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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00917-9
10.1016/j.ijscr.2024.110136
110136
Case Report
The era of 3D-reconstruction techniques in a medical setting: Earlier experience with video using botulinum toxin for complex ventral incisional hernia
Quijano Yolanda yolandaquijanocollazo@gmail.com
a
Vicente Emilio correo@emiliovicente.es
a
Quijano Pablo Ruiz pabloruizquijano@gmail.com
a
Alvarez Luzdivina Rellan luzrellan@gmail.com
b
Ferri Valentina valenpeglio@gmail.com
a
Caruso Riccardo ricaruso2@gmail.com
a⁎
a Sanchinarro University Hospital, General Surgery Department, Madrid, Spain. Health Sciences Faculty HM Hospital, "Camilo Jose Cela" University
b Sanchinarro University Hospital, Anesthesia Service, Madrid, Spain
⁎ Corresponding author: R. Caruso, Sanchinarro University Hospital, C/Oña nº 10, Madrid 28050, Spain. ricaruso2@gmail.com
14 8 2024
10 2024
14 8 2024
123 11013625 3 2024
1 8 2024
7 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Incisional hernias occur in about 15 % of all patients that undergo abdominal surgery. Treatment of giant incisional ventral hernias (GIH) results in a surgical challenge associated with postoperative morbidities, risk of hernia recurrence, and costs. In recent years the use of both botulinum toxin (BT) to overcome abdominal cavity leakage and improved preoperative imaging studies by 3D-reconstruction has improved outcomes after these complex procedures.

Case presentation

We describe a case of 3D-reconstruction technique before and after the use of botulinum toxin for complex ventral incisional hernia. No intraoperative complications or technical failures of the system were recorded. The operative time was 180 min, and the length of hospital stay was five days.

Discussion

In this preliminary study we showed our experience with the use of 3D-reconstruction of abdominal wall following preoperative BT preparation for elective surgical repair of recurrent complex incisional hernias.

Conclusion

The use of 3D-recostruction provides important information for a correct pre-surgical planning.

Highlights

• The use of botulinum toxin for giant ventral hernia

• The use of 3D-reconstruction technology in the abdominal wall field

• News about pre-surgical planning in the abdominal wall field

• Tools for elective surgical repair of complex incisional hernias

Keywords

3D-reconstruction
Case report
Incisional hernia
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pmc1 Introduction

Incisional hernias are a frequent complication after abdominal surgery [1]. The treatment of giant ventral incisional hernias (GIH) represents a surgical challenge associated with important postoperative morbidities, risk of hernia recurrence and costs [2]. In recent years the development of new technologies, such as the introduction of new surgical mesh improved the clinical results, but the post-operative morbidity and hernia recurrence remains high [3]. The high recurrence rate in patients with giant ventral hernia depends on the big loss of the abdominal cavity volume that in most cases doesn't allow a tension free repair [4]. In recent years both the use of botulinum toxin (BT) to overcome abdominal cavity leakage and improved preoperative imaging studies by a 3D-reconstruction has improved outcomes after these complex procedures [5].

In this preliminary study we show our experience with the use of 3D-reconstruction of abdominal wall following preoperative BT preparation for elective surgical repair of GIH.

2 Material and methods

2.1 Preoperative study

This is a preliminary single center experience of a patient who underwent preoperative BT abdominal wall injections and 3D-reconstruction prior to elective surgical repair of a recurrent giant incisional hernia. The aforementioned patient had large complex incisional hernias with a big domain loss and with a linear defect length of more than 6 cm. The clinical case described in this study was discussed by a multidisciplinary committee. The patient was evaluated with comprehensive blood chemistry and were subjected to a general evaluation which included cardiological tests (cardiology visit, baseline ECG and second level tests on request), respiratory (blood gas analysis and on request respiratory function tests). The anesthetic risk was assessed through the ASA scoring system (Goldman cardiac index). The preoperative imaging study was performed through conventional computed tomography (CT) scan and magnetic resonance imaging (MRI). 3D imaging reconstruction with 3D-MSP® models is performed for each patient at baseline assessment, post-BT (preoperative), post-operatively of the three muscle layers of the lateral abdominal wall after BTA treatment. Flaccid relaxation results in thinning and lengthening of the three muscle layers of the lateral abdominal wall after BTA treatment.

