Preoperative Botulinum Toxin Research Articles

Flu-like symptoms following botulinum toxin A application before incisional hernia repair: A case report

Abstract Botulinum toxin has been used for the treatment of numerous medical conditions. Recently, preoperative botulinum toxin A (BTA) injections into the lateral abdominal wall muscles are beneficial for facilitating ventral hernia repairs and improving surgical outcomes. Early and late, local and systemic adverse effects of BTA application have been described, some of them are flu-like symptoms (FLS). However, no case of FLS following botulinum toxin injections before ventral hernia repair has been described. In this report, we present a 58-year-old female patient who developed FLS episodes throughout preoperative and postoperative periods following BTA injections.

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

PurposeVentral 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.MethodsA 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.ResultsTen 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.ConclusionPreoperative 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.

PATIENT CASE STUDY: REBUILDING A PATIENT’S LIFE NOT JUST THEIR ABDOMINAL WALL – EXPERIENCE FROM A TERTIARY HERNIA CENTRE ON THE IMPACT OF ABDOMINAL WALL RECONSTRUCTION ON QUALITY OF LIFE

Abstract Introduction Abdominal wall reconstruction is a transformative intervention, significantly improving the quality of life for individuals with complex defects. This paper focuses on sharing a patient's experience post-surgery. Case Presentation The patient presented with a complex incisional hernia following a laparotomy, Hartmann’s procedure and splenectomy for perforated diverticular disease. Their CT scan showed a 16.5 × 17.5 cm defect, with a separate component involving their colostomy and lateral displacement of their muscle complexes. The hernia significantly impacted the patient's quality of life, manifesting as daily moderate pain that hindered routine activities. They required daily dressings and antibiotics due to skin changes over the hernia. Furthermore, dissatisfaction with the cosmetic appearance of the hernia contributed to the overall burden on the patient. Management and Outcomes The patient underwent pre-operative botulinum toxin injections six weeks prior to their abdominal wall reconstruction. They received 200 units divided equally between internal and external obliques. During their surgery they required a left sided transversus abdominus release and an &amp;gt;5cm mesh overlap was achieved in all directions. A post-operative CT scan conducted ten days after the surgery revealed no complications. The patient's recovery progressed well, leading to their discharge 12 days post-surgery. Discussion The patient was reviewed nine months post-surgery. Expressing high satisfaction with the surgical outcome, they conveyed a profound positive impact on their quality of life. The patient's newfound confidence in the improved cosmesis of their hernia was evident. Overall, the surgery proved transformative, liberating the patient from the burdens of frequent medical appointments and instilling a renewed sense of self-assurance.

Decompression Surgery in Elderly Patients with Hemifacial Spasm Refractory to Botulinum Toxin.

Botulinum toxin is an effective treatment for hemifacial spasm in elderly patients. However, some patients do not tolerate the side effects and frequency of botulinum toxin treatments. The purpose of this study was to evaluate the characteristics and outcomes of a cohort of elderly patients referred by neurologists for surgical decompression of the facial nerve following botulinum toxin treatment. In a prospective cohort study, logistic regression was used to detect potential predictors of spasm-freedom after surgical decompression of the facial nerve in elderly patients that received ≤8 and >8 botulinum toxin treatments for hemifacial spasm before surgery. Age, sex, side, preoperative symptom duration, and preoperative botulinum toxin treatment were assessed as potential predictors of spasm-freedom at last follow-up. Of 76 elderly patients with hemifacial spasm treated with botulinum toxin and microvascular decompression, with at least 2-years of follow-up (median, 44.5 months), 84.2% were spasm-free at last follow-up. Age (P = 0.38), sex (P = 0.59), side (P = 0.15), preoperative symptom duration (P = 0.7), and number of preoperative botulinum toxin treatments (P = 0.3) were not predictors of long-term spasm-freedom. Permanent ipsilateral hearing loss was the most frequent complication (3.9%). This study provides evidence that elderly patients can undergo botulinum toxin treatment for hemifacial spasm without compromising their likelihood of achieving spasm-freedom with future surgical decompression. Therefore, surgical decompression of the facial nerve is an effective therapy for elderly patients with hemifacial spasm refractory to botulinum toxin.

