APPLICATION OF BOTULINUM TOXIN A WITH VERTICAL FASCIO-MUSCLE TRACTION FOR THE REPAIR OF LOSS OF DOMAIN HERNIA – FIRST LITERATURE AUTHENTICATED CASE FROM WESTERN INDIA divyata.vasa@gmail.com

PW01-09

APPLICATION OF BOTULINUM TOXIN A WITH VERTICAL FASCIO-MUSCLE TRACTION FOR THE REPAIR OF LOSS OF DOMAIN HERNIA – FIRST LITERATURE AUTHENTICATED CASE FROM WESTERN INDIA

3

India

Oral or Poster

Complex hernias, characterized by loss of domain due to lateralization of abdominal muscles, are challenging to manage due to inability to achieve tension-free closure. Techniques like progressive pneumoperitoneum, botulinum toxin A (BTA) injection, Transversus Abdominis Release (TAR), and component separation have been used. We report the first literature-authenticated case from Western India using intraoperative fascio-muscle tension for managing a complex hernia.

A 65-year-old male presented with a large reducible incisional hernia (20x15 cm) extending from the supraumbilical to suprapubic region. Preoperative CT showed an inter-rectus distance (IRD) of 17 cm. The patient received 150 IU of BTA injected under ultrasound guidance into the lateral abdominal muscles bilaterally at three levels, four weeks before surgery, reducing IRD to 13 cm. During surgery, an indigenous fascial traction device applied dynamic vertical fascio-muscle tension. This enabled midline closure, reinforced with onlay prolene meshplasty.

BTA and fascio-muscle tension each contributed 4 cm of muscle elongation, allowing successful abdominal wall closure. The patient required 48 hours of postoperative ventilation but had no signs of abdominal compartment syndrome or respiratory compromise. He was discharged on postoperative day 15. He developed a surgical site infection managed with dressings. At 3-month follow-up, there was no recurrence or wound dehiscence.

BTA-induced muscle elongation combined with vertical fascio-muscle traction enables rectus medialization and tension-free abdominal wall closure. This method requires minimal dissection, resulting in a smaller subcutaneous wound than component separation or TAR. We believe it would reduce complications compared to traditional techniques. Further prospective studies are warranted.