Preoperative botulinum toxin a enables fascial closure and reduces morbidity in complex incisional hernias: results from the BRIDGE-HERNIA study.

backgroundAchieving tension-free midline fascial closure in complex midline incisional hernias frequently necessitates posterior component separation with transversus abdominis release (TAR). Preoperative administration of botulinum toxin A (BTA) has been proposed as an adjunctive strategy to induce temporary chemical relaxation of the lateral abdominal wall, potentially facilitating primary fascial closure and reducing the need for TAR. This study evaluates the impact of BTA within the BRIDGE-HERNIA protocol on surgical management of patients with complex incisional hernia.

methodsThis retrospective multicenter observational cohort study conducted across three centers included 42 patients with complex midline incisional hernias and transverse defect width ≥ 10 cm. All patients underwent ultrasound-guided preoperative injections of BTA into the lateral abdominal wall muscles. Computed tomography (CT) scans obtained before and after BTA administration were used to assess changes in transverse defect width and lateral muscle elongation. Surgical repair was tailored intraoperatively based on fascial tension, with Rives-Stoppa repair performed when feasible and TAR reserved for cases with persistent tension.

resultsAfter BTA administration, 33 of 42 patients (78.6%) underwent successful Rives-Stoppa repair without the need for TAR. Mean lateral muscle elongation was 3.5 ± 1.2 cm per side, associated with a significant reduction in transverse defect width from 12.4 ± 3.1 cm to 10.1 ± 2.6 cm (p < 0.001). Fascial closure was achieved in all patients treated with Rives-Stoppa repair. The overall complication rate was 23.8%, with a significantly lower incidence of postoperative complications in the Rives-Stoppa group compared with the TAR group (15.2% vs. 55.6%, p < 0.05). Median length of hospital stay was shorter in patients managed without TAR (4.6 vs. 6.2 days, p = 0.034). One early recurrence was observed, occurring in the TAR group. EuraHS-QoL scores demonstrated significant improvement at both 6 and 12 months postoperatively, indicating a sustained enhancement in hernia-specific quality of life.

conclusionsPreoperative BTA administration within the BRIDGE-HERNIA protocol effectively facilitated midline fascial closure and substantially reduces the need for TAR in patients with complex midline incisional hernias. This approach appeared safe, was associated with reduced postoperative morbidity and shorter hospitalization, and led to meaningful improvements in patient-reported quality of life. CT-based morphometric assessment confirmed objective muscular elongation and supports its selective use as a decision-support tool in high-complexity cases, where preoperative stratification of TAR probability has meaningful clinical implications.