We measured the thickness and lengthiness of the lateral abdominal wall muscle from an axial CT image at the same vertebral level (Fig. 1). Lateral abdominal wall muscle thickness was measured from the superficial surface of the external oblique to deep surface of transversus abdominis muscle. The transverse abdominal wall length on each side was measured along the inner surface of the abdominal muscle complex from the lateral edge of quadratus lumborum to medial edge of rectus abdominis. Measurements of lateral abdominal wall length were performed using a single CT image and the 3D-MSP® models. Measurements of the hernia linear defect both before and after BTA were performed with CT scanner and by 3D reconstruction. We used 3D reconstruction (before and post botox® injections) for calculating the hernia sac volume (HCS) and abdominal cavity volume (ACS) in the complex large incisional hernia in accordance with its score described by Tanaka et al. [8]. Radiological assessments were all performed by the same radiologist group. Each patient included in the study underwent abdominal wall BT injection 6 weeks prior to surgery in an outpatient setting. They received 50 units of BT in 150 mL 0.9 % saline per patient for each muscle group: transverse muscle, internal and external oblique muscle (a total of 300 units of Botox® A). The patient was placed in a supine position and using high resolution ultrasound and electromyographic guide, three sites were identified and marked along the anterior axillary line equidistant between the inferior border of the rib cage and anterior superior iliac spine, according to positions identified by Smoot [9]. The patients underwent open mesh hernia repairs using a posterior component separation. All surgeries were performed by the same two surgeon six weeks after the Botox® injection. This work has been reported in line with the SCARE criteria [10].Fig. 1 Preoperative abdominal CT before and after botulinum toxin A (BTA) injection showing the linear defect size.

Fig. 1

2.2 Image interpretation

Regarding conventional CT scan and MRI two different radiologist reviewed the studies independently. All surgeons on the team interpreted the 3D reconstruction, analyzing the wall defect size.

2.3 Case presentation

We introduce the case of a patient (BMI 33 kg/m2) who underwent Hartmann procedure 4 years earlier for diverticulitis disease. He came to our outpatient clinic for abdominal pain. After a CT scanner study he was diagnosed of incisional ventral hernia. He denied allergies and previous surgical operations. A complete preoperative study was performed including: CT scan, abdominal wall MRI and blood analysis.

3 Results

The patients (male), 75 years old, included in the study underwent abdominal wall BT injections 6 weeks before elective ventral incisional hernia repair. Preoperative abdominal CT before and after botulinum toxin A (BTA) injection showed the reduction of linear defect size in (Fig. 1). The images are compared at the same lumbar level. There is also partial reduction of the abdominal viscera. A comparison of baseline (pre-BT) and post-BT abdominal CT measurements demonstrated significant relaxation in thinning and lengthening of the three muscle layers of the lateral abdominal wall after BTA treatment: thickness decreased by 22 mm and an increased lengthening of 20 mm (Fig. 2). The HCS, ACS and Tanaki score of the patient before and after Botox® injections are showed in the 3D-reconstruction (Fig. 3). The patient showed an increase in abdominal circumference at 6 weeks post BT injections. The patient experienced no side effects after treatment with BT and he returned to the normal daily activities prior to surgery. A comparison of 3D- abdominal wall reconstruction before and after BT injection showed an increased abdominal muscle length and decrease in hernia defect (Fig. 4). The patient underwent a successful repair procedure. The operation time was 180 min. No intraoperative blood transfusion was necessary. Liquid diet was restored on the first day post-surgery, and in the following days a normal diet was allowed. The postoperative hospital stay was five days. Subcutaneous drains were placed and removed on the fourth day. The VAS (Visual Analogue Scale) score in the post-operative time was 5.Fig. 2 Preoperative abdominal CT before and after botulinum toxin A (BTA) injection. Flaccid relaxation results in thinning and lengthening of the three muscle layers of the lateral abdominal wall after BTA treatment.

