Preoperative Botulinum Toxin and Progressive Pneumoperitoneum are Useful in the Treatment of Large Incisional Hernias

Large incisional hernias (LIHs) represent a challenge for the abdominal wall surgeon. Preoperative tools such as progressive pneumoperitoneum (PPP) or botulinum toxin type A (BT) have been reported as useful in the preparation of patients with this type of hernias. Both procedures are complementary to hernia repair, using no-strain mesh techniques that support patients’ integral management.1 The purpose of this observational study was to report our experience in the treatment of 80 patients with LIH, with the combined use of PPP and BT. Of 643 patients operated on for ventral incisional hernia between May 2010 and May 2017 in our hospital, we analyzed retrospectively 80 patients with LIH, using prospectively collected data. Diameters of the abdominal cavity and hernia sac, as well as volume of the incisional hernia (VIH) and volume of the abdominal cavity (VAC), were calculated from multidetector CT scan, based on a modified index of Tanaka.2 Considering these measurements and physical examination, our group created an algorithm that was approved by our hospital’s Ethics Committee (Fig. 1). With the measurement of the VIH and VAC (calculating previously diameters of hernia and abdominal cavity, respectively), a VIH/VAC ratio was calculated. If this ratio was less than 20 per cent, the procedure of choice depended on the location and size of the hernia (anterior or posterior component separation, RivesStoppa repair, etc.), not being a candidate for our study. However, if the VIH/VAC ratio was higher than or equal to 20 per cent, regardless of the size of the hernia defect, the patient was included in the protocol of preoperative techniques. BT injections were performed as an outpatient procedure, four weeks before the planned operation, according to previous description of the technique.1 The location of the points for injection is guided by ultrasound to visualize the three lateral muscle layers to be infiltrated (external oblique, internal oblique, and transverse). The patient is placed in a lateral position, and five points of infiltration are defined: two on the axillary midline, at equidistant points between the rib edge and the iliac crest, and three more points on the anterior axillary and mid-clavicular line between the rib edge and superior iliac crest. This method is repeated on the contralateral side of the abdomen. A 5-mL injection of Dysport 1 (50 units/5 mL) is administered at each point: 50 U of BT are infiltrated in each of the five specific points on the right side and five on the left, for a total of 500 U, under ultrasound vision into each of the three muscle bellies of the lateral muscles. In our case, electromyographic (EMG) guidance complimented the ultrasound localization, confirming whether the muscle where we applied BTwas denervated or fibrotic, and it allowed modification of the injection point to another muscular area, ensuring its effectiveness. To apply PPP, an intraperitoneal catheter was placed preferably in the upper left quadrant, as was previously described.1 Catheter placement and initial insufflation were performed within hospital admission, and patients were discharged home within 48 to 72 hours of the onset of the process, continuing at the Home Care Unit on an outpatient basis. Approximately, the total volume of insufflation was three times the VIH (cc) in CT findings. This volume was introduced in small doses for one to two weeks for progressive adaptation: we induced an initial insufflation between 500 and 1000 cc of ambient air, monitoring the patient in his bed and asking him about the appearance of symptoms such as abdominal pain, dyspnea, or nausea. Subsequently, we insufflated 500 to 1000 cc of air to complete the scheduled daily volume. Patients were given prophylactic enoxaparin injections, which were withheld in the 24-hour preceding surgery. Pneumoperitoneum was maintained until the time of operation. Address correspondence and reprint requests to José Bueno Lledó, Ph.D., Department of Surgery, Hospital Universitari i Politecnic La Fe, Calle Gabriel Miró 28, Puerta 12, Valencia, Spain 46008. E-mail: bueno_joslle@gva.es.