Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair

Abstract

Background Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP. Methods All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12 cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences. Results Twenty-three patients were included. Median age was 65 years (range 28-77) and median BMI was 31.4 (range 22.7-38.0 kg/m 2 ). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5 months (range 10-60 months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%). Conclusion Our algorithm using both anterior or posterior component separation, together with preoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.

The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure

“…Several groups with extensive BTX experience have developed specific treatment algorithms, describing precise indications (17)(18)(19). These algorithms often discuss BTX use in association with PPP, describing their separate indications and potential synergy-PPP potentially helping to stretch out pre-paralysed abdominal wall muscles (17).…”

“…Yurtkap et al describe another algorithm where BTX is given for facial defects 14-18 cm in size (18). If 18-22 cm in size, PPP is added for hernias with significant LOD; both PPP and BTX are used for fascial defects >22 cm.…”

Fascial closure in giant ventral hernias after preoperative botulinum toxin a and progressive pneumoperitoneum: A systematic review and meta-analysis

“…Loss of domain ratio >20% or >25% 22,24,25,35 Measurements (hernia width or loss of domain ratio) 14,21,32,34,35 Hernia width >10 cm 23,30 Hernia width cut-off þ loss of domain ratio >20% 14,21 Surgeon preference or expected difficulty closing midline 11,27 Hernia contents cannot be reduced back to abdominal cavity 26 Foreseen problems during surgery 29 Open abdomen 12,28 Undefined/surgeon's decision 10,31,33,36 BT, Botulinum Toxin A; cm, centimeter; PP, progressive pneumoperitoneum.…”

“…to 500 units has been described, divided over 6 to 10 injection sites, in 2 or all 3 lateral abdominal muscle layers, and timeframes ranging from 45 to 6 days before surgery. 11,12,14,21,27,28,35 One study even described the use of BT injections on the day of surgery itself, barely allowing the BT to enter into force, and, therefore, the observed effects could be obelized as the result of a placebo effect. 11 The reported complications after the use of BT seemed minor; complications during or after the use of PP, however, were frequent and sometimes severe.…”

“…40 Costs are rarely reported, but are estimated to be between 400 and 600 euros when BT is injected into the abdominal wall musculature. 21,34 These numbers seem considerable but become less so when reoperations owing to recurrences and severe postoperative complicationsdconsequences of invasive techniques to obtain fascial closuredcan be prevented. PP is a costly procedure, in particular when performed on an inpatient basis.…”