Fig. 2

Fig. 3 ACS (abdominal cavity volume), HCS (hernia sac volume) and Tanaki score.

Fig. 3

Fig. 4 3D wall reconstruction before and after BT injection showed an increased abdominal muscle length and decrease in hernia defect.

Fig. 4

The patient did not suffer a postoperative increase in intra-abdominal pressure, there was not any abdominal compartment syndrome accompanied by respiratory dysfunction. No recurrence or chronic pain occurred during the follow-up period (24 months).

4 Discussion

Incisional hernia is a common complication after laparotomy and the treatment remains one of the most frequently performed surgical procedures [2,3]. Among incisional hernias, the treatment of GIH is often complex and associated with high rates of morbidity, failure and high cost [4]. Over the years thanks to the several innovations in surgical techniques and the use of new surgical mesh, an improvement in post-operative outcomes has been reached [11]. The aim during GIH repair is to achieve tension-free midline fascial closure [6]. In patients with large abdominal wall defects, retraction of lateral abdominal wall muscles and irreducible visceral content, the midline closure can be a significant surgical challenge. Surgical component separation techniques increase abdominal wall flexibility and facilitate fascial medialization [3]. Nevertheless, in those cases with great “loss of domain” a surgical reparation is not enough if it's not associated with other pre-operative procedures. Over the years more and more experiences published described the use BT to overcome the loss of the abdominal cavity volume in cases of GIH [12]. BT is a neuromodulating agent used for several clinical applications [13,14]. In the abdominal wall repair field, BT improves: analgesia in the post operatory time, increasing the volume of the abdominal cavity without disrupting the fascial integrity of the abdominal wall. Furthermore, the toxin decreases lateral traction and reduce tension before and after surgical repair [15]. After BT abdominal wall injections is very important to establish the correct time to perform the surgery. Nowadays, preoperative imaging study with CT scan, MRI and 3D- reconstruction are essential for planning the abdominal wall defect repair. Among the most common diagnostic imaging techniques CT scan and MRI, allow only two-dimensional images to obtain information on different pathologies. This requires excellent visualization skills from non-specialized medical doctors. 3D printing has been developed to overcome the current disadvantages of conventional imaging techniques. In the last years 3D printing has progressively gained widespread interest for its several applications in many medical fields [[5], [6], [7]]. The 3D models are created from the combination of diagnostic studies (abdominal wall MRI, CT scan) with a process that fuse advanced medical imaging algorithms and medical image processing, which are supervised by specialized radiologists. We believe that the great advantage of 3D reconstruction is that it facilitates easy interpretation even by non-specialized medical staff. In daily clinical practice we usually use the 3D models to study complex cases, to practice procedures, and to teach students and patients. This is the first worldwide study giving an overview of the application of 3D- techniques reconstruction of the abdominal wall and botulinum toxin for the treatment of giant ventral incisional hernias.

Further studies are needed to confirm our preliminary results and assess the ideal dose and timing of preoperative BT treatment as well as the additional benefits of 3D- reconstruction in the surgical management of complex incisional hernias.

5 Conclusion

The use of 3D-recosntruction provides important information for a correct pre-surgical planning. Abdominal wall BT injection and 3D-reconstruction has been well tolerated in our patient. Further studies are important to confirm our results.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in- Chief of this journal on request.

Ethical approval

Ethical approval was not necessary in this study.

Funding

No sources of funding.

Guarantor

Riccardo Caruso.

CRediT authorship contribution statement

Riccardo Caruso proposed the study. Riccardo Caruso performed the research and wrote the first draft. The rest of the authors: Emilio Vicente, Yolanda Quijano, Valentina Ferri and Pablo Ruiz contributed to the design and interpretation of the study. Lura Arrieta interpreted the CT imaging

Declaration of competing interest

All authors are in agreement with the content of the manuscript. The manuscript has been read and approved by all named authors. We declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere. We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no financial support for this work that could have influenced its outcome. We hope you find our manuscript suitable for publication and look forward to hearing from you.
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