title: Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using Botulinum Toxin A.
abstract: OBJECTIVE
  The operative management of complex ventral hernia poses a formidable challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. This study examines the effect of pre-operative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce temporary flaccid paralysis in order to facilitate laparoscopic repair of large complex ventral hernia.
  
  
  METHODS
  This is a prospective evaluation of 27 patients from January 2013 to August 2015 who underwent ultrasound guided BTA injections to the lateral abdominal wall muscles prior to elective complex ventral hernia repair. Non-contrast serial CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size and abdominal wall muscle thickness and length. Fascial defects were closed and hernias repaired using laparoscopic or laparoscopic-assisted intra-peritoneal onlay mesh (IPOM) techniques.
  
  
  RESULTS
  27 patients received pre-operative BTA injections which were well tolerated with no complications. Comparison of pre-BTA and post-BTA CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm pre-BTA to 19.9 cm post-BTA (p < 0.0001), with mean unstretched length gain of 4.2 cm/side (range 0-11.7 cm/side). All hernias were surgically reduced and repaired with mesh, with no early recurrences.
  
  
  CONCLUSIONS
  Pre-operative administration of BTA is a safe and effective technique in the pre-operative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes the laterally retracted abdominal muscles and enables laparoscopic closure of large complex ventral hernia.
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia.|Hernia Institute Australia, Edgecliff, Australia.
authors.forename: K E
authors.initials: KE
authors.lastname: Elstner
authors.affiliation: Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
authors.forename: A S W
authors.initials: AS
authors.lastname: Jacombs
authors.affiliation: Castlereagh Imaging, St Leonards, Australia.|Macquarie Medical Imaging, Macquarie University Hospital, Technology Place, Macquarie, Australia.
authors.forename: J W
authors.initials: JW
authors.lastname: Read
authors.affiliation: Hernia Institute Australia, Edgecliff, Australia.
authors.forename: O
authors.initials: O
authors.lastname: Rodriguez
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia.|Faculty of Medicine, Western Sydney University, Sydney, Australia.
authors.forename: M
authors.initials: M
authors.lastname: Edye
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia.|Hernia Institute Australia, Edgecliff, Australia.
authors.forename: P H
authors.initials: PH
authors.lastname: Cosman
authors.affiliation: Boca Raton Regional Hospital, Boca Raton, FL, USA.
authors.forename: A N
authors.initials: AN
authors.lastname: Dardano
authors.affiliation: Hernia Institute Australia, Edgecliff, Australia.
authors.forename: A
authors.initials: A
authors.lastname: Zea
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia.
authors.forename: T
authors.initials: T
authors.lastname: Boesel
authors.affiliation: Ohio State University Wexner Medical Centre, Columbus, OH, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Mikami
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia.
authors.forename: C
authors.initials: C
authors.lastname: Craft
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, Australia. dri@zip.com.au.|Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia. dri@zip.com.au.|Hernia Institute Australia, Edgecliff, Australia. dri@zip.com.au.
authors.forename: N
authors.initials: N
authors.lastname: Ibrahim
mesh_terms: D000009:Abdominal Muscles / Q000187:drug effects / Q000601:surgery; D034861:Abdominal Wall / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D011300:Preoperative Care; D011446:Prospective Studies; D013526:Surgical Mesh; D014945:Wound Healing / Q000187:drug effects
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A
keywords: Botulinum Toxin A; Chemical component relaxation; Complex ventral hernia; Incisional hernia