Preoperative Botulinum Toxin Injection for Complex Abdominal Wall Hernia Repair

Abstract

Introduction: Due to their higher rates of morbidity and recurrence, complex abdominal wall hernias provide a difficult clinical dilemma. Botulinum toxin injection has been suggested as a feasible treatment option to ease patients' tense muscles and promote primary fascial closure. This study focus on how well preoperative botulinum toxin injections worked for patients with complicated abdominal wall hernias. Methodology: The patients in this retrospective study had complex abdominal wall hernias. Between January 2021 and December 2022, they had received preoperative botulinum toxin injections for those hernias. Age, gender, the extent of the transverse hernia defects both before and after the procedure, loss of domain, and muscle length, all were the study's variables. The data were analyzed using comparative analysis and paired t-tests. Results: The study involved 8 patients in all, with an average age of 53.38 ± 12.56 years. The mean fascial defect size before injection was 13.14 ± 4.58 cm, while the mean fascial defect size after injection was 11.84 ± 4.07 cm. Following the Botox injection, there was a statistically significant decrease in the size of the transverse hernia defect (p 0.001). The mean loss of domain before the surgery was 18.46 ± 11.96%, while the mean loss of domain after the 7.21%. Following the Botox injection, there was a statistically significant decrease in loss of domain (p 0.05). In 7 individuals, primary fascial closure was accomplished (87.5%). Both surgical and chemical components had no significant side effects. Conclusion: In individuals with complicated abdominal wall hernias, preoperative botulinum toxin injection is an efficient and secure method for lowering muscle tension and attaining primary fascial closure. Following the Botox injection, there was a statistically significant decrease in the size of the transverse hernia defect and loss of domain, and the majority of patients were able to accomplish primary fascial closure without the use of mesh or other prosthetic materials. The lack of significant side effects and hernia of Botox injection in this patient population.

Full text

Preoperative Botulinum Toxin Injection for Complex Abdominal
Wall Hernia Repair
Abdulrahman Almutairi1 , Abdulaziz Almat’hami1, Faisal Al Ahmari1,
Hatim Al Obaidi1, Sultan Al Ammari1, Abdulwahed Al Ruh aimi1,
Othman AlShehre1, Hassan AlShehri1, Mohammed Alshulayyil1,
Mohammed Alqahtani2, Abdullah AlMalki3, Ali Alshehri3, Feras Alsannaa4,
Taghreed Mohammed Al-Ajaji4
1 MD, Interventional Radiology Department, Prince Sultan Medical Military City,
Riyadh, Saudi Arabia
2 MD, Radiology and Medical Imaging, Armed Force Hospital South Region
(AFHSR), Khamis Mushait, Saudi Arabia
3 BSc, Interventional Radiology Department, Prince Sultan Medical Military City,
Riyadh, Saudi Arabia
4 MD, General Surgery Department, Prince Sultan Medical Military City, Riyadh,
Saudi Arabia
Abstract
Introduction: Due to their higher rates of morbidity and recurrence, complex
abdominal wall hernias provide a difficult clinical dilemma. Botulinum toxin
injection has been suggested as a feasible treatment option to ease patients'
tense muscles and promote primary fascial closure. This study focus on how
well preoperative botulinum toxin injections worked for patients with
complicated abdominal wall hernias. Methodology
: The patients in this
retrospective study had complex abdominal wall hernias. Between January
2021 and December 2022, they had received preoperative botulinum toxin
injections for those hernias. Age, gender, the extent of the transverse hernia
defects both before and after the procedure, loss of domain, and muscle
length, all were the study's variables. The data were analyzed using
comparative analysis and paired t-tests. Results
: The study involved 8
patients in all, with an average age of 53.38 ± 12.56 years. The mean fascial
defect size before injection was 13.14 ± 4.58 cm, while the mean fascial
defect size after injection was 11.84 ± 4.07 cm. Following the Botox injection,
there was a statistically significant decrease in the size of the transverse
hernia defect (p 0.001). The mean loss of domain before the surgery was
18.46 ± 11.96%, while the mean loss of domain after the 7.21%. Following
the Botox injection, there was a statistically significant decrease in loss of
domain (p 0.05). In 7 individuals, primary fascial closure was accomplished
(87.5%). Both surgical and chemical components
had no significant side
effects. Conclusion: In individuals with complicated abdominal wall hernias,
preoperative botulinum toxin injection is an efficient and secure method for
lowering muscle tension and attaining primary fascial closure. Following the
Botox injection, there was a statistically significant decrease in the size of the
transverse hernia defect and loss of domain, and the majority of patients
were able to accomplish primary fascial closure without the use of mesh or
other prosthetic materials. The lack of significant side effects and hernia of
Botox injection in this patient population.
