title: Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia.
abstract: Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair.
  
  
  
  This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh.
  
  
  
  Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0-11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date.
  
  
  
  Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects.
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia.|Hernia Institute Australia, Edgecliff, NSW, Australia.
authors.forename: Kristen E
authors.initials: KE
authors.lastname: Elstner
authors.affiliation: Castlereagh Imaging, St Leonards, NSW, Australia.|Macquarie Medical Imaging, Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia.
authors.forename: John W
authors.initials: JW
authors.lastname: Read
authors.affiliation: Hernia Institute Australia, Edgecliff, NSW, Australia.
authors.forename: Omar
authors.initials: O
authors.lastname: Rodriguez-Acevedo
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia.|Hernia Institute Australia, Edgecliff, NSW, Australia.|Western Sydney University, Penrith, NSW, Australia.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Cosman
authors.affiliation: Boca Raton Regional Hospital, Boca Raton, FL, USA.
authors.forename: Anthony N
authors.initials: AN
authors.lastname: Dardano
authors.affiliation: Faculty of Medicine and Health Sciences, Macquarie University, Macquarie, NSW, Australia.
authors.forename: Anita S W
authors.initials: AS
authors.lastname: Jacombs
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia.|Western Sydney University, Penrith, NSW, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Edye
authors.affiliation: Hernia Institute Australia, Edgecliff, NSW, Australia.
authors.forename: Aaron
authors.initials: A
authors.lastname: Zea
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia.
authors.forename: Tillman
authors.initials: T
authors.lastname: Boesel
authors.affiliation: Ohio State University Wexner Medical Centre, Columbus, OH, USA.
authors.forename: Dean J
authors.initials: DJ
authors.lastname: Mikami
authors.affiliation: Macquarie University Hospital, Technology Place, Macquarie, NSW, Australia. Dri@zip.com.au.|Hernia Institute Australia, Edgecliff, NSW, Australia. Dri@zip.com.au.|Faculty of Medicine and Health Sciences, Macquarie University, Macquarie, NSW, Australia. Dri@zip.com.au.
authors.forename: Nabeel
authors.initials: N
authors.lastname: Ibrahim
mesh_terms: D000009:Abdominal Muscles / Q000000981:diagnostic imaging*; D034861:Abdominal Wall / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D017558:Elective Surgical Procedures; D005205:Fascia; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D009929:Organ Size; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D013526:Surgical Mesh; D014057:Tomography, X-Ray Computed
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A
keywords: Botulinum toxin A; Chemical component relaxation; Complex ventral hernia; Incisional hernia