The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction

Abstract

Background: Fascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias.Methods: A prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias.Results: A total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 AE 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 AE 5.5 cm; hernia sac volume 2154 AE 3251 cm 3 ) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up.Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P ¼ 0.002) than patients who did not require CST.

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

“…Examining the outcomes of use of botulinum toxin (BTA) in abdominal wall reconstruction, Deerenberg et al (38) reported on a cohort of 108 patients with large incisional hernias with loss of domain that underwent preoperatively botulinum injection under Computer Tomography fluoroscopic or ultrasound guidance. No complications from the injection were reported.…”

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

“…When Nielsen et al looked at the long-term safety of BTX, it was given on "clinical suspicion of difficult closure, " with additional CS if necessary (13). Similarly, when Deerenberg produced a prospective study of 108 patients from the Carolinas Medical Centre, the decision to use BTX was based on opinion and discussion among expert hernia surgeons (14). Others have identified further qualitative CT findings such as shortened or thickened lateral abdominal muscles (12).…”

“…Some discrepancy in dosage between groups may be due to different BTX preparations, such as Botox R or Dysport R . In their largest, most recent paper Bueno Lledó et al (19) describe using Dysport R (Ipsen, Boulogne-Billancourt, France) whereas both Yurtkap et al (18) and Deerenberg et al (14) describe using Botox (Botulinum toxin Allergan, Inc., Irvine, California). Jacombs et al (17) describe using an equivalent dose of either of the two formulations.…”

“…Theoretically the paralysis of the lateral abdominal wall muscles would reduce tension across the wound, creating a more tensionfree healing process. van Rooijen et al (12) and Deerenberg et al (14) have both commented on the particularly low hernia recurrence rates after BTX treatment, the latter adding that insufficient long term studies exist to confirm how BTX may effect recurrence rates. Rodiriguez-Acevedo et al assert in their work that that BTX helps to protect midline wounds over the initial 3 months of healing (16).…”

“…After a decade of use, BTX seemingly offers a low side-effect profile, and has been described as so by analysis from the Abdominal Core Health Quality Collaborative (22). Its use has been described as either safe, low morbidity or lacking complications in several publications (13)(14)(15)22). Given its inherent non-invasiveness, it is likely to be significantly safer than techniques such as PPP.…”