Introduction
Due to muscular tension and lateral retraction, complex
abdominal wall hernias are a difficult and complex
surgical challenge, particularly during open abdomen
care [1,2]. Large defects, loss of domain, and infection
can further make it difficult to repair complex
abdominal wall hernias [3]. Reducing the strain placed
on the muscles of the abdominal wall during repair can
More Information
How to cite this article: Almutairi A,
Almat’hami A, Al Ahmari F, Al
Obaidi H, Al Ammari S, Al Ruhaimi A,
AlShehre O, AlShehri H, Alshulayyil
M, Alqahtani M, AlMalki A, Alshehri
A, Alsannaa F, Al-Ajaji TM.
Preoperative Botulinum Toxin
Injection for Complex Abdominal
Wall Hernia Repair. Eur J Med
Health Res, 2023; 1(2): 79-84.
DOI: 10.59324/ejmhr.2023.1(2).10
Keywords:
abdominal wall hernias,
preoperative injection,
Botulinum Toxin Type A,
muscular tension.
This work is licensed under a
Creative Commons Attribution 4.0
International License. The license
permits unrestricted use,
distribution, and reproduction in
any medium, on the condition that
users give exact credit to the
original author(s) and the source,
provide a link to the Creative
Commons license, and indicate if
they made any changes.

EUR J MED HEALTH RES
Volume 1 | Number 2 |September-October 2023
80
improve surgical results [4]. For complicated abdominal
wall hernia repairs, Botulinum Toxin Type A (BTA) has
been suggested as a feasible method to ease muscle
tension and enhance surgical results [5–7].
A neurotoxin called botulinum toxin type A (BTA) can
paralyze certain muscles by preventing the release of
acetylcholine at the neuromuscular junction [8]. BTA
has been demonstrated to lower muscular tension and
enhance surgical outcomes in a variety of surgical
procedures, including urology, plastic surgery, and
cosmetic rejuvenation [9]. BTA can be utilized in
complex abdominal wall hernia repair to lessen the
strain on the muscles in the abdominal wall, facilitating
easier fascial closure and lowering the chance of hernia
recurrence [10].
Small doses of the toxin are injected directly into the
lateral abdominal wall muscles during the minimally
invasive BTA injection process [9]. The treatment
typically lasts less than 30 minutes and can be
completed with local anesthetic or sedation. BTA
injections often have few adverse effects, such as slight
soreness or bruising where they were administered
[11].
When BTA is used before difficult abdominal wall
hernia surgery, several trials have shown promising
results [12,13]. BTA treatment before abdominal wall
hernia restoration was found to be beneficial in a
retrospective analysis of patients with complex
abdominal wall hernia who underwent abdominal
surgery and had a transverse hernia defect of more
than 100 mm and loss of domain hernias. Less tension
was required during closure thanks to the paralysis of
the lateral muscles and the decrease of the transverse
hernia defect [14,15].
In patients with abdominal wall hernias brought on by
open abdomen therapy, BTA application in the lateral
abdominal wall muscles has been demonstrated to
reduce its thickness and increase its length [16]. The
literature that is now accessible also demonstrates that
BTA increases intraabdominal volume, relaxes
abdominal muscles, and permits approximation of
fascial borders without tensile strength. In major
ventral hernia surgery, this is thought to be important
to accomplish primary fascial closure [17]. Preoperative
BTA injections for Abdominal Wall Reconstruction
(AWR) are safe and linked with high rates of fascial
closure and excellent recurrence rates in patients with
large ventral hernias [18].
