Publication:

Botulinum toxin type A and progressive pneumoperitoneum for loss-of-domain hernia: a narrative review

The management of incisional hernias with loss of domain (LOD) represents a significant surgical challenge. Preoperative conditioning with botulinum toxin type A (BTX-A) and preoperative progressive pneumoperitoneum (PPP) has emerged as an effective strategy in specialized centers. To synthesize the available evidence on the pathophysiological basis, clinical and volumetric indications, and outcomes of the combined use of BTX-A and PPP in hernias with LOD. A narrative review of the literature was conducted through searches in PubMed, SciELO, and Scopus, including studies related to the pathophysiological basis, indications, technical aspects, and clinical outcomes of BTX-A and PPP in hernias with LOD. The combination of BTX-A and PPP produces elongation of the lateral abdominal muscles, reduces the hernia defect, and induces adaptive volumetric expansion of the abdominal cavity through progressive insufflations. When applied 15-30 days before surgery, these interventions allow primary fascial closure rates approaching or exceeding 95%. However, adequate patient selection based on volumetric and clinical criteria, while considering potential complications, is essential. The evidence available to date suggests that the combined use of BTX-A and PPP optimizes fascial closure in complex hernias, with high efficacy in experienced centers. However, the evidence remains limited to observational studies; therefore, protocol standardization and controlled clinical trials are required to increase the level of evidence and allow this sequential therapeutic method to become a standard of care in routine clinical practice.