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.

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.

Preoperative Botulinum Toxin Injection for Complex Abdominal Wall Hernia Repair

Introduction: Due to their higher rates of morbidity and recurrence, complex abdominal wall hernias provide a difficult clinical dilemma. Botulinum toxin injection has been suggested as a feasible treatment option to ease patients' tense muscles and promote primary fascial closure. This study focus on how well preoperative botulinum toxin injections worked for patients with complicated abdominal wall hernias. Methodology: The patients in this retrospective study had complex abdominal wall hernias. Between January 2021 and December 2022, they had received preoperative botulinum toxin injections for those hernias. Age, gender, the extent of the transverse hernia defects both before and after the procedure, loss of domain, and muscle length, all were the study's variables. The data were analyzed using comparative analysis and paired t-tests. Results: The study involved 8 patients in all, with an average age of 53.38 ± 12.56 years. The mean fascial defect size before injection was 13.14 ± 4.58 cm, while the mean fascial defect size after injection was 11.84 ± 4.07 cm. Following the Botox injection, there was a statistically significant decrease in the size of the transverse hernia defect (p 0.001). The mean loss of domain before the surgery was 18.46 ± 11.96%, while the mean loss of domain after the 7.21%. Following the Botox injection, there was a statistically significant decrease in loss of domain (p 0.05). In 7 individuals, primary fascial closure was accomplished (87.5%). Both surgical and chemical components had no significant side effects. Conclusion: In individuals with complicated abdominal wall hernias, preoperative botulinum toxin injection is an efficient and secure method for lowering muscle tension and attaining primary fascial closure. it is challenging to make firm judgments on the effectiveness of preoperative Botox injection for complex abdominal wall hernia repair in the absence of a control group. The results of the current study need to be confirmed by larger studies with longer follow-up times and a control group.

Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression.

We aimed to report efficacy, safety, and health-related quality of life (HRQoL) outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression among patients with thoracic outlet syndrome (TOS). TOS is a challenging condition where controversy remains in diagnosis and treatment, primarily given a lack of data exploring various treatment approaches and associated patient outcomes. Patients who underwent unilateral, supraclavicular thoracic outlet decompression, or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and symptomatic improvement compared with baseline. Among 2869 patients evaluated (2007-2021), 1032 underwent surgery, including 864 (83.7%) supraclavicular decompressions and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes among surgical patients were neurogenic (75.4%) and venous TOS (23.4%). Most patients (92.9%) with nTOS underwent preoperative botulinum toxin injection; 56.3% reported symptomatic improvement. Before surgical consultation, few patients reported participation in physical therapy (10.9%). The median time from first evaluation to surgery was 136 days (interquartile range: 55, 258). Among 864 patients who underwent supraclavicular thoracic outlet decompression, complications occurred in 19.8%; the most common complication was chyle leak (8.3%). Four patients (0.4%) required revisional thoracic outlet decompression. At a median follow-up of 420 days (interquartile range: 150, 937) 93.3% reported symptomatic improvement. Based on low composite morbidity, need for very few revisional operations, and high rates of symptomatic improvement, a multidisciplinary treatment approach including primarily supraclavicular thoracic outlet decompression is safe and effective for patients with TOS.

Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR).

