Botox Injection and Progressive Preoperative Pneumoperitoneum to Facilitate a Complex Abdominal Hernia Repair

A loss-of-domain (LOD) hernia refers to a large hernia that contains a substantial portion, if not the majority, of intra-abdominal contents (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar). Repairing an LOD hernia is typically complex and is associated with significant morbidity and mortality due to decreased abdominal wall musculature compliance. Techniques such as progressive preoperative pneumoperitoneum (PPP) and injection of botulinum toxin A (BTA) into the abdominal wall have been developed to aid in repair and work by elongating, and inducing flaccid paralysis of, the contracted musculature (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar). PPP and BTA injection can be used concurrently and have shown promising results; however, data for this approach are limited and heterogeneous (2Deerenberg E.B. Elhage S.A. Raible R.J. 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: 1-7Crossref PubMed Scopus (24) Google Scholar, 3Timmer A.S. Claessen J.J.M. Atema J.J. Rutten M.V.H. Hompes R. Boermeester M.A. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction.Hernia. 2021; 25: 1413-1425Crossref PubMed Scopus (8) Google Scholar, 4Bueno-Lledó J. Carreño-Saenz O. Torregrosa-Gallud A. Pous-Serrano S. Preoperative botulinum toxin and progressive pneumoperitoneum in loss of domain hernias-our first 100 cases.Front Surg. 2020; 7: 3Crossref PubMed Scopus (25) Google Scholar). This case report describes the repair of an LOD hernia after combined image-guided PPP and BTA injections and includes 1-year postoperative abdominal cavity and abdominal wall musculature analysis. This report was granted institutional review board exemption. A 72-year-old woman with a body mass index of 37.1 kg/m2 and surgical history of 4 cesarean sections, abdominal hysterectomy, and 3 prior hernia repairs presented for a general surgery consultation for a large, chronic incisional abdominal hernia, which required repair prior to spinal surgery. Computed tomography (CT) scan with intravenous and oral contrast (Figure 1, Figure 2) revealed a large, broad-based abdominal wall hernia containing a nonobstructed small bowel and colon. Relevant measurements and calculations are shown in the Table.Figure 2The axial abdominal computed tomography image with oral contrast demonstrated an example of how the regions of interest (ROIs) were selected for the calculations for the abdominal (purple outline) and hernia sac (red outline) volumes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)TableMeasurements and Calculations from the PPP and BTA Injection CT and Postoperative CTAbdomen and hernia sac measurmentsPre-PPP and BTA injection CTPostoperative CTAbdominal wall defect size (CC × transverse)17 × 18 cmN/AHernia sac/protruded bowel∗The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2. size (CC × AP × transverse)36.4 × 11.0 × 32.3 cm31.8 × 10.6 × 32.4 cm∗The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2.Abdominal compartment size (CC × AP × transverse)37.3 × 10.6 × 25.1 cm37.4 × 13.2 × 31.2 cmHernia sac/protruded bowel∗The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2. volume6,771 mL5,661 mL∗The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2.Abdominal volume5,189 mL8,021 mLHernia sac volume/abdominal volume ratio130%70%∗The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2.Mean abdominal wall musculature length†Measurement of the abdominal wall musculature length was averaged from the length taken at 3 different axial slices.Right, 13.8; left, 11.8 cmRight, 16.7 cm; left, 15.5 cmAP = anteroposterior; BTA = botulinum toxin A; CC = craniocaudal; CT = computed tomography; N/A = not available; PPP = progressive preoperative pneumoperitoneum.∗ The protruded bowel was used for calculations on the postoperative imaging, using the same technique as shown in Figure 2.† Measurement of the abdominal wall musculature length was averaged from the length taken at 3 different axial slices. Open table in a new tab AP = anteroposterior; BTA = botulinum toxin A; CC = craniocaudal; CT = computed tomography; N/A = not available; PPP = progressive preoperative pneumoperitoneum. Because of the expected complex repair, interventional radiology was consulted for combined pre–hernia repair PPP and BTA injection. Thirty-five days prior to the surgical procedure, a total of 300 units of BTA (Botulinum Toxin Type A; Allergan, Madison, New Jersey) was injected into the internal oblique, external oblique, and transversus abdominis muscles at their superior, mid, and inferior portions with a 22-gauge needle under ultrasound (US) and CT guidance (Fig 3). Subsequently, using CT guidance, after initial access with a 19-gauge trocar, an 8-F locking loop