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

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 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm3) 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 = 0.002) than patients who did not require CST.

CONCLUSIONS: In patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.