Application of botulinum toxin as part of the multimodal treatment of complex postoperative hernias
DOI:
https://doi.org/10.5281/zenodo.19571544Keywords:
complex postoperative hernias, botulinum toxinAbstract
Introduction: Anterior abdominal wall hernias are one of the most common surgical diseases, the treatment of which is perceived by patients and many surgeons as routine and easy. This perception can be very misleading in the case of so-called complex hernias, in which standard techniques can lead to serious technical difficulties, a high risk of recurrence, and even a threat to the patient's life if compartment syndrome occurs.
Case presentation: We present a 47-year-old obese man with a complex postoperative hernia after two previous unsuccessful interventions with the placement of a Mesh, described below. In 2007, a gastric band was placed for weight loss. In 2011, during hospitalization for gangrenous cholecystitis, intraluminal migration of the device with its entrapment in the ileum was detected, which is why cholecystectomy and device extraction with enterotomy and subsequent intestinal suturing were performed. Due to suture insufficiency, peritonitis, and necrotizing fasciitis, relaparotomy with intestinal resection and multiple revisions of the surgical wound and treatment with VAC© was carried out. In 2013, a hernioplasty complicated by wound infection was conducted, and the patient was treated again with VAC©. In 2018, the patient underwent a new hernioplasty with the placement of a two-component Symbotex© Mesh.
Conclusion: Complex anterior abdominal wall hernias are a challenging pathology that often requires a multidisciplinary approach. The most important condition for their successful treatment is a detailed assessment of the hernia and risk factors, followed by precise treatment planning. Botulinum toxin is a safe and useful adjunct in the treatment of complex ventral hernias.
References
1. Barbosa C, Faria M, Messias B. Predictive factors for complexity in abdominal wall hernias: a literature scope review. Rev Col Bras Cir 2024;51:20243670.
2. Ramirez O, Ruas E, Dellon A. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86(3):519-526.
3. Torregrosa-Gallud A, Sancho Muriel J, Bueno-Lledo J, et al. Modified components separation technique: Experience treating large, complex ventral hernias at a University Hospital. Hernia 2017;21:601-608.
4. Novitsky Y, Elliott H, Orenstein S, Rosen M. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2012;204(5):709-716. doi: 10.1016/j.amjsurg.2012.02.008.
5. Ibarra-Hurtado T, Nuño-Guzmán C, Echeagaray-Herrera J, et al. Use of botulinum toxin type A before abdominal wall hernia reconstruction. World J Surg 2009;33:2553-2556.
6. Blair LJ, Ross SW, Huntington CR, Watkins JD, Prasad T, Lincourt AE, et al. Computed tomographic measurements predict component separation in ventral hernia repair. J Surg Res 2015;199(2):420-427. doi: 10.1016/j.jss.2015.06.033.
7. Love MW, Warren JA, Davis S, Ewing JA, Hall AM, Cobb WS, et al. Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release? Hernia 2021;25(2):471-477. doi: 10.1007/s10029-020-02181-y.
8. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009;13(4):407-414. doi: 10.1007/s10029 009-0518-x.
9. Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia 2008;12(4):359-362. doi: 10.1007/ s10029-008-0356-2.
10. Christy MR, Apostolides J, Rodriguez ED, Manson PN, Gens D, Scalea T. The component separation index: a standardized biometric identity in abdominal wall reconstruction. Eplasty 2012;12:17.
11. Tanaka EY, Yoo JH, Rodrigues AJ, Utiyama EM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 2010;14(1):63-69. doi: 10.1007/s10029-009-0560-8.
12. Ibarra-Hurtado TR, Nuño-Guzmán CM, Miranda-Díaz AG, Troyo Sanromán R, Navarro-Ibarra R, Bravo-Cuéllar L. Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management. Hernia 2014;18:647-652. doi: 10.1007/s10029-014-1280-2.
13. Gandhi JA, Shinde PH, Banker AM, Takalkar Y. Computed tomography for ventral hernia: Need for a standardised reporting format. J Minim Access Surg 2023;19(1):175-177. doi: 10.4103/jmas. jmas_34_22.
14. Hodgkinson JD, Leo CA, Maeda Y, Bassett P, Oke SM, Vaizey CJ, Warusavitarne J. A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias. Hernia 2018;22(4):617-626. doi: 10.1007/s10029-018-1757-5.
15. Whitehead-Clarke T, Windsor A. The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure. Front Surg 2021;8:753889. doi: 10.3389/fsurg.2021.753889.
16. Zielinski MD, Goussous N, Schiller HJ, Jenkins D. Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen. Hernia 2013;17:101–107. doi: 10.1007/s10029-012-0995-1.
17. Smoot D, Zielinski M, Jenkins D, Schiller H. Botox A injection for pain after laparoscopic ventral hernia: a case report. Pain Med 2011;12:1121–1123. doi: 10.1111/j.1526-4637.2011.01147.x
18. Timmer AS, Ibrahim F, Claessen JJM, Aehling CJ, Kemper TCPM, Rutten MVH and Boermeester M. Comparison of Two Versus Three Bilateral Botulinum Toxin Injections Prior to Abdominal Wall Reconstruction. J. Abdom Wall Surg 2023;2:11382. doi: 10.3389/jaws.2023.11382.
19. Elstner KE, Read JW, Saunders J, Cosman PH, Rodriguez-Acevedo O, Jacombs ASW, et al. Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair. Hernia 2020;24:287-293. doi: 10.1007/s10029-019-01939-3.
20. Bueno-Lledó J, Martinez-Hoed J, Torregrosa-Gallud A, Menéndez-Jiménez M, Pous-Serrano S. Botulinum toxin to avoid component separation in midline large hernias. Surgery 2020;168(3):543-549. doi: 10.1016/j.surg.2020.04.050.
21. Timmer AS, Claessen JJM, Atema JJ, Rutten MVH, Hompes R, Boermeester MA. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction. Hernia 2021;25(6):1413-1425. doi: 10.1007/s10029-021-02499-1.
22. Nielsen MØ, Bjerg J, Dorfelt A, Jørgensen LN, Jensen KK. Short-term safety of preoperative administration of botulinum toxin A for the treatment of large ventral hernia with loss of domain. Hernia 2020;24(2):295-299. doi: 10.1007/s10029-019-01957-1.
23. The Cleveland Clinic. Preoperative BOTOX® Injection for Large Ventral Hernia Repair (PRETOX). https://clinicaltrials.gov/study/NCT07220382 .
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Daniel Stefanov, Georgi Popivanov, Slavi Asov, Desislava Videva, Vessela Mihneva, Marina Konakchieva, Ventsislav Mutafchiyski (Author)
This work is licensed under a Creative Commons Attribution 4.0 International License.
