Reducing Transversus Abdominis Release Hernioplasty Operative Volume Using Preoperative Botulinum Toxin Injections.

Large postoperative ventral hernias present significant challenges for repair, particularly in patients with comorbidities and wide defects. Here, we report the case of a 65-year-old male with a recurrent midline postoperative ventral hernia classified as M1-4W3R1 according to the European Hernia Society. CT revealed a defect measuring 15.1 × 18.2 cm with loss of domain. To facilitate closure, the patient underwent preoperative intramuscular injections of 500 units of botulinum toxin type A (BTA) into the external oblique, internal oblique, and transversus abdominis muscles under ultrasound guidance. Four weeks later, imaging demonstrated elongation of the lateral abdominal muscles and reduction of the defect width to 10.8 cm, which allowed a change in operative strategy from bilateral to unilateral transversus abdominis release hernioplasty. Primary tension-free fascial closure was achieved, reinforced with a 30 × 30 cm retromuscular polypropylene mesh. The postoperative course was uneventful, and at the sixth-month follow-up, there was no recurrence, with a marked improvement in quality of life. This case illustrates the feasibility and effectiveness of preoperative BTA injections in reducing operative complexity and enabling safe repair of large recurrent ventral hernias.