Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia.

Abstract

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. 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. All hernia defects (mean transverse width 12.9 ± 5.2cm) 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 ± 2.2cm/side (p < 0.001). In 43 patients with defects < 12cm 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] 12cm 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. 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 12cm. BTA may also decrease the rate of hernia recurrence.