# Anaesthesiology and Ultrasound-Guided Injection of Botulinum Toxin in the Abdominal Wall: A State-of-the-Art and Technical Adaptation

## TL;DR

This paper describes a novel use of botulinum toxin injections under ultrasound guidance to aid in hernia surgery by reducing muscle tension and improving recovery.

## Contribution

The study introduces a new adjuvant technique using ultrasound-guided botulinum toxin injections in hernioplasty, leveraging anaesthesiologists' expertise.

## Key findings

- Botulinum toxin A injection reduced hernia size by 1.5 cm in width after four weeks.
- The patient experienced stable surgery and effective postoperative pain control without opioids.
- Ultrasound-guided injections facilitated fascial medialization and minimized tension.

## Abstract

Ventral incisional hernia represents a prevalent postoperative complication, characterized by high morbidity and significant healthcare burden. Surgical management can be technically demanding, with a notable risk of recurrence and perioperative complications. This report describes a patient scheduled for hernioplasty with posterior component separation and bilateral transversus abdominis release. As an adjuvant technique, she was proposed botulinum toxin A (BTA) injection under ultrasound guidance into the three lateral abdominal muscle layers (transversus abdominis, internal oblique, and external oblique), to minimize tension and facilitate fascial medialization. Owing to their expertise in regional anatomy and proficiency in ultrasound-guided interventions, anaesthesiologists were consulted to perform the procedure. After four weeks, the size of the hernia decreased by 1.5 cm (width). On the day of surgery, combined anaesthesia was performed, with bilateral transversus abdominis plane block, followed by balanced general anaesthesia. The surgery lasted about five hours. There were no surgical complications, and the patient remained hemodynamically stable. The patient was transferred to the ICU under invasive mechanical ventilation. Ventilatory weaning was achieved after approximately 12 hours. Postoperative pain control was achieved through conventional analgesia, enhanced by the preoperative injection of BTA to alleviate muscle tension, avoiding neuraxial analgesia or intravenous opioids.