Welcome to the AHS 2020 ePoster Session. Please scroll down to view all of the submitted posters or press Control-F to search. To view the poster and its abstract, click on the poster image. Many posters also have a brief audio introduction which can be played by going to the bottom of the poster screen.
P062: PREOPERATIVE BOTOX FOR LOSS OF DOMAIN: EXPANDING THE REALM OF MINIMALLY INVASIVE HERNIA REPAIR
Hazim Hakmi; Amir Sohail, MD; Joaquin Cagliani, MD; Leo Amodu; Nicholas Georgiou, MD; Jason Hoffman, MD; David Halpern; NYU-Winthrop
Loss of Domain (LOD) due to a large abdominal hernia can be challenging to many surgeons. Depending on the size of the defect and sac, and reducibility of the abdominal contents, different algorithms are used for repair of ventral hernias. Some large non-reducible and partially reducible hernias with LOD are deemed inoperable.
The emergence of preoperative Botulin Toxin-A (BTA) injections to allow surgical repair in such patients is not a novel concept. Despite the use of BTA, many patients still require the use of abdominal wall component separation techniques in order to achieve successful repair. The large hernia defects, redundant skin and complex anatomy of patients with LOD have traditionally led surgeons to choose and open approach for surgical repair. As compared to open surgery, previous studies have shown that robotic techniques offer decreased cost, wound complication rate, and length of stay. We have expanded the use of BTA as an adjunct to robotic abdominal wall reconstruction in order determine its feasibility, and whether the benefits of the robot would apply to this unique patient population. We are not aware of another published series in which the robot was used for myofascial release post BTA.
In our cohort, we used CT and adjunctive ultrasound guided BTA injections at 3 select points on each side of the abdominal wall. We injected ~8.3cc of 2 units/cc into each muscle of the triple layer (external oblique, internal oblique, and transversus abdominis) to a max of 50 units at each injection site. A total of 150 units was injected on each side of the abdominal wall (300 units per patient). The technique was modified with each patient in order to target the area of muscle with the greatest degree of contracture.
A significant change on physical exam and CT scan imaging was achieved within 2–4 weeks post injection. There was a reduction in the hernia volume to peritoneal volume ratio post BTA.
The 3 patients that underwent surgical intervention in our case series had defects ranging from 10x12cm to 20x20cm. All were repaired using robotic transversus abdominis release (TAR). The post-operative length of stay was 3-4 days. We had only one post-operative complication, that patient developed a subcutaneous hematoma in the hernia sac. The hematoma became secondarily infected with MRSA, complicated by a small dehiscence of the fascia in the midline. The patient was successfully treated with a washout, wound vacuum placement and antibiotics without the need to explant the mesh.
It has been postulated that the duration of effect of BTA might offer a protective effect during the first 3-6 months of wound healing, allowing for decreased tension on the repair, and decreased hernia recurrence. BTA is also felt to decrease nociceptive pain. We noted improved cosmetic outcomes and no hernia recurrences.
Our case series has shown that robotic techniques can be applied to this highly complex and challenging group of patients. Further studies are necessary to determine the beneficial aspects of robotic repair in this unique population.
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