Synchronous Surgical Treatment of Morbid Obesity and Complex Ventral Hernia After Progressive Pneumoperitoneum and Botulinum Toxin A Injection

The worldwide increase in morbidly obese patients with complex hernia raises controversies in the choice of the appropriate treatment timing: synchronous bariatric and abdominal wall surgery versus delayed abdominal wall surgery. We report an innovative tailored surgical treatment carried out at our Institution. The approach provided the injection, 6 weeks before surgery, of 500 IU of botulinum toxin A on either side of the large abdominal wall muscles. Four weeks before surgery, pneumoperitoneum was inducted and out-patient daily sessions of progressive insufflation with ambient air were then carried out. Surgery was scheduled 48 days after botulinum injection. Sleeve gastrectomy and simultaneous posterior component separation with transversus abdominis release were performed. Two prosthetic meshes were placed sublay. Postoperative superficial surgical site infection was successfully treated with negative pressure wound therapy. At a 1-year follow-up, no hernia recurrence was recorded while total body weight loss was 31%. A delay in ventral hernia repair could worsen the quality of life of morbidly obese patients. In such high-risk patients, the choice of the best surgical strategy remains controversial. There is great concern in performing bariatric surgery simultaneously to hernia repair, although there is lack of evidence on which is the ideal treatment modality. Synchronous bariatric surgery and complex ventral hernia repair should be approached in high-volume centres where a consolidated experience of multidisciplinary teamwork is available. Combined botulinum toxin A and preoperative progressive pneumoperitoneum administration allow for a safe resolution of loss of domain.