Complex Hernia and Prehabilitation of the Abdominal Wal

Complex Hernia and Prehabilitation of the Abdominal Wall

June 19, 2025 –
Ernesto Escobar, MD

A hernia is an abnormal opening in the abdominal wall through which internal organs, such as the intestine or visceral fat, protrude and create a bulge.
A practical way to define a complex hernia is one that cannot be treated using conventional methods (standard open or laparoscopic surgery) because the edges of the defect cannot be closed.

Incisional hernia in a 29-year-old patient with a failed prior repair. Surgery involved biological mesh placement and scar revision. Image taken 4 months postoperatively. Source: Mr. David Floyd, Complex Hernia Surgery View article

There are several situations that can lead to the development of a complex hernia, including:

1. History of complicated intra-abdominal disease (such as perforated appendicitis, perforated ulcers, intestinal infarction, abdominal trauma — including stab wounds, gunshot wounds, accidents, or blunt trauma) or surgery in a patient with poor nutritional status who later develops a hernia.
2. Obesity
3. Chronic diseases that impair wound healing
4. Surgical site infections that result in wound dehiscence.

Due to the complexity of these cases, achieving a successful repair requires several key steps:

a. Proper evaluation of the hernia, usually through a CT scan
b. Assessment of the patient’s overall health
c. Management of conditions that may impair healing (diabetes, smoking, malnutrition, obesity)
d. Abdominal Wall Prehabilitation**

With this last point—Abdominal Wall Prehabilitation—we will highlight two major techniques that contribute to a successful closure of the hernia defect:
1. Botulinum Toxin Injection
2. Progressive Pneumoperitoneum

Botulinum Toxin Injection

Botulinum toxin has been widely used for cosmetic purposes in Plastic Surgery, Dermatology, and Aesthetic Medicine under various brand names (Dysport, Botox, Xeomin, Allergan, Azalure, Jeuveau, Myobloc/Neurobloc, Bocouture, Cbtx a/prosigne®/lantox, Daxxify, HUGEL, Ipsen, Merz Pharma GmbH & Co. KGaA, Neuronox, Vistabel, etc.).

The mechanism of action of Botulinum Toxin is to paralyze the muscles where it is applied, producing a certain degree of flaccidity. The same effect occurs in the abdomen.

When Botulinum Toxin is injected into the abdominal muscles, they relax, making it easier to close the hernia during surgery. This reduces the likelihood of hernia recurrence in the future.

Ultrasound-guided botulinum toxin injection into the abdominal wall muscles of a patient with a complex hernia. Dr. Ernesto Escobar

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Una publicación compartida por Dr. Ernesto Escobar (@bariatricasv)

Progressive Pneumoperitoneum

Pneumoperitoneum means “air inside the abdomen.” In this context, air is gradually insufflated into the abdominal cavity to allow the abdomen to expand, release adhesions (internal scar tissue from the hernia), and facilitate the closure of complex hernias.
To insufflate air into the cavity, a plastic catheter must be placed and left in position for several days. The patient must attend follow-up visits with the surgeon for the gradual introduction of gas.
After several sessions, the patient will be ready to undergo the surgical procedure.

These techniques (botulinum toxin and progressive pneumoperitoneum) are reserved for complex hernias and are not routinely used for all types of hernias.

Support from the multidisciplinary team and optimization of the patient’s health status, as well as prehabilitation measures, will help ensure a successful treatment.