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Botulinum toxin A in laparocele surgery

All of the Surgeons who deal with. abdominal wall have a primary goal to achieve in their interventions: that of achieving the so-called "tension-free" repair, that is, a repair in which the means used to repair the wall defect - the sutures, the prosthesis...-are not under tension.
There is no clear agreement in the international surgical community on what "tension" is. However, it appears that at least two factors play an important role in determining tension: theIncreased pressure within the abdomen and the so-called "distractive forces" of the abdominal wall, that is, those that tend to increase the diameter of the wall defect, be it a hernia, a laparocele or a diastasis of the rectus. To balance the effect of these "tensional" forces, the Surgeon has several weapons at his disposal, which he uses according to his experience and skills: from the more classic ones, such as the separation techniques ofanal fissure, anal fissure, anal pain, botulinum toxin a, laparocele, rectus diastasis, abdominal wall surgery, abdominal wall components or the use of large prosthesis, to more modern ones, such as the preoperative use of adjuvant techniques such as the botulinum toxin A and the preoperative progressive pneumoperitoneum. On the Surgeon's side there are then some "biological" factors, such as the ability of the organism to "integrate" (i.e., to make the prostheses used become part of itself): the latter ability, however, also depends on the material of which the prosthesis is made, and the position in which it is placed. Today we know, for example, that it should be avoided as much as possible to place a mesh inside the peritoneum, in contact with the abdominal viscera, because of the damage it may cause to the latter; and that in any case, even when placing an intraperitoneal prosthesis, the wall defect should always be sutured first. This last indication - the so-called IPOM PLUS technique - Unfortunately, it is followed by very few surgeons in Italy today, as the abdominal wall surgery is not still considered an autonomous specialty, and there are very few Professionals who have specific training in this regard.

Then there are "patient-side" factors that sensitively affect repair tension: the most important isobesity-and in fact no Wall Surgeon would operate (unless in an emergency situation) on an obese patient without first getting him or her to lose weight, even resorting to bariatric surgery if necessary.
Extremely important and interesting from the point of view of surgical technique are the "distractive" forces. When a defect in the abdominal wall forms, especially if it is apost-surgical hernia (also known as an incisional hernia or laparocele) or a diastasis of the rectus, the three lateral muscles of the abdomen (external oblique, internal oblique, and transverse) lose one of their insertions, the medial one, on the fascia of the rectus muscles of the abdomen; over time the muscles go into fibrosis, shorten, thicken, and lose, at least in part, their elastic capabilities. When it comes to surgery, such profound structural changes in the muscles are one of the main causes of repair tension, especially if the defect is large. This explains why if abdominal wall defects, and especially anincisional herniaor laparocele, or even a large diastasis of the rectus, are repaired with a simple suture and without using prostheses, recurrences, 10 years after surgery, are up to 50 percent of cases.
Laparocele is always consequent to a laparotomy, i.e., surgery involving incision of the abdominal wall (e.g., after surgery for removal of the gallbladder, appendix, open bowel cancer, removal of the uterus, etc.) and is common in patients undergoing surgery for cancer. We know that if, at the time of laparotomy closure, we use a "prophylactic" mesh (i.e., a mesh implanted for the purpose of reducing the likelihood of laparocele formation), the incidence of laparocele itself, at 10 years, plummets to 5-10%. The "prophylactic" mesh is normally much smaller than those used in laparocele repair: this is because at the time of laparotomy closure, the muscles are much more elastic than those of a patient with a laparocele, and can be easily brought closer together.
From this simple but important observation, an equally simple idea was born: if the muscles of patients with a large abdominal wall defect - a laparocele, for example, as mentioned; but also a large diastasis of the rectus with a diameter of more than 8 cm - could be restored to their original length and elasticity, the tension of the sutures at the time of laparocele repair would be greatly reduced, and consequently the risk of recurrence would be reduced.
This idea was first applied to laparocele surgery by an ingenious Mexican surgeon, Dr. Tomás Ibarra Hurtado, in 2007. Dr. Ibarra Hurtado thought that the

Botulinum toxin A, laparocele, rectus diastasis, abdominal wall
Dr. Tomás Ibarra Hurtado
Dr. Ibarra Hurtado teaches us his technique with botulinum toxin A

