Ultrasound-Guided Botulinum Toxin A as an Adjunct to Intraoperative Fascial Traction in Incisional Hernia Repair: Registry-Based Cohort Study

<b>Background</b>: AchievTing primary fascial closure in complex incisional hernia repair can be challenging when abdominal wall compliance is reduced. Preoperative ultrasound-guided botulinum toxin A (BTA) is used as a chemical component relaxation adjunct, and intraoperative fascial traction (IFT) is a traction-based technique to facilitate medialization. This study assessed the association of adding BTA to a traction-treated cohort. <b>Methods</b>: Retrospective observational analysis of prospectively collected Herniamed Registry data from the Hamburg Hernia Center (1 February 2022-13 October 2025) was conducted. Elective incisional hernia repairs with IFT were included and stratified into BTA + IFT versus IFT-only. The primary outcome was primary fascial closure as documented in the registry. Categorical variables were compared using Fisher's exact test. <b>Results</b>: A total of 81 patients were analyzed (BTA + IFT, <i>n</i> = 64; IFT-only, <i>n</i> = 17). Primary fascial closure was achieved in 51/64 (79.7%) in the BTA + IFT group and 8/17 (47.1%) in the IFT-only group (OR 4.3, 95% CI 1.22-15.84; <i>p</i> = 0.013). Mean operative time was similar (193 vs. 195 min). Mean length of stay was longer in the BTA + IFT group (8 vs. 5 days). Perioperative complications were recorded 8/64 (12.5%) in the BTA + IFT group and 0/17 (0.0%) in the IFT-only group. <b>Conclusions</b>: In traction-assisted incisional hernia repair, adjunctive preoperative ultrasound-guided BTA was associated with higher primary fascial closure rates compared with traction alone. Findings are hypothesis-generating due to non-randomized allocation and baseline differences between cohorts.