Use of botulinum toxin in abdominal wall surgery: results of a nationwide Italian survey

Background: Botulinum toxin type A (BT-A) has recently emerged as a less invasive adjunct in abdominal wall reconstruction, acting as a chemical component separation tool. Despite encouraging evidence, its use remains off-label and highly heterogeneous, with no standardized protocols available. Methods: A nationwide cross-sectional survey was conducted among Italian surgeons between May and June 2025 through the official communication channels of the Italian Hospital Surgeons Association (Associazione Chirurghi Ospedalieri Italiani). The 32-item questionnaire addressed demographics, institutional activity, awareness, indications, technical details of BT-A administration, safety, adjunctive strategies, radiological protocols, and clinical impact. Results: A total of 160 responses were collected from 101 Italian hospitals. Although 87% of surgeons were aware of BT-A, only 30.1% reported direct clinical experience, mainly limited by regulatory barriers. Botox (62%; Allergan/Pharma Allergan) was the most frequently used formulation, followed by Dysport (36%). Injections were predominantly ultrasound-guided (86%), performed in an outpatient setting, with common dosages of 300–500 IU. Most respondents (77.4%) targeted all three lateral abdominal wall muscles, although literature suggests comparable outcomes with two-layer injection techniques. Administration was typically performed 30 days preoperatively, while 2% reported shorter intervals; novel rapid-onset formulations under investigation may broaden its use in urgent settings. Postinjection radiological assessment was performed in 70% of cases, mainly with computed tomography. Reported indications included hernia defects more than 10 cm, loss of domain, and cases requiring posterior component separation with transversus abdominis release. No adverse reactions were observed; literature similarly describes a favorable safety profile, with only rare reports of transient discomfort or systemic toxicity. Perceived clinical impact was significant: 41.6% believed BT-A helped avoid more invasive procedures, 14.3% considered it indispensable, while 24.7% reported no change in surgical strategy. Conclusions: This first nationwide Italian survey highlights a growing awareness and interest in BT-A use for complex abdominal wall reconstruction, but also substantial heterogeneity in its practical application. Standardized protocols regarding dosage, timing, target muscles, and radiological assessment are lacking. The findings emphasize the need for prospective multicenter studies to define optimal patient selection, validate clinical benefits, and explore emerging rapid-onset formulations for urgent scenarios.