Botulinum Toxin Type a and Progressive Pneumoperitoneum: Preoperative Adjuvants for the Management of Complex Hernia with Loss of Dominance: A Case Report

Introduction: The rising prevalence of complex ventral hernias (CVH), due to factors like obesity and previous surgeries, requires new and innovative preoperative approaches. Progressive pneumoperitoneum (PPP) and botulinum toxin (BTX) are emerging adjuncts that can improve surgical outcomes for hernias with loss of domain by aiding fascial closure and reducing recurrence rates.Clinical Case: A 33-year-old female presented with a giant, non-reducible ventral hernia (30cm × 20 cm) following multiple abdominal surgeries. Imaging revealed a Tanaka index of 20%, confirming a complex hernia with loss of domain. Preoperative management included BTX injection (500 units) and progressive pneumoperitoneum insufflation (8500 cc total) over seven days. Surgical repair involved posterior component separation with mesh placement. The patient recovered favorably, with no complications or recurrence. Discussion: Preoperative optimization with BTX and PPP facilitated fascial closure by improving muscle compliance and reducing adhesions. These techniques enhanced surgical feasibility and reduced postoperative complications. Conclusions: This case demonstrates the benefits of using BTX and PPP as preoperative adjuncts for complex hernia repair. Further studies are needed to standardize protocols and assess long-term outcomes.