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Background Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP. Methods All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12 cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences. Results Twenty-three patients were included. Median age was 65 years (range 28-77) and median BMI was 31.4 (range 22.7-38.0 kg/m 2 ). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5 months (range 10-60 months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%). Conclusion Our algorithm using both anterior or posterior component separation, together with preoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.

Introduction: B. virosa is a gram-negative rod who was first identified in rat faeces in 2009. Since then only six human infections have been described in literature. We report a clinical case of a subcutaneous infection mimicking necrotizing fasciitis due to B. virosa. Patient and methods: A 78-year-old man was referred to our hospital because of a wound infection with suspicion of necrotizing fasciitis. Treatment consisted of immediate surgical exploration with obtainment of intra-operative specimens for microbiologic examination, 15 days of negative pressure wound therapy (NPWT) and antibiotic treatment with piperacillin-tazobactam (12 days) plus vancomycin (9 days). Results: Surgical exploration did not show necrotising fasciitis but a subcutaneous infection mimicking necrotising fasciitis. The intra-operative specimens revealed the presence of Butyricimonas virosa and Finegoldia magna. Cultures taken during the NPWT replacements became negative and the patient was able to leave the hospital after 18 days. Conclusions: Considering there was no necrotizing infection present it may have been possible to safely close the wound sooner. However it is difficult to differentiate between an actual necrotizing fasciitis and a subcutaneous infection mimicking necrotizing fasciitis. Therefore further studies on effective assessment tools to diagnose necrotizing fasciitis could be helpful.

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