botulinum toxin A, a drug widely used both in neurology (e.g., for the treatment of facial muscle spasms), in plastic surgery (for the treatment of facial wrinkles), and in proctology (for the treatment of anal fissures), injected into the muscles of the abdominal wall prior to laparocele surgery, could cause those muscles to relax: at this point, the pressure exerted on those muscles by the viscera contained within the abdomen would cause them to lengthen. This hypothesis was confirmed by CT studies carried out at 2 to 4 weeks of toxin administration: in patients undergoing such treatment, all of whom had large laparoceles, the lateral muscles of the abdomen were indeed significantly lengthened and thinned. This makes it much easier to bring the muscles closer together and thus repair the defect without tension.
Dr. Ibarra Hurtado's technique is now widely used throughout the world, and used by leading surgeons specializing in abdominal wall repair. In Italy, however, our group-I learned the technique directly from Dr. Ibarra, as part of a splendid seminar he held in 2018 in Madrid during the congress of the Sociedad Hispano-Americana de Hernia-is the only one to use botulinum toxin A in reconstructions of large wall defects.
The effect of botulinum toxin A persists for about 3 months; in this time frame, tissue repair processes and prosthesis integration progress to such an extent that, once the effect of the toxin has ceased, the soundness of the repair is no longer at risk.
The use of botulinum toxin A in the surgery of large wall defects has confirmed that the main risk factor for recurrences of laparoceles and other large abdominal wall defects (such as large diastases of the rectus, with diameters greater than 8 cm) is precisely suture tension. Its use, together with other preoperative strategies of preparation and optimization of the surgery (e.g., weight loss, smoking cessation, diabetes control, etc.) allows to significantly reduce recurrences and postoperative pain and to use smaller mesh sizes.
In our country, the National Health System does not recognize the use of botulinum toxin A for abdominal wall surgery; therefore, as mentioned above, its use is virtually unknown.


Dr. Salvatore Cuccomarino
Cuccomarino, MD
Dr, Cuccomarino coordinates a multidisciplinary medical team dedicated to the treatment of abdominal wall defects. He was the first in Europe to perform REPA, the minimally invasive endoscopic surgery of diastasis of the rectus.
61 Amerigo Vespucci Street
Phone +39 011 0438161


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hernia, abdominal hernia, abdominal hernia surgery, hernia surgery, Chivasso Hospital
Inguinal and abdominal hernia surgery in Chivasso: new surgical techniques

surgery for inguinal hernia , surgery for laparocele, Chivasso, Chivasso Hospital, inguinal hernia, abdominal hernia, laparoceleAlready for some months we have introduced, In our hospital in Chivasso, some important technical news in the inguinal and abdominal hernia and laparocele surgery.

Especially with regard to laparoscopic, minimally invasive surgery of abdominal hernia and laparocele, we have introduced, first in Italy, a new technique that allows us not to place nets in contact with the intestinal loops. In fact, it is now increasingly common within scientific societies and specialized websites to report serious complications related to prostheses; in particular, it is now clear that there is no mesh that does not cause the formation of adhesions, and expose the patient to the risk of intestinal injury and occlusive crisis. For this reason, we have begun to place prostheses outside the peritoneum, with a technique known as TAPP (trans abdominal pre peritoneal) and previously used only for inguinal hernias. We have also modified, in suitable cases, the surgical access so that the scars are truly invisible. The following is a video of this new technique.

We also introduced a new and revolutionary surgical technique for the treatment of large abdominal hernias and large laparoceles (i.e., when the defect is greater than 12 cm). This is the anatomical separation of components sec. Carbonell-Bonafé, which was passed on to us precisely by Prof. Fernando Carbonell Tatay of the University of Valencia-currently one of the greatest wall surgeons in Europe.

The technique, as complex as it is effective, involves placing two large nets in the
(behind the rectus abdominis muscles and in the space between the external oblique and internal oblique muscles, to be precise); in cases of loss of right of domicile (i.e., when the abdominal space has shrunk so much that it can no longer accommodate herniated viscera), the use of botulinum toxin infiltrated preoperatively allows a good portion, if not all, of the lost volume to be recovered. Here is a video of the technique, made by our team for a recent scientific meeting of the Sociedad Hispanoamericana de Hernia.

In short, placing these new techniques alongside the already established procedures of hernioplasty according to Trabucco and laparoscopic inguinal hernioplasty, ' inguinal and abdominal hernia surgery in Chivasso becomes increasingly effective, refined, and safe.

For any information, please feel free to contact us through our website cuccomarinomd.com or by phone at 011-0438161


Dr. Salvatore Cuccomarino
Cuccomarino, MD
Coloproctology, advanced laparoscopic surgery, hernia and abdominal wall surgery
Corso Galileo Ferraris 3
Phone 0110438161

Laparocele, hernia, incisional hernia, abdominal hernia, eventration
And after the surgery, the laparocele

Laparocele, hernia, incisional hernia, abdominal hernia, eventrationAnd after the surgery, the laparocele. It is not so uncommon (indeed!) that after abdominal surgery a "bulge" appears near the surgical scar. It is the laparocele, o incisional hernia: the wall suture has failed ("suture dehiscence"), and now the viscera contained in the abdomen press toward the skin.

