Preoperative BOTOX® Injection for Large Ventral Hernia Repair
NCT ID: NCT07220382
Last Updated: 2025-11-21
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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RECRUITING
PHASE4
188 participants
INTERVENTIONAL
2025-11-03
2029-12-15
Brief Summary
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Participants will be randomly assigned (like a coin flip) to receive either the BOTOX® medicine or a saltwater (placebo) injection. Neither patients nor the care team will know which one was given. All participants will still have their planned hernia repair in the standard way that we repair patients who are not part of the study. The study will track whether the abdomen can be closed without leaving a gap, and investigators will also look at recovery, complications, time in the ICU or on a ventilator, length of stay, pain, and quality-of-life scores. Most information will be collected during participants' hospital stay, but the investigators will continue to see how participants are doing up to 2 years after surgery. Short phone check-ins will occur before surgery, and after surgery follow-up happens around 30 days, 90 days, 1 year, and 2 years.
Possible risks from the injection include temporary muscle weakness, trouble swallowing or breathing, pain or infection at the injection site, and (if CT is used for guidance) a small amount of radiation exposure. Surgery itself carries the usual risks (pain, bleeding, wound problems). Benefits are not guaranteed, but the injection may make closure easier and recovery smoother. About 188 people will take part at Cleveland Clinic.
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Detailed Description
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Massive ventral hernias (pre-op axial width ≥15 cm and/or Tanaka volume ratio \>25%) seldom achieve primary fascial closure (PFC) and are associated with higher respiratory morbidity, intensive care unit (ICU) utilization, post-operative pain, hospital length of stay (LOS), cost, and recurrence. Spasticity/fibrosis of the external oblique-internal oblique-transversus abdominis (EO/IO/TA) complex likely limits lateral abdominal wall compliance and impedes midline medialization. Pre-operative, image-guided onabotulinumtoxinA (BOTOX®) has been proposed to elongate the lateral wall, enlarge the functional abdominal domain, reduce closure pressures, and thereby increase the primary fascial closure (PFC) rate. Prior institutional data show \~77% PFC in this population without pre-op toxin, whereas retrospective series suggest \~95% with toxin utilization, motivating a definitive randomized trial.
Design:
Single-center, randomized, double-blind, placebo-controlled superiority trial. Randomization uses pre-generated block allocation (statistician-generated). Analyses will be intention-to-treat (ITT), with a parallel per-protocol (PP) analyses limited to participants who receive the assigned injection and undergo AWR within 21-48 days post-injection. A single interim analysis is planned at 50% completion of primary endpoint. Intention-to-treat (ITT) is primary method of analysis; however, a per-protocol (PP) analysis will also be conducted as this supports causal inference among adherent participants. An independent DMC will review interim results and advise on continuation/early stopping.
Interventions:
Fully described in 'Arms and Interventions' section. Participants will either receive image-guided injections of BOTOX® at six sites on the lateral abdominal wall (three sites per side) with a total of 300 units give (2 u / cc concentration; 25 cc at each site); or, participants will receive the same volume of a 0.9% saline solution (25 cc at each site).
End Points and Outcomes:
Fully described in the 'Outcomes Measures' section. Primary endpoint is primary fascial closure (PFC), the successful closure of hernia defect at the conclusion of the case. Additional secondary outcomes regarding clinical course and patient-reported outcomes will be captured at 30 days, 90 days, 1 year, and 2 years.
Exploratory outcomes include cost and healthcare utilization information, as well as comparison of physiological parameters between treatment groups.
Data Stewardship:
Primary data capture occurs in the ACHQC registry, supplemented by an institutional REDCap database for variables not routinely captured (e.g., physiologic measures) in the registry.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
TRIPLE
Surgeon(s) performing the hernia repair will be blinded to the intervention drug.
Only study personnel and pharmacists who are not participating in a patient's surgery will know the randomization group (intervention or placebo).
Study Groups
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OnabotulinumtoxinA Group
These patients will receive image-guided botulinumtoxin injections as described 21-48 days prior to open ventral hernia repair.
OnabotulinumtoxinA Injection
A total of 300 units of onabotulinumtoxinA will be reconstituted 150 cc of injectable 0.9% NaCl (for a final concentration of 2 units / cc). Each side of the abdominal wall will receive a total 75 cc distributed across three injection sites (six injection sites total per patient). At each injection site, the muscle bodies of the transversus abdominis, internal oblique, and external oblique will receive an equivalent volume of product under ultrasonic or radiographic visualization.
