Low-Dose Pre-Operative Botulinum Toxin A Effectively Facilitates Complex Ventral Hernia Repair: A Case Report and Review of the Literature

Ali P Mourad,Robert D Winn,Marie Shella De Robles

doi:10.3390/medicina57010014

Abstract

Background: Complex ventral hernias following laparotomy present a unique challenge in that repair is hindered by the lateral tension of the abdominal wall. A novel approach to overcome this is the “chemical component separation” technique. Here, botulinum toxin A (BTA) is instilled into the muscles of the abdominal wall. This induces flaccid paralysis and effectively reduces tension in the wall, allowing the muscles to be successfully joined in the midline during surgery. We describe a method where a large incisional hernia was repaired using this technique and review the variations in methodology. Case report: A woman in her mid-40s developed a ventral hernia in the setting of a previous laparotomy for a small bowel perforation. Computed tomography (CT) of the abdomen demonstrated an 85 (Width) × 95 mm (Length) ventral hernia containing loops of the bowel. Pre-operative botulinum toxin A administration was arranged at the local interventional radiology department. A total of 100 units of BTA were instilled at four sites into the muscular layers of the abdominal wall under CT-fluoroscopic guidance. She underwent an open incisional hernia repair 4 weeks later, where the contents were reduced and the abdominal wall layers were successfully joined in the midline. There was no clinical evidence of hernia recurrence at 3-months follow-up. Conclusion: Low-dose BTA effectively facilitates the surgical management of large ventral incisional hernias. There is, however, significant variation in the dosage, concentration and anatomical landmarks in which BTA is administered as described in the literature. Further studies are needed to assess and optimise these variables.

Highlights

Incisional hernia occurrence is an unfortunate complication associated with open abdominal surgery
Complex incisional hernias encountered after laparotomy surgery present a unique challenge
The essence of all these definitions, is the same—a ventral incisional hernia where primary fascial closure is unlikely to be possible without adjunctive techniques

Summary

Introduction

Incisional hernia occurrence is an unfortunate complication associated with open abdominal surgery. Ploited, allowing tension-free closure of the hernia defect several weeks later This obviIn this article, we describe a case where low-dose was used to facilitatearclosure of ates the needs to separate the layers intraoperatively, thusBTA preserving the myofascial achitecture complexof ventral hernia. A woman mid-40s underwent an emergency in the settingand of an complicated byinanher admission to the intensive care unitlaparotomy for inotropic support a surgical acute abdomen related to small bowel perforation Her post-operative recovery was comsite infection requiring a return to theatres for washout. Using a 22-guage needle, 8–10 units of BTA were instilled by an interventional radiologist into the external oblique, internal oblique and transversus abdominus muscles under CT-fluoroscopic guidance at each injection site (Figure 2). Post-operative CT scanning at 2 weeks demonstrated successful left on for additional reinforcement and was subsequently removed along with the skin months revealed no clinical evidence of hernia recurrence. Follow-up at 3 months revealed no clinical evidence of hernia recurrence

Discussion

Conclusions