The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR). Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05). PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

OC-092 Giant inguinoscrotal hernia treated with botulinum toxin, pneumoperitoneum and scrotoplasty associated to hernia repair

Abstract Aim Inguinal hernias are the most frequent hernias of the abdominal wall, but giant hernias are a rare entity in developed countries. The surgical repair of these hernias is a challenge for surgeons, with high rates of postoperative morbi-mortality and recurrence. There are limited reports of cases of giant inguinal hernia treated with preoperative botulinum toxin and pneumoperitoneum and hernia repair associated with scrotoplasty. Material &amp; Methods We present the case of a male patient of 68 years-old suffering from a giant inguinoscrotal bilateral hernia with loss of domain that was causing an extreme limitation to ambulate. The index of Sabbagh measured by images of computed tomography was 48,8%. Results We administrated preoperative botulinum toxin and progressive pneumoperitoneum (14100cc of air) before surgery. We realized a Rives-Stoppa technique with partial transverse abdominis release and scrotoplasty. Intra-abdominal pressures were measured during the early postoperative period. Seven days after surgery a restrictive respiratory failure was diagnosed needing non-invasive mechanical ventilation. Nevertheless, the evolution was satisfactory, and the patient was discharged on postoperative day 20. After a follow-up of 1 year neither hernia recurrence and no chronic pain were recorded. His quality of life improved notably. Conclusions In order to avoid the development of an abdominal compartment syndrome, the preoperative administration of pneumoperitoneum and botulinum toxin is suggested as a therapeutic option in giant hernias. Furthermore, adding scrotoplasty to hernia repair can improve functional and aesthetic results.

P-062 SEVERE COMPLICATION AFTER EVENTROPLASTY: NECROSIS OF RECTUS ABDOMINIS MUSCLES

Abstract Aim Rectus abdominis muscles are supplied mainly by superior and inferior epigastric arteries, forming an arcade between them. The ligation of one of them during a surgical intervention usually has no clinical repercussions. However, when both arteries flow are interrupted, there is another clinical scenario. Material and Methods We describe the case of a 74 years-old woman who was admitted for an elective surgery of fourth recurrence of a midline eventration (M2-5W3 European Hernia Society Classification). We treated using preoperative botulinum toxin and Rives-Stoppa surgical technique. On the second postoperative day, the patient suffered a cardiorespiratory arrest due to a pulmonary embolism, therefore anticoagulation was necessary. After anticoagulation the patient showed severe anemia (Hemoglobin 5 g/dL) and tomography computed scan images revealed a big hematoma of the abdominal wall with active bleeding. Results Embolization of both epigastric, right mammary and left pectoral arteries was performed by interventional radiologists. After 12 days, the patient showed cutaneous surgical wound dehiscence and serohematic foul-smelling fluid. We detected necrosis of the rectus muscles when we debrided the wound. It was treated with daily cures and vacuum therapy without mesh removal, achieving a progressive closure. After six months of follow-up, there are no signs of recurrence. Conclusions Ischemia of the rectus muscles is a severe complication after eventroplasty that can be treated with debridament of necrotic muscle and vacuum therapy, without removal of mesh if it is sufficiently extended along the healthy abdominal wall and cover the necrotic defect.