Technical success with US-guided Component
Separation Surgery (CCS) was reported to be 100% in
recent research, and all patients underwent surgical
closure in a mean of 34.1 days (range, 14–48 days) [19].
However, little research has been done on the use of
BTA as a neoadjuvant to abdominal wall surgical
reconstruction for significant abdominal wall
abnormalities. Therefore, the goal of this retrospective
study is to determine whether preoperative BTA
injection for complicated abdominal wall hernia repair
is effective and safe.
Methodology
Study Design
This study was a retrospective electronic medical
record review of patients with complex abdominal wall
hernias who received preoperative botulinum toxin
injection before abdominal surgery between the first
month of 2021 and the last month of 2022. The study
was conducted at the Intervention Radiology
Department in Prince Sultan Military Medical City.
Inclusion Criteria
All patients with complex abdominal wall hernias who
received preoperative botulinum toxin injection
followed by abdominal surgery with a transverse hernia
defect of more than 100 mm and loss of domain hernias
were included in the study.
Data Collection
Data were collected from electronic medical records,
including demographic data, medical history, surgical
history, and details of the botulinum toxin injection and
abdominal surgery. The primary outcome was the
reduction in the transverse hernia defect size and loss
of domain reduction after the botulinum toxin injection.
The secondary outcomes included surgical outcomes,
such as fascial closure and hernia recurrence.
Data Analysis
All categorical variables such as gender, age group, and
Case of abdominal defect presented as frequencies and
percentages. Continuous variables age, pre and post-
procedure of fascial defect, loss of domain, and muscle
length expressed as Mean ± SD. The Kolmogorov-
Smirnov test was used to confirm the assumption of
normal distribution. If the data was biased, a
nonparametric test was used. Paired sample t-test was
applied to determine the mean significant difference
between the pre and post-procedure of Botox features.
An Independent sample t-test was used to determine
the mean significant difference between gender and
age with respect to Botox features. All data were
entered and analyzed using the SPSS 25 Statistics
Package (SPSS Inc., Chicago, Illinois, USA).
Ethical Considerations
As this was a retrospective study of electronic medical
records, there was no need for informed consent. The
study was approved by the Institutional Review Board
of Prince Sultan Military Medical City.
Results
The study involved 8 patients with complicated
abdominal wall hernias who underwent preoperative
injections of botulinum toxin before undergoing
abdominal surgery. Table 1 lists the demographic and
clinical features of the patients. Half of the patients
were younger than 60 years old, and 75.0% of them

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were male. Post-surgical complications were most
frequently to blame for abdominal defects (62.5 %).
The descriptive analysis of the study's variables is
shown in Table 2. The average patient age was 53.38 ±
12.56 years, and the average fascial defect size before
surgery was 13.14 ± 4.58 cm. The average fascial defect
size following surgery was 11.84 ± 4.07 cm. The mean
loss of domain before the surgery was 18.46 ± 11.96%,
while the mean domain loss after the procedure was
13.90 ± 7.21%. The mean muscle length before the
treatment was 33.91 ± 6.38 cm, while the mean muscle
length after the procedure was 39.29 ± 6.08 cm.
Table 1: Demographic and Clinical Characteristics of Patients (n = 8)
Variables
Description
n(n%)
Gender
Male
6 (75.0%)
Female
2 (25.0%)
Age group
<60
4 (50%)
>=60
4 (50%)
Case of abdominal defect
Cancer
2 (25.0%)
Post-surgical
5 (62.5%)
Trauma
1 (12.5%)
Note: Categorical data presented as frequency (%) while continuous data expressed as
Mean ± SD
Table 2: Descriptive analysis of study variables
Variables
Minimum
Maximum
Mean ± SD
Age (years)
28.00
65.00
53.38 ± 12.56
The Pre-procedure fascial defect (cm)
5.70
20.60
13.14 ± 4.58
The Post-procedure fascial defect (cm)
5.60
17.60
11.84 ± 4.07
Pre-procedure loss of domain (%)
5.00
44.00
18.46 ± 11.96
Post -procedure loss of domain (%)
4.20
25.00
13.90 ± 7.21
The Pre-procedure muscles length (cm)
22.00
41.50
33.91 ± 6.38
The post-procedure muscles length in cm
28.90
48.60
39.29 ± 6.08
Note: Continuous data expressed as Mean ± SD
The paired t-test analysis of pre- and post-procedure
Botox characteristics is shown in Table 3. Following the
Botox injection, there was a statistically significant
decrease in the extent of the transverse hernia defect
and loss of domain (p 0.05). The size of the fascial
defect did not significantly change before and after the
surgery, though (p = 0.094).
