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

Background: 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. Methods: 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. Results: A total of 81 patients were analyzed (BTA + IFT, n = 64; IFT-only, n = 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; p = 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. Conclusions: 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.