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Introduction <p>Large incisional hernias (LIHs), particularly those with loss of domain (LOD), are associated with substantial morbidity, reduced quality of life, and complex operative management. The aims of this study are to describe a high‑volume abdominal wall unit’s 15&#xa0;years of experience using a combined botulinum toxin type A (BTA) and preoperative progressive pneumoperitoneum (PPP) protocol in patients with LIHs, to analyze perioperative outcomes and complications in these patients, and to propose a pragmatic algorithm for the selection of these preoperative techniques.</p> Methods <p>The inclusion criteria stipulated that all study patients should be aged ≥ 18&#xa0;years, have a ventral or incisional hernia with a fascial defect ≥ 10&#xa0;cm in transverse diameter and/or a hernia sac volume (VIH) / abdominal cavity volume (VAC) ratio ≥ 20% on preoperative CT, and have plans for elective reconstruction with curative intent. Patients with small-to-medium defects without LOD or laparoscopic repairs were excluded.</p> Results <p>Two hundred and twenty consecutive patients with LIHs and LOD who had undergone elective repair between June 2010 and December 2024 were analyzed. A combination of PPP and BTA was performed in all patients. A significant average reduction of 14% (<i>p</i> = 0.001) of the VIH/VAC ratio was observed on CT after a combination of PPP and BTA was performed. Several reconstructive techniques were carried out, but the most frequent method of hernia repair was Rives-Stoppa repair. At postoperative follow-up, which averaged 33.5&#xa0;months (range: 11–60&#xa0;months) after surgery, 20 cases (9%) of hernia recurrence were reported. In patients with LIHs that are without LOD (VIH/VAC &lt; 20%) but with W3 transverse defects (≥ 10&#xa0;cm), BTA alone may be sufficient to facilitate fascial closure. In contrast, when the VIH/VAC ratio is ≥ 20% (especially in patients with true LOD), PPP should be added to progressively adapt diaphragmatic and respiratory mechanics.</p> Conclusions <p>PPP and BTA represent complementary tools for the prehabilitation of patients with LIHs. Their combined use in a standardized protocol increases the likelihood of tension‑free primary fascial closure, maintaining acceptable morbidity.</p>

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A practical algorithm for the combined use of preoperative progressive pneumoperitoneum and botulinum toxin A in large incisional hernia repair: learnings after 15 years of experience

  • 期刊论文

  • 发表日期：

    2026年3月11日

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  • José Bueno-Lledó,
  • Omar Carreño-Sáenz,
  • David Quevedo-Cruz,
  • Alba Serrano-Molina,
  • Jesus Martinez-Hoed,
  • Santiago Bonafé-Diana,
  • Victoria Pareja-Ibars,
  • Providencia Garcia-Pastor,
  • Salvador Pous-Serrano

摘要

Introduction

Large incisional hernias (LIHs), particularly those with loss of domain (LOD), are associated with substantial morbidity, reduced quality of life, and complex operative management. The aims of this study are to describe a high‑volume abdominal wall unit’s 15 years of experience using a combined botulinum toxin type A (BTA) and preoperative progressive pneumoperitoneum (PPP) protocol in patients with LIHs, to analyze perioperative outcomes and complications in these patients, and to propose a pragmatic algorithm for the selection of these preoperative techniques.

Methods

The inclusion criteria stipulated that all study patients should be aged ≥ 18 years, have a ventral or incisional hernia with a fascial defect ≥ 10 cm in transverse diameter and/or a hernia sac volume (VIH) / abdominal cavity volume (VAC) ratio ≥ 20% on preoperative CT, and have plans for elective reconstruction with curative intent. Patients with small-to-medium defects without LOD or laparoscopic repairs were excluded.

Results

Two hundred and twenty consecutive patients with LIHs and LOD who had undergone elective repair between June 2010 and December 2024 were analyzed. A combination of PPP and BTA was performed in all patients. A significant average reduction of 14% (p = 0.001) of the VIH/VAC ratio was observed on CT after a combination of PPP and BTA was performed. Several reconstructive techniques were carried out, but the most frequent method of hernia repair was Rives-Stoppa repair. At postoperative follow-up, which averaged 33.5 months (range: 11–60 months) after surgery, 20 cases (9%) of hernia recurrence were reported. In patients with LIHs that are without LOD (VIH/VAC < 20%) but with W3 transverse defects (≥ 10 cm), BTA alone may be sufficient to facilitate fascial closure. In contrast, when the VIH/VAC ratio is ≥ 20% (especially in patients with true LOD), PPP should be added to progressively adapt diaphragmatic and respiratory mechanics.

Conclusions

PPP and BTA represent complementary tools for the prehabilitation of patients with LIHs. Their combined use in a standardized protocol increases the likelihood of tension‑free primary fascial closure, maintaining acceptable morbidity.