drain was placed over a guide wire into the anterolateral intraperitoneal space and sutured in place. The abdomen was then insufflated with 300 mL of air, and CT images confirmed appropriate tube position and pneumoperitoneum (Fig 4). The drain was left in place, and the patient was discharged.Figure 4The axial abdominal unenhanced computed tomography image demonstrated the peritoneal catheter entering the abdominal cavity (arrow) and the resultant pneumoperitoneum (arrowhead).View Large Image Figure ViewerDownload Hi-res image Download (PPT) An additional 200–300 mL of air was insufflated weekly in the surgeon’s office, resulting in approximately 1,300 mL of air in the abdomen. Four days prior to the surgery, PPP was terminated, and the 8-F drain was removed. The patient then underwent laparotomy that required a 25 × 40–cm mesh for abdominal wall closure. She was discharged 10 days after surgery. Approximately 11 months later, the patient returned to the hospital for reasons unrelated to the hernia or hernia repair, and unenhanced CT (Fig 5) was performed. This demonstrated diffuse, broad protuberance of the lower anterior abdominal and pelvic contents, all contained within the mesh repair, without evidence of recurrent hernia. Relevant measurements are shown in the Table. The postoperative measurements are of the protruded bowel. The combination of PPP and BTA injection prior to large abdominal hernia repairs has shown promising results although data are limited to a few small studies and there is still a lack of concise patient selection criteria, procedural standardizations, and understanding of long-term alterations to the abdominal wall (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar, 2Deerenberg E.B. Elhage S.A. Raible R.J. 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: 1-7Crossref PubMed Scopus (24) Google Scholar, 3Timmer A.S. Claessen J.J.M. Atema J.J. Rutten M.V.H. Hompes R. Boermeester M.A. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction.Hernia. 2021; 25: 1413-1425Crossref PubMed Scopus (8) Google Scholar). In general, a wall defect size of 10 cm or a hernia-volume-to-abdominal-compartment-volume ratio of >20% or >25% has been used as a relative indication for PPP and/or BTA injection (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar,3Timmer A.S. Claessen J.J.M. Atema J.J. Rutten M.V.H. Hompes R. Boermeester M.A. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction.Hernia. 2021; 25: 1413-1425Crossref PubMed Scopus (8) Google Scholar). A variety of techniques to perform PPP and BTA injection have been reported. PPP can vary from the volume of induced pneumoperitoneum to the type of gas utilized during the procedure (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar). The BTA injection techniques also vary in multiple aspects, such as the number and location of injection sites, BTA dosage, and timing of injection (2Deerenberg E.B. Elhage S.A. Raible R.J. 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: 1-7Crossref PubMed Scopus (24) Google Scholar, 3Timmer A.S. Claessen J.J.M. Atema J.J. Rutten M.V.H. Hompes R. Boermeester M.A. A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction.Hernia. 2021; 25: 1413-1425Crossref PubMed Scopus (8) Google Scholar, 4Bueno-Lledó J. Carreño-Saenz O. Torregrosa-Gallud A. Pous-Serrano S. Preoperative botulinum toxin and progressive pneumoperitoneum in loss of domain hernias-our first 100 cases.Front Surg. 2020; 7: 3Crossref PubMed Scopus (25) Google Scholar). The sole use of US guidance to inject BTA is the most common method (1Martínez-Hoed J. Bonafe-Diana S. Bueno-Lledó J. A systematic review of the use of progressive preoperative pneumoperitoneum since its inception.Hernia. 2021; 25: 1443-1458Crossref PubMed Scopus (20) Google Scholar,2Deerenberg E.B. Elhage S.A. Raible R.J. 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: 1-7Crossref PubMed Scopus (24) Google Scholar,4Bueno-Lledó J. Carreño-Saenz O. Torregrosa-Gallud A. Pous-Serrano S. Preoperative botulinum toxin and progressive pneumoperitoneum in loss of domain hernias-our first 100 cases.Front Surg. 2020; 7: 3Crossref PubMed Scopus (25) Google Scholar). The combined use of US and CT helps to ensure optimal visualization and injection of BTA into the musculature, particularly when the musculature is severely atrophied or US visualization is limited because of body habitus. Follow-up imaging 1 year later was able to show the relatively long-term success of the PPP and BTA injection–assisted complex hernia repair from both cosmetic and surgical standpoints by demonstrating a maintained increase in the abdominal compartment volume as well as an increase in the abdominal wall musculature length, with a 46% decrease in the ratio of the herniated/protruded bowel volume and abdominal volume.