Preoperative use of botulinum toxin for the closure of large abdominal wall defects: a case series

Introduction: Reconstruction of complex abdominal wall defects in pediatric patients remains technically challenging. Botulinum toxin type A (BTA) has been used as a preoperative adjunct in adults, with limited experience reported in pediatric population. Case presentation: Case 1: A 12-year-old boy with a complex ventral hernia secondary to a giant omphalocele underwent ultrasound-guided infiltration of 300 IU of BTA into the rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles bilaterally in a single preoperative session. Surgical repair using the Rives–Stoppa technique with mesh placement was performed four weeks after BTA injection. Adequate abdominal wall relaxation was achieved, allowing tension-free closure. The postoperative course was uneventful, with complete wound healing and no complications on follow-up. Case 2: A 4-year-old boy with bladder exstrophy underwent ultrasound-guided infiltration of 150 IU of BTA into the lateral abdominal wall muscles in a single preoperative session. Definitive urinary and abdominal wall reconstruction was performed four weeks after BTA administration. Abdominal wall closure was achieved without prosthetic material. A superficial wound dehiscence occurred postoperatively, requiring conservative management, with subsequent complete healing. On follow-up, a small residual ventral hernia (2 cm) was identified. Conclusion: Preoperative BTA seems to be a safe and feasible adjunct in selected pediatric patients undergoing complex abdominal wall reconstruction.