Revisiting large complex ventral hernia repair: multimodal hybrid technique deploying preoperative Botulinum Toxin A injection, laparoscopic anterior components separation and open mesh repair.

In the past, various techniques had been described to repair large complex ventral hernias. Laparoscopic technique of components separation showed low complication rates and better overall outcome. Recently, Botulinum Toxin A (BTA) has shown benefit in achieving tension-free repair. We describe here our multimodal technique combining BTA injection, laparoscopic anterior components separation (LACS) and open mesh repair. Ten consecutive cases performed over 3 years were studied. A standardised technique was used with a reasonably short learning curve. Patients who generally fit for general anaesthesia were offered surgery after detailed preoperative imaging work up and informed consent. Demographic details, preoperative risk stratification, intraoperative and postoperative outcomes were recorded and analysed. A structured step by step management strategy was adopted. Total ten (n = 10) cases with median age of 42.5 years (range 28-76 years), male to female ratio of 8:2 and median BMI of 32.6 were included. Three patients had pre-existing stomas. Median diameter of hernial defect was 10 cm, IQR 4.8 cm and range of 6-20 cm. No intraoperative or immediate complications were observed. Median hospital stay was 6 days. Two seromas (20%) and two return to theatre (20%) were observed. One recurrence (10%) was observed after median follow-up of 32 months. No 90-day mortality was recorded. Multimodal technique of BTA injection, LACS and midline mesh repair is a reproducible, safe and effective option to repair large complex ventral hernias.