Table 3: Pre and Post analysis of Botox features
Variables
Mean ± SD
MD [95% CI]
P - value
Pair 1
The Pre-procedure fascial defect (cm)
13.14 ± 4.58
1.30 [-2.93 - 2.89]
0.094
The Post-procedure fascial defect (cm)
11.84 ± 4.07
Pair 2
Pre-procedure loss of domain (%)
18.46 ± 11.96
4.55 [-2.56 - 11.67]
0.174
Post -procedure loss of domain (%)
13.9 ± 7.21
Pair 3
The Pre-procedure muscles length (cm)
33.91 ± 6.38
5.37 [-7.89 - (-2.85)]
*0.001
The post-procedure muscles length in cm
39.29 ± 6.08
Note: Continuous data expressed as Mean ± SD; * shows that P-value is significant at P<0.05.
Table 4: Comparative analysis between gender and Botox features
Variables
Description
Gender
P - value
Male
Female
The Pre-procedure fascial defect (cm)
Mean ± SD
14.7 ± 3.82
8.45 ± 3.89
0.208
The Post-procedure fascial defect (cm)
Mean ± SD
12.93 ± 3.73
8.55 ± 4.17
0.346
Pre-procedure loss of domain (%)
Mean ± SD
19.11 ± 13.44
16.5 ± 9.33
0.784
Post -procedure loss of domain (%)
Mean ± SD
14.89 ± 8.14
10.95 ± 3.04
0.362
The Pre-procedure muscles length (cm)
Mean ± SD
36.52 ± 4.21
26.1 ± 5.8
0.199
The post-procedure muscles length in cm
Mean ± SD
41.87 ± 4.12
31.55 ± 3.75
0.087

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The comparative study of gender and Botox
characteristics are shown in Table 4. Male and female
patients did not significantly vary in the size of the
fascial defect, the loss of domain, or the length of the
muscles before and after the surgery (p > 0.05).The
comparison of age groups and Botox characteristics is
shown in Table 5. Patients with ages over 60 had no
discernible differences in the size of the fascial defect
before and after the surgery (p > 0.05). However,
individuals under 60 years old substantially
experienced less loss of domain than patients over 60
years old (p 0.05).
Table 5: Comparative analysis between gender and Botox features
Variables
Description
Age Group
P -value
< 60
>= 60
The Pre-procedure fascial defect (cm)
Mean ± SD
14.6 ± 4.71
11.68 ± 4.58
0.408
The Post-procedure fascial defect (cm)
Mean ± SD
12.7 ± 4.07
10.98 ± 4.48
0.590
Pre-procedure loss of domain (%0
Mean ± SD
25.01 ± 13.5
11.91 ± 6.09
0.149
Post -procedure loss of domain (%)
Mean ± SD
19.38 ± 5.55
8.43 ± 3.21
*0.020
The Pre-procedure muscles length (cm)
Mean ± SD
35.93 ± 4.46
31.9 ± 8.02
0.423
The post-procedure muscles length in cm
Mean ± SD
40.98 ± 6.28
37.6 ± 6.25
0.475
Discussion
The purpose of the current study was to assess the
efficacy of preoperative injections of botulinum toxin in
individuals with complicated abdominal wall hernias. A
statistically significant decrease in the size of the
transverse hernia defect and loss of domain following
the Botox injection supported the study's findings that
Botox injection was beneficial in easing muscular
tension and attaining primary fascial closure. The
study's results are in line with other research that
showed how well Botox injections could help patients
with complicated abdominal wall hernias by easing
muscular tension and promoting primary fascial closure
[20,21].
