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Background and Aims A 65-year-old white male, ASAIII, presented to an ED General Surgery with bulky left incisional hernia with need of surgical correction of incision hernia with loss of home subsequent epigastric hernia repair (2016). On examination, the patient had a voluminous left incisional hernia reducible and non-tender. Patient was suggested to do an elective procedure pre-surgery, injections of botulinum toxin guided US in abdominal wall and then to a Rives-Stoppa-Wantz hernioplasty.

Methods Patient have given your informed consent. On 18th August 2022, an anesthesiology, near 10am, did 10 injections in studied points of abdominal wall, guided by US without any complication. About 200 units of Botulinum Toxin A was injected in aliquots of 25 units.

Results He was admitted to the HFF ED on 19th August 2022 progressed with alteration dysarthria, drop in MSE in PBE, FM with grade 3 in MIE and grade 4 on the right and generalized fatigue (patient with significant limitations due to severe atrosis). He CT-CT scans with reveal and hypothesis of acute ischemic stroke. During OR stay, was assessment for tetraparesis and possible autonomic dysfunction. Probable diagnosis: Following diagnostic hypotheses were posed: 1. Iatrogenic botulism was excluded with 3 subsequent negative searches 2. Myasthenia Gravis with anti-AChR ac were excluded by 3 subsequent negative searches 3. Guillain-Barré syndrome - an aggravation of autoimmune disease, initiated targeted therapy (initially made IVIG and corticosteroids) During ICU period were medicated with Pyridostigmine, Prednisolone, Immunoglobulin.

Conclusions On 29th December 2023, patient finality made Rives-Stoppa-Wantz hernioplasty, with any complications