Fascial closure in giant ventral hernias after preoperative botulinum toxin a and progressive pneumoperitoneum: A systematic review and meta-analysis

Abstract

Background: The primary objective was to assess the perioperative efficacy of the preoperative use of progressive pneumoperitoneum or Botulinum Toxin A injections in ventral hernia repair. Methods: Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar were systematically searched. Studies in English reporting on fascial closure, indications, complications or postoperative outcomes in adult patients that had undergone progressive pneumoperitoneum, Botulinum Toxin A injections, or both before ventral hernia repair were included. Study quality was assessed with the Oxford Levels of Evidence guidelines and the Methodological Index for Non-Randomized Studies criteria. A pooled fascial closure rate and recurrence rate were calculated with random effects models. Results: Twenty studies were included from the 905 identified, comprising the use progressive pneumoperitoneum (n ¼ 11), Botulinum Toxin A (n ¼ 6), and both techniques (n ¼ 3). The overall fascial closure rate was 0.94 (95% confidence interval 0.89e0.98). Indications for the use of progressive pneumoperitoneum or Botulinum Toxin A were based on objective (eg, computed tomography measurements) or subjective measures (eg, foreseen surgical problems). In contrast to the use of Botulinum Toxin A, reported complications with the use of progressive pneumoperitoneum were ample and sometimes severe. The cumulative reported recurrence rate was 0.03 (95% confidence interval 0.01e0.06). Conclusion: Preoperative progressive pneumoperitoneum and Botulinum Toxin A can facilitate fascial closure without causing significant numbers of adverse events. Botulinum Toxin A qualifies for lowthreshold use, yet progressive pneumoperitoneum should be used cautiously owing to a larger number of complications. Definitive recommendations cannot be made as the quality of included studies is low, bias is present, and comparative information is scarce. Registration number Information about the design and conduct of this systematic review has been registered on PROSPERO, registration number CRD42020181679.

The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure

“…A number of groups have described potential indications for BTX which range from specific hernia characteristics such as defect width, to less specific criteria driven by expert opinion or multi-disciplinary team meetings. A systematic review by van Rooijen et al (12) concluded that whilst certain given indications for PPP were fairly definitive (e.g., loss of domain more than 20%), indications for BTX were less so.…”

“…Similarly, when Deerenberg produced a prospective study of 108 patients from the Carolinas Medical Centre, the decision to use BTX was based on opinion and discussion among expert hernia surgeons (14). Others have identified further qualitative CT findings such as shortened or thickened lateral abdominal muscles (12).…”

“…Due to its long-acting effects, the ideal timing of pre-operative BTX likely involves a window of several days and has been described differently between authors. Early papers affirmed that the maximum effect of BTX is achieved at 2 weeks after injection (9,27), however a recent systematic review and metaanalysis found BTX being given anywhere between 6 and 45 days before surgery (12). When originally described, CT images were reviewed 4 weeks post BTX-upon which most patients has experienced a reduction in fascial defect size (7).…”

“…There have now been several systematic reviews that have looked at the quantifiable benefits of BTX. Early reviews only assessed fascial closure rates and hernia defect reduction (30) whereas others chose to focus on fascial closure rates as a primary variable (12). Wegdam et al (31) focused specifically on the quantifiable benefits of preoperative BTX.…”

“…Theoretically the paralysis of the lateral abdominal wall muscles would reduce tension across the wound, creating a more tensionfree healing process. van Rooijen et al (12) and Deerenberg et al (14) have both commented on the particularly low hernia recurrence rates after BTX treatment, the latter adding that insufficient long term studies exist to confirm how BTX may effect recurrence rates. Rodiriguez-Acevedo et al assert in their work that that BTX helps to protect midline wounds over the initial 3 months of healing (16).…”