OC-042 LAPAROSCOPIC ETEP APPROACH TO VENTRAL HERNIAS: SHORT-TERM OUTCOMES

Abstract Aim Ventral hernias are a pathology with a high incidence within general surgery.Repair techniques have been evolving, and the minimally invasive approach to this type of pathology is currently on the rise due to the advantages of the MIS. Material &amp; Methods We analyzed our database of patients with ventral hernias undergoing laparoscopic-eTEP approach,August-2021 to December-2022. We present our short-term outcomes. Results A total of 31 patients(men:54.8%,age:64(RIQ:43–73years)). LOS:1.48±0.62days. Pathological history:diabetes mellitus(19.4%),arterial hypertension(45.2%),dyslipidemia(51.6%), smoking(25.8%), alcohol consumption(13.3%), cardiovascular disease(12.9%). ASA Classification:I(32.3%), II(45.2%), III(22.6%). BMI:30.6±4.68kg/m2. Overweight:11(35.5%) and obesity:17(54.8%). Primary hernias:4(26.7%) and incisional hernias:19(61.3%).Location:midline(100%), supraumbilical:58.1%,umbilical:87.1% and infraumbilical:25.8%.Hernia width (EHS classification): W1:12.9%, W2:80.6% and W3:6.5%, transverse hernia diameter: 5.5±2.1cm, hernia length size:6.1±4.4cm. Associated with diastasis:24(77.4%),diastasis width:4.9±1.7cm. Associated with inguinal hernia:6(19.4%). Type of laparoscopic surgical technique performed:Rives-Stoppa: 24(77.4%), unilateral TAR:5(16.1%), bilateral TAR:2(6.5%).Number of trocars used by procedure:4(RIQ:4–5). Preoperative botulinum toxin:7(22.6%). Posterior sheath closure:23(74.2%). Mesh fixation type:Glutack 5(16.1%), Tisseel 19(61.3%), no fixation 7(22.6%). Mesh type used: Low density wide-pore polypropylene 11(35.5%),PVDF-Mesh 18(58.1%), PVDF-IPOM mesh 2(6.5%). Mesh size: width 18(RIQ:16–22cm) and length 28(RIQ:25–30cm). Drainage: 3(9.7%). Surgical time:200(RIQ:180–300min). Global and serious complications (CD≥III): 4(12.9%) and 1(3.2%), Re-IQ due to incarcerated hernia due to posterior sheath dehiscence: 1 (3.2%). No intraoperative complications. Clinical seroma:3(9.7%).No cases of hematoma or surgical wound infection.No recurrence. Conclusions The laparoscopic eTEP approach of ventral hernias has a low rate of global complications,despite being our first cases performed. It also has low rates of postoperative pain and shorter LOS.We can conclude that in our Hospital the laparoscopic eTEP approach is a safe, efficient and effective technique.

OC-126 PRESERVATION OF DEEP EPIGASTRIC PERFORATORS DURING ANTERIOR COMPONENT SEPARATION TECHNIQUE (ACST) RESULTS IN EQUIVALENT WOUND COMPLICATIONS COMPARED TO TRANSVERSUS ABDOMINIS RELEASE (TAR)

Abstract Aim The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction (AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between PS-ACST and TAR. Material &amp; Methods Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015–2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. Results A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p=0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p&amp;lt;0.001). The PS-ACST group had a larger hernia defect size (375.2±156.7 vs 234.4±126.9cm2, p&amp;lt;0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p&amp;lt;0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p=0.129) nor was the mesh infection rate (0% vs 1.6%, p=0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p&amp;gt;0.05). Conclusion PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

Botulinum Toxin Use for Abdominal Wall Reconstruction

INTRODUCTION: Preoperative botulinum toxin (BTX) injection may assist in fascial closure of large incisional hernia repair. We examine outcomes of incisional hernia patients who receive BTX injections before abdominal wall reconstruction (AWR). METHODS: A retrospective cohort study of patients from 2019–2021 who underwent BTX abdominal wall injections and interval AWR was conducted. A matched cohort who underwent IH repair without BTX treatment was selected for comparable defect size and BMI. Clinical and demographic data were extracted from charts. RESULTS: Twenty patients received BTX injections, and 30 comparable patients did not. There was no difference in average age (58.6 and 61.4 years, p = 0.514), BMI (32.9kg/m2 and 32.4kg/m2, p = 0.813), or defect size (663.9 cm2 and 608.43 cm2, p = 0.513). Primary outcome of fascial closure was achieved in every patient in the BTX group (20 of 20) vs 86.7% (26 of 30) in the non-BTX group (p = 0.089). The BTX group had a lower rate of component separation (65.0% of the BTX group vs 93.3%, p = 0.01). The BTX group had higher rates of seroma (p = 0.03) and longer surgery time, 4:07 vs 3:58 (p < 0.01). The postoperative period had one dehiscence (non BTX group). There was no difference in incidence of surgical site infection, abscess, delayed healing, respiratory failure, pulmonary embolism, acute kidney injury, or length of stay. CONCLUSION: Patients receiving botulinum toxin injections into their abdominal wall musculature achieved greater rates of closure with good outcomes. We conclude that botulinum toxin injection for large incisional hernias is an effective method for relaxation of abdominal wall muscle and closure of large abdominal wall.

