Using an innovative technique, Macquarie University Hospital is now able to treat large, previously inoperable hernias through the use of pre-operative Botox.

A new multidisciplinary team at Macquarie University Hospital is using a novel technique for treating large ventral incisional hernias often deemed inoperable.

These are patients with a bad surgical history and for whom repeated attempts at repair have failed,” said Dr Nabeel Ibrahim, General Surgeon at Macquarie University Hospital and founder of the Australian Hernia Centre.

Unlike small hernia repair, where tissue regrows over the mesh used, in these larger hernias, complete tissue ingrowth cannot occur across the wide defect. Typically these hernias have been treated through major reconstruction of the abdominal wall, with mesh used as an adjunct to reduce recurrence – an approach that compromises lateral muscle function and possible long term trunk and back instability complication.”

In a recent innovation, Dr Ibrahim and his team have implemented a novel approach that uses pre-operative Botulinum toxin A (BTA) injections into the lateral abdominal wall muscles. Botox promotes relaxation, and subsequent elongation of the oblique muscles of the abdominal wall.

“The relaxation brought about by the Botox means the two sides of the hernia opening come together with remarkable ease,” explained Dr Ibrahim.

“This approach means we no longer have to sacrifice lateral muscles to rebuild the hernia closure defect area.”

BTA also contributes to a tension-free repair in the post-operative period, as it remains active for two months or longer protecting the repair line during the critical healing period. Early data suggests BTA also assists with pain management. At Macquarie University Hospital, the hernia team is able to perform almost all of these procedures laparoscopically or, in some cases, robotically.

“The key to this procedure is a focused multidisciplinary team consisting of surgeons, radiologists, pain control specialists, microbiologists and nurse educators,” said Dr Ibrahim. “The team must understand the procedure. For example, it is important to have radiologists who understand the abdominal wall and can look at each patient from a clinical point of view.

“The pre-operative imaging and assessment done by a dedicated radiologist is paramount and can assist the surgeon by providing insight not only into the structural defects of the hernia, but also into related issues around overall abdominal wall function.”

The Botox procedure is carried out 10 days prior to surgery and in some cases, in conjunction with the use of progressive preoperative pneumoperitoneum (PPP) – first used in 1947 as a technique designed to expand the capacity of the abdominal cavity. In larger hernia repair, PPP helps to further stretch the muscles and so reduce the risk of post-operative increase of intra-abdominal pressure. It also assists with pre-operative functional imaging to further delineate hernia anatomy.

“Ultimately, a multidisciplinary team in hernia surgery can also ensure that care is coordinated,” said Dr Ibrahim.

“Total patient management and integrated care is increasingly recognised as a factor that can improve patient care and outcomes. Because some patients undergoing large incisional hernia repair are obese, our team can also work with bariatric specialists and surgeons to consider weight loss surgery prior to hernia repair. Excess weight is a major factor in the failure of large hernia repair.”

The Botox program for hernia repair has been running for three years, and the team is currently collecting three-year data. They have performed around 50 repairs using this technique and have not recorded a single failure. The team is the only multidisciplinary hernia team in Australia.


Wendi Murray went undiagnosed with a large hernia for 15 months. When she finally had an abdominal CT scan, it showed a clinical incisional hernia that had grown to 19cm by 16.5cm. She was referred to Dr Nabeel Ibrahim, who gave her six Botox injections – three on each side – about a month prior to the operation. When operating, Dr Ibrahim closed the hernia by bringing the two sides together, using mesh reinforcement.

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