Preoperative combination of PPP and BT is feasible and a useful tool in the surgical management of LIH, although at the cost of some specific complications.
Using a CT volumetric protocol, combination of PPP and BT decreases the VIH/VAC ratio and hernia defect diameters, which constitutes a key factor in the treatment of LODH.
Objectives: Preoperative botulinum toxin type A (BT) and progressive pneumoperitoneum (PPP) are useful tools in the preparation of patients with loss of domain hernias (LODH). The purpose of our retrospective study is to report our experience in the treatment of 100 consecutive patients with LODH, with the combined use of these techniques. Methods: Of the 753 patients operated on for ventral incisional hernia between June 2010 and December 2018 in our hospital, 100 patients with LODH were analyzed retrospectively. Diameters of abdominal cavity and hernia sac, and volumes of incisional hernia (VIH) and abdominal cavity (VAC) were calculated from CT scan, based on the index of Tanaka.Results: The median insufflated volume of air for PPP was 8,600 ± 4,200 cc (4,500-15,250). BT administration time was 38.2 days (33-48). A significant average reduction of 15% of the VIH/VAC ratio was observed on CT scan after the combination of PPP and BT (p = 0.001). Anterior component separation (CST) and transversus abdominis release (TAR) were the most frequent repair techniques. Complete fascial closure was possible in 97%, and mesh bridging was needed in three cases. In postoperative follow-up of 34.5 months (11-62), we reported eight cases of hernia recurrence (8%).Conclusion: PPP and BT are useful tools in the treatment of LODH. These techniques significantly reduce the VIH/VAC ratio, allowing the reduction of the hernia content into the abdominal cavity, which represents a key factor in the management of these hernias.
Preoperative diagnosis of MS is difficult, but it is essential in the proper management of the disease. Investigations as magnetic cholangiography resonance and endoscopic retrograde cholangiopancreatogram contribute to the success of preoperative identification. LC should be reserved to MS type I and type II highly selected cases. This pathology should be treated by experienced surgeons to decrease the risk of iatrogenia.
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