Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia

Omar Rodriguez-Acevedo, Kristen E. Elstner, Anita S. W. Jacombs, John W. Read, Rodrigo Tomazini Martins, Fernando Arduini, Michael Wehrhahm, Colette Craft, Peter H. Cosman, Anthony N. Dardano, Nabeel Ibrahim

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Introduction: Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. Methods: This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. Results: 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7 years, and mean BMI was 30.9 kg/m2 (range 21.8–54.0). Maximum defect size was 24 × 27 cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1 cm to 20.1 cm per side, a mean gain of 4.0 cm/side (range 1.0–11.7 cm/side) (p < 0.0001). This corresponds to an unstretched mean length gain of 8.0 cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26 months post-operative. Conclusion: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.

LanguageEnglish
Pages831-839
Number of pages9
JournalSurgical Endoscopy and Other Interventional Techniques
Volume32
Issue number2
DOIs
Publication statusPublished - Feb 2018

Fingerprint

Ventral Hernia
Type A Botulinum Toxins
Abdominal Wall
Abdominal Muscles
Muscles
Inlays
Pneumoperitoneum
Herniorrhaphy
Traction
Hernia
Paralysis
Abdomen
Observational Studies
Prospective Studies
Pressure
Injections

Keywords

  • Botulinum toxin A
  • Complex ventral hernia
  • Component separation
  • Laparoscopic repair
  • Preoperative progressive pneumoperitonealisation

Cite this

Rodriguez-Acevedo, O., Elstner, K. E., Jacombs, A. S. W., Read, J. W., Martins, R. T., Arduini, F., ... Ibrahim, N. (2018). Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia. Surgical Endoscopy and Other Interventional Techniques, 32(2), 831-839. https://doi.org/10.1007/s00464-017-5750-3
Rodriguez-Acevedo, Omar ; Elstner, Kristen E. ; Jacombs, Anita S. W. ; Read, John W. ; Martins, Rodrigo Tomazini ; Arduini, Fernando ; Wehrhahm, Michael ; Craft, Colette ; Cosman, Peter H. ; Dardano, Anthony N. ; Ibrahim, Nabeel. / Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia. In: Surgical Endoscopy and Other Interventional Techniques. 2018 ; Vol. 32, No. 2. pp. 831-839.
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abstract = "Introduction: Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. Methods: This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. Results: 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7 years, and mean BMI was 30.9 kg/m2 (range 21.8–54.0). Maximum defect size was 24 × 27 cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1 cm to 20.1 cm per side, a mean gain of 4.0 cm/side (range 1.0–11.7 cm/side) (p < 0.0001). This corresponds to an unstretched mean length gain of 8.0 cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26 months post-operative. Conclusion: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.",
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Rodriguez-Acevedo, O, Elstner, KE, Jacombs, ASW, Read, JW, Martins, RT, Arduini, F, Wehrhahm, M, Craft, C, Cosman, PH, Dardano, AN & Ibrahim, N 2018, 'Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia', Surgical Endoscopy and Other Interventional Techniques, vol. 32, no. 2, pp. 831-839. https://doi.org/10.1007/s00464-017-5750-3

Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia. / Rodriguez-Acevedo, Omar; Elstner, Kristen E.; Jacombs, Anita S. W.; Read, John W.; Martins, Rodrigo Tomazini; Arduini, Fernando; Wehrhahm, Michael; Craft, Colette; Cosman, Peter H.; Dardano, Anthony N.; Ibrahim, Nabeel.

In: Surgical Endoscopy and Other Interventional Techniques, Vol. 32, No. 2, 02.2018, p. 831-839.

Research output: Contribution to journalArticleResearchpeer-review

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T1 - Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia

AU - Rodriguez-Acevedo, Omar

AU - Elstner, Kristen E.

AU - Jacombs, Anita S. W.

AU - Read, John W.

AU - Martins, Rodrigo Tomazini

AU - Arduini, Fernando

AU - Wehrhahm, Michael

AU - Craft, Colette

AU - Cosman, Peter H.

AU - Dardano, Anthony N.

AU - Ibrahim, Nabeel

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N2 - Introduction: Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. Methods: This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. Results: 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7 years, and mean BMI was 30.9 kg/m2 (range 21.8–54.0). Maximum defect size was 24 × 27 cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1 cm to 20.1 cm per side, a mean gain of 4.0 cm/side (range 1.0–11.7 cm/side) (p < 0.0001). This corresponds to an unstretched mean length gain of 8.0 cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26 months post-operative. Conclusion: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.

AB - Introduction: Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. Methods: This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. Results: 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7 years, and mean BMI was 30.9 kg/m2 (range 21.8–54.0). Maximum defect size was 24 × 27 cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1 cm to 20.1 cm per side, a mean gain of 4.0 cm/side (range 1.0–11.7 cm/side) (p < 0.0001). This corresponds to an unstretched mean length gain of 8.0 cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26 months post-operative. Conclusion: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.

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KW - Complex ventral hernia

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