Pre-operative Preparation with Botulinum Toxin A as a Component Separation Technique in Incisional Hernia with Loss of Domain: A Clinical Case Report

Giant incisional hernia with loss of abdominal wall capacity is a condition that significantly impacts patients’ quality of life, with high rates of morbidity, mortality and recurrence. Its history is notable for its progression from an anatomical defect to a complex “abdominal wall disease,” characterized by the permanent displacement of viscera into the hernial sac. Classic research by Rives, Stoppa and Carbonell has established the basis for the use of retromuscular prostheses and the Component Separation Technique (CRT) to restore respiratory dynamics and abdominal cavity volume. Contemporary studies emphasize the importance of preoperative management with progressive pneumoperitoneum or botulinum toxin to prevent postoperative abdominal compartment syndrome. This scientific basis allows the current approach not only to close the defect but also to functionally reintegrate the abdominal contents with a significantly lower recurrence rate. Chronic abdominal wall defects grow and progressively alter the physiology of the abdominal wall, making it difficult to return the contents of the sac to the abdominal cavity. In operational terms, a loss-of-compartment hernia is classified as one with a defect of 10 cm or greater or whose volume represents at least 25% of the abdominal cavity volume. Repair of these defects can lead to several serious pathophysiological problems, such as abdominal compartment syndrome with acute respiratory compromise secondary to a sudden increase in intra-abdominal pressure. Managing these hernias remains a challenge for the surgeon; however, proper preoperative planning will improve the conditions for surgery.