Botulinum Toxin Type a and Progressive Pneumoperitoneum: Preoperative Adjuvants for the Management of Complex Hernia with Loss of Dominance: A Case Report
Main Article Content
Abstract
Introduction: The rising prevalence of complex ventral hernias (CVH), due to factors like obesity and previous surgeries, requires new and innovative preoperative approaches. Progressive pneumoperitoneum (PPP) and botulinum toxin (BTX) are emerging adjuncts that can improve surgical outcomes for hernias with loss of domain by aiding fascial closure and reducing recurrence rates.
Clinical Case: A 33-year-old female presented with a giant, non-reducible ventral hernia (30cm × 20 cm) following multiple abdominal surgeries. Imaging revealed a Tanaka index of 20%, confirming a complex hernia with loss of domain. Preoperative management included BTX injection (500 units) and progressive pneumoperitoneum insufflation (8500 cc total) over seven days. Surgical repair involved posterior component separation with mesh placement. The patient recovered favorably, with no complications or recurrence.
Discussion: Preoperative optimization with BTX and PPP facilitated fascial closure by improving muscle compliance and reducing adhesions. These techniques enhanced surgical feasibility and reduced postoperative complications.
Conclusions: This case demonstrates the benefits of using BTX and PPP as preoperative adjuncts for complex hernia repair. Further studies are needed to standardize protocols and assess long-term outcomes.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
I. Parker SG, Halligan S, Liang MK, et al. Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons. World J Surg. 2020;44(4):1070-1078. doi:10.1007/S00268-019-05317-Z
II. 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/METRICS
III. Leopoldo Maldonado García E, Torreón Coahuila A, Salgado García I, Martínez Reyes J, López Hernández C, Moreno González G. Hernia incisional gigante y oclusión intestinal, un reto médico-quirúrgico. Acta Médica Grupo Angeles. 2022;20(3):272-274. doi:10.35366/105733
IV. López Sanclemente MC, Robres J, López Cano M, et al. Neumoperitoneo preoperatorio progresivo en pacientes con hernias gigantes de la pared abdominal. Cir Esp. 2013;91(7):444-449. doi:10.1016/J.CIRESP.2012.08.004
V. Deerenberg EB, Elhage SA, Raible RJ, et al. Image-guided botulinum toxin injection in the lateral abdominal wall prior to abdominal wall reconstruction surgery: review of techniques and results. Skeletal Radiol. 2021;50(1). doi:10.1007/S00256-020-03533-6
VI. Hernández López A, Villalobos Rubalcava EJ. Infiltración de toxina botulínica en la preparación preoperatoria de las hernias con defectos de 10 cm (y hasta 15 cm). Revista Hispanoamericana de Hernia. 2016;4(2):43-49.
doi:10.1016/J.REHAH.2016.02.003
VII. Ibarra Hurtado TR, Negrete Ramos GI, Preciado Hernández F, Nuño Guzmán CM, Tapia Alcalá E, Bravo Cuellar L. Toxina botulínica A como adyuvante en hernia inguinoescrotal bilateral con pérdida de domicilio. Informe del primer caso y revisión bibliográfica. Revista Hispanoamericana de Hernia. 2014;2(4):139-144.
doi:10.1016/J.REHAH.2014.06.002
VIII. Pous Serrano S, Bueno Lledó J, García Pastor P, et al. Utilización de la toxina botulínica tipo A en la prehabilitación de la musculatura de la pared abdominal para la reparación herniaria. Una propuesta de consenso. Cir Esp. 2024;102(7):391-399. doi:10.1016/J.CIRESP.2023.12.004
IX. Serafio-Gómez JL, Aragón-Quintana C, Bustillos-Ponce M, et al. Effective Management of Giant Ventral Hernias: A Comprehensive Approach Combining Preoperative Botulinum Toxin Application, Modified Ramírez’s Component Separation, and Rives-Stoppa Hernioplasty. Cureus. 2023;15(11). doi:10.7759/CUREUS.48967