OnabotulinumtoxinA
300 units of onabotulinumtoxinA will be prepared and administered as described in: "Procedure/Surgery: OnabotulinumtoxinA Injections"
Open Ventral Hernia Repair
Open abdominal wall reconstruction will be conducted in our standard fashion for the repair of very large hernias. The surgery is the same for patients who are not in the study. Surgeons will be blinded to the study arm of participant patients.
Placebo Group
These patients will receive image-guided saline (placebo) injections as described 21-48 days prior to open ventral hernia repair.
Saline (placebo) Injection
150 cc of injectable 0.9% NaCl will be prepared. Each side of the abdominal wall will receive a total 75 cc distributed across three injection sites. At each injection site, the muscle bodies of the transversus abdominis, internal oblique, and external oblique will receive an equivalent volume of product under ultrasonic or radiographic visualization.
0.9 % Normal Saline
150cc of normal saline will be prepared and administered as described in: "Procedure/Surgery: Saline (placebo) Injection".
Open Ventral Hernia Repair
Open abdominal wall reconstruction will be conducted in our standard fashion for the repair of very large hernias. The surgery is the same for patients who are not in the study. Surgeons will be blinded to the study arm of participant patients.
Interventions
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OnabotulinumtoxinA Injection
A total of 300 units of onabotulinumtoxinA will be reconstituted 150 cc of injectable 0.9% NaCl (for a final concentration of 2 units / cc). Each side of the abdominal wall will receive a total 75 cc distributed across three injection sites (six injection sites total per patient). At each injection site, the muscle bodies of the transversus abdominis, internal oblique, and external oblique will receive an equivalent volume of product under ultrasonic or radiographic visualization.
Saline (placebo) Injection
150 cc of injectable 0.9% NaCl will be prepared. Each side of the abdominal wall will receive a total 75 cc distributed across three injection sites. At each injection site, the muscle bodies of the transversus abdominis, internal oblique, and external oblique will receive an equivalent volume of product under ultrasonic or radiographic visualization.
OnabotulinumtoxinA
300 units of onabotulinumtoxinA will be prepared and administered as described in: "Procedure/Surgery: OnabotulinumtoxinA Injections"
0.9 % Normal Saline
150cc of normal saline will be prepared and administered as described in: "Procedure/Surgery: Saline (placebo) Injection".
Open Ventral Hernia Repair
Open abdominal wall reconstruction will be conducted in our standard fashion for the repair of very large hernias. The surgery is the same for patients who are not in the study. Surgeons will be blinded to the study arm of participant patients.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
* Candidate for elective open repair of ventral hernia
* Preoperative imaging demonstrating either:
* ventral hernia defect width of at lest 15 cm; AND/OR,
* Tanaka volume ratio of at least 25%
* Planned elective hernia repair in an open fashion via a midline laparotomy with posterior component separation and transversus abdominis release
Exclusion Criteria
* Pregnancy and/or breastfeeding at time of intramuscular injection
* Inability to provide informed consent
* Inability to receive either study intervention (i.e. allergy to local anesthetics utilized for intervention administration, allergy and/or contraindication to any botulinum toxin, inability to attend outpatient administration of study intervention, inability to conform to safety check schedule)
* Known congenital or acquired neuromuscular disorder
* Presence of stoma
* Current infection at time of intramuscular injection
* Flank hernias s defined by EHS L1-L4
* BMI \> 45 kg/m\^2
* Diaphragmatic hemiparesis or chronic obstructive pulmonary disease (COPD) with chronic oxygen dependence
18 Years
ALL
No
Sponsors
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Joseph and Florence Mandel Family Foundation
UNKNOWN
The Cleveland Clinic
OTHER
Responsible Party
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Lucas Beffa
Assistant Professor of Surgery
Principal Investigators
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Lucas R Beffa, MD
Role: PRINCIPAL_INVESTIGATOR
The Cleveland Clinic
Locations
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Cleveland Clinic Main Campus
Cleveland, Ohio, United States
Countries
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Central Contacts
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Facility Contacts
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Other Identifiers
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25-824
Identifier Type: -
Identifier Source: org_study_id
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