respiratory problems and wound complications), and costs [2]. BTI has been proved to counteract the tension of the abdominal wall and to reduce hernia size (frequently turning bridged repairs into direct repairs or direct repairs facilitated by myofascial compartment mobilization – MCM). This logic may apply to POVH secondary to conservative treatment of omphaloceles or after complications of the planned closure of neonatal omphaloceles. In what concerns the treatment of POVH, only two case reports are available, one of those in Danish [5, 6]
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