Effect of Preoperative Botulinum Toxin Injection on Surgical Repair of Ventral Hernia: A Meta-Analysis

Effect of Preoperative Botulinum Toxin Injection on Surgical Repair of Ventral Hernia: A Meta-Analysis

P-077 SURGICAL TREATMENT OF LARGE INCISIONAL HERNIA WITH BOTULINUM TOXIN A INJECTION: STUDY PROTOCOL FOR A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL

Abstract Aim The best strategy for W3 incisional hernia (IH) repair is not known to date and is associated with high risks of recurrence and morbidity. We aim to demonstrate that preoperative Botulinum Toxin A (BTA) injection in the lateral abdominal wall muscles reduces the rate of postoperative morbimortality after large IH (EHS W3) repair with mesh, compared with placebo injection. Material &amp; Methods This study will be a prospective, national multi-center, double-blinded, randomized (1:1) superiority phase III trial with two parallel arms: BTA versus placebo injection. Participants will be selected based on an abdomino-pelvic CT-scan without contrast injection performed in the 6 months preceding the patient's surgery. Main inclusion criteria will comprise midline anterior primary or recurrent IH (subxiphoidal to suprapubic), of width ≥ 10 cm, without loss of domain. Patients included will be randomized (1: 1 ratio), by using a computer-generated randomization scheme, and randomization will by stratified on the center and width of the IH (10–15 cm and &amp;gt; 15 cm). Participants will be randomized on the day of the injection, at least 4 weeks before the surgery. Results The primary endpoint will be the occurrence of Clavien-Dindo classification grade II or higher post-operative complication during the 90-day postoperative period. Secondary endpoints will include the rates of primary fascial closure, occurrence of component separation techniques, radiological response to injections, consumption of analgesics and pain, and occurrence of clinical and radiological recurrences. Conclusions Protocol version 2.0 is currently being assessed for funding by the French Ministry of Health.

P-024 COMPLEX ABDOMINAL WALL RECONSTRUCTION BY RETROMUSCULAR SUBLAY TECHNIQUE: INITIAL EXPERIENCE IN A THIRD-LEVEL HOSPITAL

Abstract Aim Large or complex incisional hernias require more than just mesh placement.There are techniques such as component separation, retromuscular techniques (Rives-Stoppa, transversus abdominis muscle release-TAR), which help to repair the hernia and physiologically rebuild the abdominal wall.However, this type of technique can present a higher incidence rate of complications, such as hematomas, seromas, SSI, skin necrosis.We present our initial experience in complex abdominal wall reconstruction using the retromuscular sublay technique (RST). Methods Retrospective study analyzing our database of patients with complex incisional hernia undergoing abdominal wall surgery using the RST, during November-2018 to October-2020.In addition, we conducted a comparative analysis with patients undergoing hernia repair using the onlay-technique. Results 44 patients underwent RST (male:56.8%, age:66(IQR: 52–73years)). Hospital stay:4(IQR: 2–6days).Pathological history: diabetes mellitus (4.5%), arterial hypertension(20.5%), dyslipidemia(36.4%), smoking(34.1%), alcohol consumption(27.3%), cardiovascular disease(9.1%).ASA-classification:I(9.1%), II(59.1%), III(31.8%). BMI: 29.3±2kg/m2. Hernia location: midline(95.5%), others(4.5%). Preoperative botulinum toxin (PBT): 20.45%. Preoperative progressive pneumoperitoneum (PPP): 9.1%. Type of surgery performed: Rives-Stoppa(68.2%), TAR(31.8%). Postoperative complications: global(13.6%), Clavien-Dindo≥III:0%, clinical seroma(13.6%) and ultrasound-seroma(22.7%), SSI(0%). Hernia recurrence:0%. In the bivariate analysis of patients undergoing hernia repair using the RST compared to patients undergoing onlay repair, we observed that the RST presented lower incidence of global complications, both clinical and ultrasound seromas, surgical site infections and recurrences (13.6% vs 39.1% p=0.004; 13.6% vs 33.3% p=0.019; 22.7% vs 39.1% p=0.07; 0% vs 14.5% p=0.008; 0% vs 5.8% p=0.1; respectively). Conclusions In our enviroment, the management of complex incisional hernias using RST and the use of PBT and PPP is effective and safe, with a lower incidence of complications and recurrences.