A laparocele is a true hernia. The difference is that it appears not at a naturally occurring orifice, but at a surgically created defect. There are many conditions that facilitate the occurrence of a laparocele, ranging from incorrect lifestyles (e.g., smoking), to physiological states (such as advanced age), dysmetabolic (e.g., malnutrition), and pathological (such as tumors).

Treatment of a laparocele is always surgical, and presupposes a careful preoperative study (the dynamic CT scan of the abdominal wall), which must lead to equally careful evaluations of the choice of surgical technique to be adopted.

Repair of a laparocele can in fact be performed either laparoscopically, minimally invasive, or open, but the two access modalities are not interchangeable. Minimally invasive surgery is effective in defects of more modest size, no more than 6-8 cm. In the case of larger defects, in fact, Placement and proper distension of the mesh can be difficult, exposing the patient to an increased risk of recurrence. In addition, a large laparocele also presents other issues that it is crucial to take into account: for example, the volume of the herniated viscera and the residual space of the abdominal cavity, which must be properly calculated: this is to avoid determining, with an incorrect repair, an intra-abdominal pressure increase, which can be a cause of respiratory failure in the patient. In addition, in large laparoceles there is oftenatrophy, associated with retraction, of the muscles of the abdominal wall: this may make it impossible to "reconstruct the midline," as it is called in the jargon, that is, to relocate the muscle-fascial layers of the wall in their correct position so as to repair the abdominal defect. In such cases, anatomical separation of components (SAC), i.e., isolation of the individual layers of the abdominal wall, is necessary: this allows both the muscle-fascial components to be brought closer to the midline and the placement of large meshes, which are essential for reconstructing both the structure and function of the abdominal wall in such cases.

These are very complex and time-consuming operations that can only be performed by highly experienced surgical teams. The most refined anatomical component separation technique is that of Carbonell-Bonafé, two Spanish surgeons who without difficulty can be counted among the great masters of 20th century wall surgery.

I was fortunate to learn the Carbonell-Bonafé technique directly from Professor Fernando Carbonell; currently, my team is among the very few (I think less than 5) in all of Italy performing it. Here is a short film of mine, summarizing in less than 20 minutes a catastrophic laparocele surgery repaired with Carbonell's technique that lasted about 5 hours.

inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photo, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms
Abdominal wall surgery in the cancer patient

inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photo, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms

Abdominal wall surgery

Abdominal wall surgery is a superspecialty surgery, in many respects more complex than most other abdominal surgeries (except, perhaps, pancreatic surgery and metabolic surgery), requiring years of study and application, and a very detailed knowledge of human anatomy, to be successfully performed. In our unfortunate country, by many of the many, too many big wigs in our own health care, abdominal wall surgery is considered a minor branch of the medical sciences; but one only has to cross the Alps to see how much it is valued, and even feared, in the international surgical environment. And this is well understood when one looks at the disasters, due to surgical unpreparedness, often combined by those who approach the operating table without due respect for the abdominal wall: which, it should be remembered, is one of the load-bearing walls of the "house" in which we live, our body. How would one live in a house with gutted walls? The quality of life would be abysmal; and abysmal is the quality of life of those who are recklessly operated on by those who do not know the laws-often very complex-that dictate that we follow the abdominal wall.

The history of abdominal wall surgery

abdominal wall surgery, inguinal hernia symptoms, inguinal hernia surgery, scrotal hernia, inguinal hernia symptoms, inguino-scrotal hernia, strangulated hernia, adult umbilical hernia, inguinal hernia surgery, inguinal hernia photos, inguinal hernia surgery, testicular hernia, abdominal laparocele, hernia symptoms, umbilical hernia surgery, inguinal hernia recurrence, crural hernia symptoms, spigastrium hernia, inguinal hernia photos,hernia symptoms, female inguinal hernia, inguinal hernia surgery, umbilical hernia surgery, epigastric hernia symptoms,La history of abdominal wall hernia surgery È the History of Surgery: all the greatest Surgeons, all those whose names are remembered, have applied and contributed to it. I have spoken about it at several national and international conferences and courses, because it is a fascinating tale; just as fascinating is the History of the invention of the prostheses we use today in abdominal wall surgery: to the eye, small sheets of plastic, but with extraordinary technological content inside that rests on more than a century of scientific research.

Course on abdominal wall surgery in the cancer patient

It is therefore a great honor for me, and a great pride, to participate, as the ONLY ITALIAN INVITED SPEAKER among dozens of sacred monsters of Spanish (among the best in the world) and Hispanoamerican Surgery, in the International Course of Abdominal Wall Surgery in the Oncological Patient organized by the Sociedad Hispanoamericana de Hernia and by theUniversity of Valencia next October.

The course is sponsored by the Generalitat Valenciana, the Asociación Española de Cirujanos and theInstituto Cervantes, to name but a few of the major Spanish institutions that have shown interest in our work; as well as by numerous international Scientific Societies.

We will hold our country's flag high, and honor our work!