Methods of abdominal wall expansion for repair of incisional herniae: a systematic review

To systematically review the available literature regarding methods for abdominal wall expansion and compare the outcome of primary fascial closure rates. A systematic search of Pubmed and Embase databases was conducted using the search terms "Abdominal wall hernia", "ventral hernia", "midline hernia", "Botulinum toxin", "botox", "dysport", "progressive preoperative pneumoperitoneum", and "tissue expanders". Study quality was assessed using the Methodological Index for Non-Randomised Studies. 21 of the105 studies identified met the inclusion criteria. Progressive preoperative pneumoperitoneum (PPP) was performed in 269 patients across 15 studies with primary fascial closure being achieved in 226 (84 %). 16 patients had a recurrence (7.2 %) and the complication rate was 12 % with 2 reported mortalities. There were 4 studies with 14 patients in total undergoing abdominal wall expansion using tissue expanders with a fascial closure rate of 92.9 % (n = 13). A recurrence rate of 10.0 % (n = 1) was reported with 1 complication and no mortalities. Follow up ranged from 3 to 36 months across the studies. There were 2 studies reporting the use of botulinum toxin with 29 patients in total. A primary fascial closure rate of 100 % (n = 29) was demonstrated although a combination of techniques including component separation and Rives-Stoppa repair were used. There were no reported complications related to the use of Botulinum Toxin. However, the short-term follow up in many cases and the lack of routine radiological assessment for recurrence suggests that the recurrence rate has been underestimated. PPP, tissue expanders and Botulinum toxin are safe and feasible methods for abdominal wall expansion prior to incisional hernia repair. In combination with existing techniques for repair, these methods may help provide the crucial extra tissue mobility required to achieve primary closure.