The Use of Botulinum toxin A elongates the lateral abdominal wall prior to surgery for giant complex ventral hernias and may replace component separation

A. Jacombs, E. Roussos, J. Read, A. Dardano, T. Boesel, M. Edye, N. Ibrahim

Research output: Contribution to journalMeeting abstract

Abstract

Introduction: Complex ventral hernias occur in up to 15% of patients undergoing abdominal surgery. Surgical repair of recurrent abdominal incisional hernia(s) can be challenging due to complex operative conditions, intense post-operative pain, potential respiratory compromise and lateral muscle traction predisposing to early recurrence. Reported recurrence rates, within 36 months vary between 15-21% for open repair and 7-15.5% for laparoscopic repair and as high as 56%, 47% and 48% after first, second and third hernia repairs. Despite innovation in surgical techniques, such as the introduction of surgical mesh and component separation, there have been minimal improvements in post-operative morbidity and hernia recurrence. Botulinum toxin type A (BTA), a neuromodulating agent, increasingly used for various clinical applications including dystonia, spasticity, cerebral palsy, hyperhidrosis, hypersalivation, bladder dysfunction, skin wrinkles and pain management over the last 40 years. There are now a few case reports, in humans and animals, using BTA for the peri-operative management in abdominal wall surgery with the aims of: I) improving analgesia, 2) using the flaccid paralysis to lengthen abdominal oblique muscles and facilitate apposition of the edges of the defect akin to the effect of component separation but without disrupting the fascial integrity and 3) decreasing lateral traction and thus reducing tension before and after surgical repair. Methods: A prospective pilot study measured the effect of preoperative BTA prior to elective repair of complex recurrent ventral hernias. Each patient received 300 untis of BTA injected in equal divided doses into the external oblique, internal oblique and transversus abdominis muscles at three sites on each side of the lateral abdominal wall (each dose 50 units). The six injections were performed in an outpatient setting under ultrasound control two weeks prior to surgery. Pre and post-BTA abdominal computed tomography (CT) measured changes in abdominal wall muscle thickness and length of the hernia defects. All hernias were subsequently repaired with laparoscopic (IPOM) or laparoscopic assisted mesh techniques in a one- or two-staged procedure with Sepramesh™ (Bard, Cranston RI, USA). Results: We report our initial 12 patients (lOM:2F), who underwent preoperative BTA prior to laparoscopic hernia repair between November 2012 and October 2014. The mean age was 59 years (range 32-83yrs) with mean defect size of 14.4 cm (range 7-28 cm, maximal linear defect). BTA injections were tolerated by all patients with no complications and they resumed normal activities between the injections and surgery. Comparison between pre and post-BTA injection abdominal CT scans demonstrated a mean unstretched lengthening of lateral abdominal muscle of 2.9 cm/side (range 0.7-5.9cm), thinning of7.3 mm (range 0.4-14.3mm). CT imaging also demonstrated reduction in loss of domain and reduction of abdominal hernia contents into the abdominal cavity in 12 patients prior to surgery. All the hernias were successfully reduced using standard laparoscopic or laparoscopic assisted techniques with surprising ease at the time of surgery without any fascial separation. There have been no post-operative recurrences, to date. The only side effect of BTA injections was the feeling of "bloatedness', day 4-day 5 post-injection, and increase abdominal girth, as reported by patient. Conclusion: Pre-operative BTA injection prior to complex abdominal hernia repair was a safe procedure that resulted in flaccid paralysis, unstretched elongation and thinning of the lateral abdominal muscles and decrease in loss of domain and hernia defect prior to surgery. We hypothesise that the flaccid paralysis of the lateral abdominal wall, due to pre-operative BTA, decreases lateral traction to enable: I) reduction of hernia defect at time of surgery, 2) decreases tension through the repair, for the first 2 months or more, during the critical healing phase and 3) may reduce the need for component separation.
Original languageEnglish
Pages (from-to)S8-S9
Number of pages2
JournalHernia : Volume 19 Issue 1 Supplement : abstracts
Volume19
DOIs
Publication statusPublished - 2015
EventWorld Conference on Abdominal Wall Hernia Surgery (1st : 2015) - Milan, Italy
Duration: 25 Apr 201529 Apr 2015

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