Skip to main content
OpenTrials
Enrolling by Invitation

NCT Number: NCT07628205

Preoperative Botulinum Toxin A to Facilitate Midline Closure in Large Chronic Ventral Hernias

In patients with large hernias, chronic retraction of the lateral abdominal wall muscles, and visceral contents that are irreducible within the hernia sac, closure of the midline can be difficult or even impossible. Component separation techniques (CST), in combination with transversus abdominis release (TAR), increase the flexibility of the abdominal wall and facilitate fascial medialization. However, these techniques alter the anatomy of the abdominal wall and are associated with higher risks of wound complications, abdominal wall disruption, and abdominal compartment syndrome (ACS).

Recently, the preoperative injection of Botulinum Toxin A (BTA) has been proposed as an effective form of chemical component separation of the muscles, or more precisely, chemical relaxation. It has been hypothesized that preoperative chemical paralysis of the lateral abdominal wall muscles through BTA increases abdominal wall compliance and facilitates fascial medialization, thereby reducing the need to resort to CST.

However, the current literature still lacks studies evaluating the impact of BTA on predictive scores for myofascial release and the correlation with intraoperative strategies.

Enrolling by Invitation

Interested in participating?

Request Info

Key information

Conditions

Hernia Pathological Conditions, Anatomical Pathological Conditions, Signs and Symptoms

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Phase 2

Primary location

Asst Ovest Milanese

Legnano, Milano, 20025, Italy

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Participant is willing and able to give informed consent for participation in the trial
  • Compliance to follow-up
  • Male and female
  • Written informed consent to preoperative BTA injection and/or surgery
  • Age 18 years old
  • Primary ventral hernia
  • Incisional ventral hernia
  • RDR < 2
  • Defect width 10 cm
  • Loss of domain (LoD) 20%

Exclusion criteria

  • Medical or psychiatric conditions that compromises the patient's ability to give informed
  • consent or comply with the study protocol
  • Personal reasons
  • Age < 18 years old
  • RDR ≥ 2
  • Defect width < 10 cm
  • LoD < 20%
  • Pregnancy and breastfeeding
  • Allergy/Intolerance to BTA
  • Neuromuscular disorders and diseases
  • Refuse to give informed consent to preoperative BTA injection and/or surgery

Treatment and study plan

Posterior Component Separation (PCS) with TAR

Procedure

Posterior Component Separation (PCS) with Transversus Abdominis Release (TAR) is an intraoperative surgical technique performed by the surgeon when a standard retromuscular repair, such as the Rives-Stoppa technique, does not allow for tension-free midline closure. In such cases, additional myofascial release is required, and PCS with TAR is subsequently performed to achieve adequate medial advancement of the abdominal wall components and enable secure, tension-free closure of the midline defect.

Rives-Stoppa

Procedure

Rives-Stoppa repair is a retromuscular abdominal wall reconstruction technique used when primary fascial closure can be achieved without the need for additional myofascial release. It represents a less invasive approach compared to component separation techniques, such as Posterior Component Separation with Transversus Abdominis Release (PCS with TAR), and is performed in cases where tension-free midline closure is feasible using a standard retromuscular plane dissection.

Primary outcomes

  1. Improvement in Preoperative Indices Following Botulinum Toxin A Injection

    Time frame: Enrollment, 4 weeks after BTA injection, and 12 months after surgery

    Changes in preoperative radiological indices following Botulinum Toxin A (BTA) injection will be assessed using abdominal computed tomography (CT) scans. The Rectus-to-Defect Ratio (RDR) will be calculated on pre- and post-injection CT imaging; each 0.5-point increase in RDR is associated with an approximate 20% linear reduction in the need for anterior myofascial release (AMR). The Component Separation Index (CSI) will be determined on axial CT images using the aorta as a fixed reference point and the medial borders of the rectus abdominis muscles. Abdominal cavity volume will be estimated using the ellipsoid volume formula based on craniocaudal, transverse, and anteroposterior diameters measured on CT imaging. Pre- and post-BTA values will be compared to evaluate improvement in abdominal wall compliance and anatomical reconstruction parameters.

Secondary outcomes

  1. Association Between Changes in Preoperative Indices After Botulinum Toxin A Injection and Surgical Strategy Selection.

    Time frame: until the end of the study

    Two surgical strategies will be considered based on abdominal wall reconstruction requirements: (A) Posterior Component Separation (PCS) with Transversus Abdominis Release (TAR), and (B) Rives-Stoppa repair, performed when no myofascial release is required. For PCS with TAR procedures, the Posterior Bridging Ratio (PBR) and Anterior Bridging Ratio (ABR) will be assessed as the proportion of the peritoneal sac used as a bridge to achieve tension-free closure of the posterior and anterior fascial layers, respectively. The extent of ABR and PBR will be analyzed in relation to the preoperative effect of Botulinum Toxin A (BTA) injection. In particular, higher percentages (>50%) of PBR and ABR will be considered indicative of poor BTA efficacy, intermediate values (25-50%) of partial efficacy, and low values (0-25%) of good to very good BTA efficacy. The relationship between changes in preoperative indices after BTA administration and the selected surgical approach will be evaluated.

Sponsors and collaborators

Lead sponsor

Azienda Socio Sanitaria Territoriale Ovest Milanese, Ospedale di Legnano

Other

Registry information

Official study title

Prehabilitation With Botulinum Toxin A in Complex Hernia: an Italian Prospective Study on Predictive Scores of Myofascial Release.

Acronym: Probhe

Important dates

Study start
2026
Primary completion
2029
Study completion
2029
First posted
Jun 4, 2026
Registry last updated
Jun 4, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

Related clinical trials

Published trials that share one or more normalized conditions with this study.