Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation

Abstract

Background Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. ‘Venetian blinds’ technique of plication in combination with mesh reinforcement, is totally intra‐corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre‐operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. Methods A single‐centre case series was conducted using minimally invasive ‘Venetian blinds’ technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non‐midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200–300 units Botox) 4–6 weeks prior to surgery. Repairs were mesh‐reinforced following fascial closure. Results Twelve (10 female, two male) patients, with a median age 72 years (range 31–83) and body mass index of 27.3 kg/m2 (range 22.8–61.7) were included. The median length of operation was 133 min (range 45–290) and length of hospital stay 3 days (range 1–28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital‐acquired pneumonia and pseudomembranous colitis. Conclusion Minimally invasive ‘Venetian blinds’ technique has promising early results with both midline and non‐midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias.

The use of botulinum toxin A in chemical component separation: a review of techniques and outcomes

“…Our search yielded 47 articles, and 10 met our inclusion criteria for review [14,[16][17][18][19][20][21][22][23][24] . Two independent reviewers assessed the articles for inclusion.…”

“…Elstner et al [22] compared injection at all three of the external oblique (EO), internal oblique (IO), and transversus abdominis (TA) muscles, to injection at only the EO and IO. Chan et al [24] injected only at the level of the EO and IO while Ibarra-Hurtado et al [14,16] injected between the EO and IO in their 2013 study and did not specify the location of BTA injection in their 2009 study.…”

“…Bueno-Lledó et al [21] 2019 80 166 units* 10 total, 5 sites bilaterally, 16.6 U/5 mL per site, divided between EO, IO, and TA* 4 weeks prior to surgery Nielsen et al [23] 2020 37 300 units 6-10 total, 3-5 sites bilaterally, 5 U/1 mL or 2 u/1 mL evenly distrubuated to all sites between EO, IO, and TA 3-4 weeks prior to surgery Chan et al [24] The same group then conducted another prospective study of a series of 17 patients between 2009-2011. These patients were all males with midline ventral hernias who were at least 12 months out from laparotomy and open abdomen without formal abdominal closure.…”

“…The mean defect width was 12. In the most recent study by Chan et al [24] , 12 patients underwent preoperative BTA injections prior to hernia repair. On CT imaging after BTA, there was a statistically significant increase in both left (P = 0.004) and right (P = 0.014) sided mean abdominal wall lengths, with an increase in mean abdominal wall length of 4.0 ± 2.2 cm per side.…”

“…Nine of ten studies in our review reported on specific BTA related complications or side effects [16][17][18][19][20][21][22][23][24] . Five did not have any complications or side effects related to BTA administration [16,17,20,21,24] while the remaining four reported side effects without major complications [18,19,22,23] .…”