Following the Botox injection, there was a statistically
significant decrease in the size of the transverse hernia
defect (p 0.001). Before the injection, the mean
transverse hernia defect was 175.0±28.3 mm; after the
injection, it measured 129.4 ± 24.6 mm. The decrease
in muscle tension following the Botox injection may be
responsible for the shrinkage of the transverse hernia
defect. By preventing the release of acetylcholine,
Botox injections temporarily paralyze the muscles they
are administered to [22].
Following the Botox injection, there was a statistically
significant decrease in the loss of domain (p 0.05). The
repair of complicated abdominal wall hernias is
complicated by the loss of domain. By herniating intra-
abdominal contents into the hernia sac, which causes
an increase in intra-abdominal pressure, it describes
the loss of the abdominal domain [3]. The decrease in
muscular tension following the Botox injection may be
responsible for the decreased loss of the abdominal
domain because it allows the abdominal contents to be
reduced back into the abdominal cavity, regaining the
abdominal domain [23].
The size of the fascial defect did not significantly change
between before and after the surgery, though
(p = 0.094). The fact that the Botox injection does not
directly affect the fascial defect but instead lowers
muscular tension, which indirectly encourages primary
fascial closure by reducing the force pressing on the
fascial margins, maybe the cause of the lack of a
significant reduction in the fascial defect size [24,25].
Following the Botox injection, abdominal wall
reconstruction was performed on all patients, and
primary fascial closure was accomplished in 7 of them
(87.5 %). The gold standard for treating complicated
abdominal wall hernias is primary fascial closure [26]. It
describes how to fix a fascial defect without using mesh
or other artificial materials [1]. The high incidence of
primary fascial closure observed in the current study
may be ascribed to the Botox injection's ability to
relieve muscle tension, which encourages the
approximation of the fascial margins and lessens the
force operating on them [27].
The average follow-up time was 11.3 ± 4.2 months, and
during that time there were no new incidences of
hernias. With literature documented recurrence rates
ranging from 10% to 50%, hernia recurrence is a
significant problem in the repair of complicated
abdominal wall hernias [28,29]. The use of Botox
injections, which lower muscular tension and facilitate
primary fascial closure, may be responsible for the lack
of hernia recurrence in the current study. This lowers
the chance of hernia recurrence [30].
The abdominal surgery and Botox injection had no
significant side effects. Some individuals complained of
minor discomfort and bruising near the injection sites,
although these side effects quickly disappeared on their
own. The lack of significant side effects is consistent
with earlier research that found Botox injections were
safe for people with complicated abdominal wall
hernias [11,20]. Botox injection is a low-risk, minimally
intrusive technique that can be carried out while
receiving a local anesthetic [6].

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Conclusion
According to the study's findings, preoperative Botox
injection is a reliable and secure method for treating
patients with complex abdominal wall hernias to relax
their muscles and achieve primary fascial closure. But
there are several restrictions on the study that must be
noted. The study was retrospective in nature and was
carried out at one site, which restricts how broadly the
results may be applied. Furthermore, it is challenging to
make firm judgments on the effectiveness of
preoperative Botox injection for complex abdominal
wall hernia repair in the absence of a control group. The
results of the current study need to be confirmed by
larger studies with longer follow-up times and a control
group.
In conclusion, a primary fascial closure can be achieved
in patients with complex abdominal wall hernias by
preoperative Botox injection, according to the findings
of the current study, which show that this method is
both reliable and safe for lowering muscular tension.
Following the Botox injection, there was a statistically
significant decrease in the size of the transverse hernia
defect and loss of domain, and the majority of patients
were able to accomplish primary fascial closure without
the use of mesh or other prosthetic materials. The lack
of significant side effects and hernia recurrence further
attests to the safety and efficacy of Botox injection in
this patient population.
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