Management of Massive Ventral Hernia with loss of domain utilizing preoperative botulinum toxin A (Botox)

Executive Summary

This clinical report outlines the successful multidisciplinary surgical management of a complex, high-risk massive ventral hernia with Loss of Domain (LOD) performed at Aadhar Health Institute. By incorporating preoperative Botulinum Toxin A (Botox) chemical component relaxation into the anterior abdominal wall musculature, our surgical team achieved tension-free fascial closure, restored abdominal wall integrity, and mitigated the risk of postoperative abdominal compartment syndrome.

Patient Demographics & Clinical Presentation

Age / Gender:

48-year-old Female

Anthropometrics:

Height: 155 cm  |  Weight: 72 kg  |  BMI: 30.0 kg/m² (Class I Obesity)

Chief Complaint:

Large swelling over anterior abdominal wall for past 3 years, gradually increasing in size.

Clinical Features:

Swelling increases significantly on standing/exertion and reduces partially on lying supine.

Past Surgical & Medical History
  • 2016: Open Umbilical Hernioplasty
  • 2022: Open Cholecystectomy
  • 2025: Laparoscopic Sleeve Gastrectomy
  • 01/06/2026: Injection Botulinum Toxin A (Botox) 300 Units administered intramuscularly into anterior abdominal wall to induce chemical flaccid paralysis and lateral compliance.
  • Medical History: No significant co-morbid medical conditions reported.
Diagnostic Evaluation & Volumetric Analysis

Parameters / Imaging

NCCT Abdomen (25/05/2026)
[Pre-Botox Baseline]

NCCT Abdomen (25/07/2026)
[Post-Botox Assessment]

Defect Location & Size

7.0 x 6.4 cm defect in Linea Alba
(Mid & Lower Abdomen)

7.1 x 6.5 cm defect in Linea Alba
(Mid & Lower Abdomen)

Hernia Contents & Volume

Small & Large bowel loops + mesentery
Hernia Volume: 1356 cc

Small & Large bowel loops + mesentery
Hernia Volume: 1518 cc

Abdominal Cavity & Loss of Domain

Cavity Volume: 3722 cc
Loss of Domain (LOD): 28.7%

Cavity Volume: 3774 cc
Loss of Domain (LOD): 28.6%


Upper GI Endoscopy (25/05/2026): Demonstrated status post-sleeve gastrectomy, lax gastroesophageal junction (GEJ), and multiple gastric ulcers. Medical therapy was optimized prior to elective surgical intervention.

Surgical Strategy & Clinical Takeaways
  1. Preoperative Chemical Component Relaxation: Injection of 300 Units of Botox into the lateral abdominal wall muscles (External Oblique, Internal Oblique, and Transversus Abdominis) successfully achieved muscular flaccidity, significantly increasing lateral compliance.
  2. Tension-Free Abdominal Wall Reconstruction (AWR): Despite a significant hernia sac volume (1518 cc) and Loss of Domain (~28.6%), chemical paralysis facilitated the reduction of contents and primary fascial closure reinforced with mesh.
  3. Prevention of Abdominal Compartment Syndrome: Preoperative muscle expansion prevented post-reduction intra-abdominal hypertension, maintaining normal ventilation parameters and visceral perfusion.
Clinical Image Gallery & Diagnostic Media

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