The Fine Art of BTA in Complex Ventral Hernia Repair

Researchers have refined the use of Botulinum Toxin A in counteracting the chronic muscle retraction required in large ventral hernia repair. By sparing the transversus abdominis from paralysis, the refined technique preserves an important component of abdominal stability and does not detract from the ability to primarily close complex defects.

Complex ventral hernia repair remains a significant challenge with high morbidity and recurrence.

Recent studies have shown significant benefits are achievable with preoperative Botulinum Toxin A (BTA) for paralysis to theabdominal wall muscles. BTA acts by causing flaccid paralysis in treated muscles, facilitating closure without disrupting the integrity of the abdominal wall tissues.

Previously, the procedure administered BTA to all three abdominal wall muscle layers – the TA, the Internal Oblique (IO) and the External Oblique (EO) – to maximise the benefits of paralysis. However, with the TA known to play an integral role in truncal stability, its paralysis can result in unwanted physiological changes, including back pain.

The newly published research – a collaboration between Macquarie University Hospital, Macquarie Medical Imaging, the University of Notre Dame and the Hernia Institute of Australia – looks at sparing the TA to retain it as an important stabiliser.

“This study is the first to report on selective administration of pre-operative BTA to internal and external oblique muscles only, thus sparing transversus abdominis from paralysis,” explained Associate Professor Nabeel Ibrahim, who operates at Macquarie University Hospital and specialises in the repair of large ventral hernias and was part of the surgical team who established the use of BTA in treating complex hernia cases.

“We undertook a prospective observational study of 46 patients who underwent either selective two-layer (IO and EO only) or standard three-layer (TA, IO and EO) abdominal wall muscle BTA injection prior to elective laparoscopic ventral hernia repair.

“Results show the same outcomes in both groups. Fascial closure was achieved in all cases, with no postoperative hernia recurrence to date. This means that patients undergoing this procedure should experience better outcomes with regard to core abdominal strength.”

The research is published in Hernia: The Journal of Hernia and Abdominal Wall Surgery by authors: K E Elstner, J W Read, J Saunders, P H Cosman, O Rodriguez-Acevedo, A S W Jacombs, R T Martins and N Ibrahim.

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