Botulinum Toxin in the Surgical Treatment of Complex Abdominal Hernias: A Surgical Anatomy Approach, Current Evidence and Outcomes

Abstract

Background/Aim: Abdominal wall hernias represent a common problem in surgical practice. A significant proportion of them entails large defects, often difficult to primarily close without advanced techniques. Injection of botulinum toxin preoperatively at specific points targeting lateral abdominal wall musculature has been recently introduced as an adjunct in achieving primary fascia closure rates. Materials and Methods: A literature search was conducted investigating the role of botulinum toxin in abdominal wall reconstruction focusing on anatomic repair of hernia defects. Results: Injecting botulinum toxin preoperatively achieved chemical short-term paralysis of the lateral abdominal wall muscles, enabling a tension-free closure of the midline, which according to anatomic and clinical studies should be the goal of hernia repair. No significant complications from botulinum injections for complex hernias were reported. Conclusion: Botulinum is a significant adjunct to complex abdominal wall reconstruction. Further studies are needed to standardize protocols and create more evidence.Abdominal wall hernias represent a common problem in current surgical practice. Over 20% of all abdominal operations performed in the US annually are complicated by development of an incisional hernia (1). In an attempt to identify the key players in the successful treatment of the most challenging subgroup of these hernias, namely the complex hernias, a scheme identifying size and location, contamination and soft tissue infection as well as patient history and risk factors has been proposed (2). Incisional hernias are well known to recur after repair (3), thus underlying the importance of solid knowledge of relevant anatomy, technique and most importantly new adjuncts in treatment. More advanced techniques in hernia repair were developed such as Rives-Stoppa retro-rectus repair and, subsequently, posterior components separation whith the goal to achieve primary and tension-free myo-fascial closure reinforced by mesh placement (4). The goal of this study was to review current evidence regarding the use of botulinum toxin in the treatment of abdominal wall hernia repair, in a critical manner.

Preoperative Botulinum Toxin Injection for Complex Abdominal Wall Hernia Repair

“…A statistically significant decrease in the size of the transverse hernia defect and loss of domain following the Botox injection supported the study's findings that Botox injection was beneficial in easing muscular tension and attaining primary fascial closure. The study's results are in line with other research that showed how well Botox injections could help patients with complicated abdominal wall hernias by easing muscular tension and promoting primary fascial closure [20,21]. Following the Botox injection, there was a statistically significant decrease in the size of the transverse hernia defect (p 0.001).…”

“…Some individuals complained of minor discomfort and bruising near the injection sites, although these side effects quickly disappeared on their own. The lack of significant side effects is consistent with earlier research that found Botox injections were safe for people with complicated abdominal wall hernias [11,20]. Botox injection is a low-risk, minimally intrusive technique that can be carried out while receiving a local anesthetic [6].…”

Approaching the Complex Abdominal Wall Hernia: General Principles of Component Separation Techniques

“…Progressive preoperative pneumoperitoneum to augment hernia sac volume and native abdominal cavity volume can be added to chemical component separation, thus further enhancing the ability to tackle complex hernias [57]. Of notice, chemical component separation, which induces temporary paralysis of abdominal wall muscles only, can have a differential effect on hernia sac versus the native abdominal cavity, thus creating a selective effect of progressive preoperative pneumoperitoneum on abdominal wall prehabilitation, essentially, canceling its otherwise non-selective nature of action on both the hernia sac volume and native abdominal cavity volume, which theoretically leaves the aforementioned ratio of them unaltered [58].…”

Toxina botulínica a em associação com curativo de pressão negativa no tratamento do abdome aberto agudo pós-operatório não intencional (evisceração)

“…4 Esta neurotoxina faz com que ocorra paralisia dos músculos da parede abdominal sem alterar sua constituição, aumentando a flexibilidade e reduzindo a força lateral em esforço para facilitar o fechamento da linha média, permitindo reconstrução cirúrgica. 4,7,12,[16][17][18][19][20][21] A injeção da TBA é mais comumente realizada guiada por ultrassom, geralmente nos músculos oblíquos externo e interno e também no músculo transverso do abdome bilateralmente. 19,21 O sistema do CPN abdominal gera pressão negativa centrípeta contínua, que promove a aproximação facial e a evacuação do exsudato inflamatório.…”

“…4,7,12,[16][17][18][19][20][21] A injeção da TBA é mais comumente realizada guiada por ultrassom, geralmente nos músculos oblíquos externo e interno e também no músculo transverso do abdome bilateralmente. 19,21 O sistema do CPN abdominal gera pressão negativa centrípeta contínua, que promove a aproximação facial e a evacuação do exsudato inflamatório. Também ajuda a proteger o conteúdo abdominal do ambiente externo, fornece separação entre a parede abdominal e as vísceras e protege o conteúdo abdominal, permitindo acesso rápido para revisão da cavidade 22 sendo mais um recurso na tentativa da reconstrução da parede abdominal.…”