P-006 LAPAROSCOPIC ETEP APPROACH TO VENTRAL HERNIAS: INITIAL EXPERIENCE AND SHORT-TERM RESULTS

Abstract Aim Ventral hernias are a pathology with a high incidence within general surgery.Repair techniques have been evolving,and the minimally invasive approach to this type of pathology is currently on the rise due to the advantages offered by the minimally invasive surgery (laparoscopic or robotic):less postoperative pain, SSI,seromas,length of stay (LOS) and faster return to routine daily activities.We present our initial series of patients with ventral hernias treated by laparoscopic eTEP approach. Material &amp; Methods Retrospective-study where we analyzed our database of patients with ventral hernias (primary and secondary)undergoing abdominal wall surgery using laparoscopic-eTEP-approach. Results 15 patients underwent laparoscopic-eTEP-surgery (men:73.3%, age:64(RIQ:41–74years)). LOS:1.73±0.7days. Pathological history: diabetes mellitus (26.7%), arterial hypertension (46.7%), dyslipidemia (66.7%),smoking (20%), alcohol-consumption(13.3%), cardiovascular disease (13.3%). ASA-Classification: I (26.7%), II(53.3%), III(20%). BMI:29.82±4.78kg/m2. Overweight: 14(93.3%) and obesity: 6(40%). Primary hernias:4(26.7%) and incisional-hernias:11(73.3%). Location:midline (100%), supraumbilical:60%, umbilical:93.3% and infraumbilical:26.7%.Hernia-width(EHS classification): W1:13.3% and W2:86.7%, transverse hernia-diameter: 6.2±2.1cm, hernia length-size:7.2±4.4cm. Diastasis:10(66.7%), diastasis-width:5.7±1.38cm. Associated with inguinal hernia:5(33.3%). Type of laparoscopic surgical technique performed: Rives-Stoppa: 10(66.7%), unilateral-TAR: 3(20%), bilateral-TAR: 2(13.3%). #trocars: 4(RIQ:4–5). Preoperative botulinum-toxin: 6(40%). Posterior-sheath-closure: 14(93.3%). Mesh fixation-type:Glutack 5(33.3%), Tisseel 6(40%), non-fixation 4(26.7%). Mesh type: Low density wide-pore polypropylene 6(40%), PVDF-Mesh 8(53.3%), PVDF-IPOM-mesh 1(6.7%). Mesh size: width 20(RIQ:18–25cm) and length 30(RIQ:26–30cm).Drainage:3(20%).Surgical time:240(RIQ:180–300min). Global and serious complications (CD≥III):1(6.7%) and Re-IQ due to incarcerated hernia due to posterior-sheath-dehiscence:1(6.7%).No intraoperative-complications.Clinical-seroma:0% and ultrasound-seroma:66.7% that resolved completely spontaneously during the first-second postoperative-months.No hematomas or surgical-wound-infection.Until the current follow-up no-recurrence. Conclusions The laparoscopic-eTEP-approach of ventral-hernias has a low rate of global-complications,despite being our first cases performed.It also has low rates of postoperative pain and shorter-LOS.We can conclude that in our Hospital the laparoscopic-eTEP-approach is a safe, efficient and effective technique.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BackgroundComplete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. MethodsA prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. ResultsMatched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%–39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4–34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). ConclusionIn a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.