Combined use of Botulinum Toxin A and Intraoperative Fascial Traction in the Treatment of Postoperative Ventral Hernia W3 with Domain Loss: a Clinical Case

The treatment of giant incisional ventral hernias with significant loss of domain is a major surgical challenge associated with a high risk of abdominal compartment syndrome and recurrence. Aim. To demonstrate the effectiveness of the combined use of preoperative injection of botulinum toxin A into the broad muscles of the anterior abdominal wall and intraoperative fascial traction in the complex treatment of postoperative ventral hernia W3 with a pronounced domain loss of 53 % based on a detailed analysis of the clinical case and current literature data. Materials and methods. A detailed analysis of the clinical case of a 55-year-old patient with incisional ventral hernia W3 (large) M3 (midline) R0 (primary), characterised by a significant loss of the abdominal domain (more than 30 % of the contents in the hernial sac) and multiple concomitant pathology is presented. The uniqueness of the case is the combination of a pronounced domain loss (53 %) with a narrow hernia gate (11 centimeter), which in typical situations is associated with moderate domain loss (10–25 %) and a lower risk of complications. Here, narrow gates and domain loss increase the risk of abdominal compartment syndrome during reduction without preparation, requiring a combined approach with botulinum toxin A and fascial traction. 4 weeks before the operation, 300 International Units Botulinum toxin A was administered to relax the muscles of the abdominal wall. Intraoperatively, fascial traction was applied to restore the volume of the abdominal cavity. Intra-abdominal pressure was controlled through a catheter in the bladder. Postoperative management included monitoring of vital functions and prevention of complications. Results. Injection of Botulinum toxin A into the broad muscles of the abdominal wall during the pre-rehabilitation period provided lengthening of the broad muscles of the abdominal wall by 3-5 centimeter on each side. Intraoperative application of intraoperative fascial traction (30 minutes of vertical diagonal traction) allowed to achieve adequate comparison of the edges of the defect measuring 20×10 centimeter without performing traumatic component separation. The intraabdominal pressure after reconstruction was 12 centimeter of water (initially 8.5 centimeter of water), which prevented the development of abdominal compartment syndrome. The patient was discharged on the 12th day in a satisfactory condition with wound healing by primary tension. Conclusion. The combined use of Botulinum toxin A and intraoperative fascial traction is a pathogenetically sound and clinically effective strategy for the treatment of complex incisional ventral hernias with domain loss. This approach allows you to minimise surgical trauma, reduce the risk of postoperative complications and improve functional results.

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