Complex ventral hernia repair in a child: An association of botulinum toxin, progressive pneumoperitoneum and negative pressure therapy. A case report on an arising surgical technique

INTRODUCTION: The purpose of this manuscript is to report the management of a child born with giant omphalocele (GO) that developed a complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect. PRESENTATION OF CASE: The patient underwent a one-step surgery to correct a ventral hernia associated with a largely prolapsed enteroatmospheric fistula (EAF) along with an ileostomy. It was managed by a pre-operative association of botulinum toxin agent (BTA) application with preoperative progressive pneumoperitoneum (PPP) and trans-operative negative pressure wound therapy (NPWT) dressing with staged abdominal closure. The patient needed 4 reoperations due to enteric fistulas. Nine days after the first surgery, it was possible to completely close the abdominal wall without mesh substitution. No signs of hernia in 9 months of follow-up. DISCUSSION: This is the second report in the literature and it reinforces the safety and effectiveness of the BTA injection associated with PPP in children. CONCLUSION: The use of BTA in association with PPP should be encouraged and best investigated in patients with GO. The fistulas were not attributed to the negative pressure. Maybe it is time to start defining better criteria to categorize GO in order to choose the best management for each patient.