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40 Temporary Abdominal Closure
417
Fig. 40.8 ( a ) Open abdomen with large defect. Markings
on the abdominal wall of 5 cm away from wound edge
and 3 cm apart to illustrate where elastomers should be
placed. Stab incisions with a knife or bovie may be made
at these points. ( b ) Open abdomen with ABRA
nal wall closure system (Canica Designs, Almonte, ON,
Canada). The perforated silicone sheet has been placed to
protect the viscera. The elastomers have been placed 5 cm
away from the wound and 3 cm apart. A spacer is placed
®
abdomi-
Fig. 40.9 A patient with open abdomen who had ABRA ®
(Canica Designs, Almonte, ON, Canada) placed and has
undergone primary fascial closure with no evidence of
recurrent hernia at 1-year follow-up
in the wound to coordinate the elastomers. The button
pads and tails have been placed. ( c ) Side view of the but-
ton pads and tails that are placed to help hold the elastomers. Placement of a surgical drape such as Ioban™ (3M,
Saint Paul, MN) (not shown in picture) may help minimize skin trauma from the button pads and tails. ( d ) View
of abdomen once ABRA
(Canica Designs, Almonte, ON, Canada) has been placed
with wound vac
®
abdominal wall closure system
Enteroatmospheric Fistulas
Patients who develop an enteroatmospheric fi stula
during treatment for an open abdomen are another
clinical challenge. Source control is essential and
is often diffi cult to achieve without reoperations
and application of multiple techniques. The
abdomen that is open for more than 5–7 days is at
greatest risk of developing this complication. It is
diffi cult to contain a fi stula’s output because an
ostomy appliance is usually not effective. The
effl uent continues to drive the infl ammatory
response and can precipitate the formation of
more fi stulas and prevent healing.
Foley catheter placement through the fi stula
should not be attempted, because it will result in
limited effl uent control and an increase in fi stula
size. Porous, petroleum-based, non-adherent
dressing can be laid on the bowel surrounding the
fi stula with white foam placed over the fi stula.
GranuFoam™ (Kinetic Concepts, Inc., San
Antonio, TX) can then be cut to the size of the
wound (not covering the white foam) and a transparent adherent dressing applied. A superfi cial
418
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W.W. Hope and W.F. Powers IV
Fig. 40.10 ( a ) Open abdomen with enteroatmospheric
fi stula . There is a good bed of granulation tissue that
would be amenable to split thickness skin grafting. ( b )
Split thickness skin grafting of open wound. Foley cathe-
portion of the white foam can then be excised and
the V.A.C. tubing system applied. The pressure
should be adjusted to the lowest pressure that prevents leakage around the stoma. A standard baby
bottle nipple can also be used for effl uent control.
A small hole is cut in the nipple to allow placement of a Foley with its balloon slightly infl ated.
The bowel is covered with a non-adherent,
petroleum- based dressing as described previously. A standard V.A.C. is applied to the remainder of the wound leaving the fi stula uncovered by
foam. The nipple can be placed over the fi stula
and isolated with stoma paste or an Eakin ring
with GranuFoam™ placed around the nipple.
The adherent drape can then be applied and the
V.A.C. set to a standard setting with the Foley
placed to gravity drainage. These two techniques
often work well for proximal fi stulas when effl uent is mostly liquid.
The fi stula ring can be instituted for distal fi stulas when the effl uent is thicker. This requires a
round piece of GranuFoam to be sandwiched
between adherent VAC tapes. An Eakin ring is
then applied to the base of the fi stula ring. A
small hole is created in the center of the ring the
size of the fi stula. Non-adherent, petroleumbased dressing is applied to exposed bowel,
excluding the fi stula, and a standard V.A.C. is
applied. The suction device is placed away from
the site of the fi stula, and an ostomy appliance is
placed over the fi stula ring. Certainly, there are
surgical techniques that can be used to facilitate
fi stula closure, but these are beyond the scope of
ter is placed in fi stula in attempts to drain and patient also
has left lower quadrant colostomy. ( c ) Wound vac placed
over split thickness skin graft with drains in fi stula as well
as colostomy
this chapter. Standard tenants of fi stula management including TPN therapy, nutritional optimization, and delayed (up to 6 months) defi nitive
surgical procedures to decrease infl ammation in
the abdomen should all be applied on a case by
case basis. In patients with enteroatmospheric fi stulas, attention is often placed on fi stula management and control, and abdominal closure
techniques are often not employed. These patients
often require open abdomen management, and
the goals of therapy are shifted to closing and
controlling the fi stula rather than abdominal wall
closure. Early skin grafting can help manage
these fi stulas and convert them from an enteroatmospheric fi stula into a standard fi stula
(Fig. 40.10a–c ). Defi nitive abdominal wall recon-
struction and closure are often delayed until the
fi stula is healed. When the fi stula doesn’t heal,
single-stage or double-stage abdominal wall
reconstructions with fi stula takedowns can be
undertaken depending on the clinical condition.
Outcomes
There are few prospective or comparative studies
on which to base decision-making regarding temporary abdominal closure, since this is a heterogeneous population and involves many different
strategies, techniques, and outcome measures.
Several reports from single centers using one
technique or protocol to manage open abdomens show good success rates and achievement
40 Temporary Abdominal Closure
419
of primary fascial closure; however, few are
comparative studies. Meta-analyses and systemic reviews have shown improvements in
primary fascial closure rates and lower mortality
rates using the Wittmann patch, VAC systems,
and dynamic retention sutures [ 6 , 7 ]; however,
fi rm conclusions cannot be made due to the
limited nature of the data.
How to Choose
With limited data to guide treatment of the open
abdomen, the surgeon is left with several options.
The treatment used is often based on previous
experience, comfort level, and patient outcomes.
Certain centers may have treatment protocols for
patients with open abdomens, and often these
result in high rates of fascial closure.
When evaluating a patient with an open abdomen requiring temporary abdominal closure, the
clinical picture must fi rst be evaluated, and
desired outcomes must be established. In some
patients, primary abdominal closure is likely not
possible, so the main priority is patient survival.
In these cases, many of the techniques described
in this chapter will suffi ce, and, often if the
patient survives, skin grafting and planned ventral hernia repair can be used. In these cases, the
V.A.C. works quite well since it is easy to apply
and facilitates superb fl uid management.
In other cases, the patient’s clinical status
improves substantially, and primary fascial closure
should be attempted. In these cases, it is important
to use one of the techniques for temporary abdominal closure that prevents fascial retraction. These
techniques are at the surgeon’s discretion and
include the V.A.C., Wittmann patch, and dynamic
fascial closure systems. Surgeons must also use
sound clinical judgment regarding how diffi cult
the abdomen will be to close.
Patients who are not obese, have minimal
abdominal edema, and do not require multiple
reoperations, are often easy to close. In this situation, a V.A.C. is a good option that provides
adequate coverage, fl uid management, and limits
fascial retraction until the patient’s abdomen can
be closed in a few days. In patients that are more
challenging (e.g., morbidly obese patients,
patients with existing hernias, patients requiring
multiple reoperations with large amounts of
edema), the Wittmann patch or dynamic fascial
closure system are good options that allow for
graduating levels of tension that can be adjusted
to prevent fascial retraction. We have begun to
use the dynamic fascial closure systems in these
cases due to our belief that that the fascia is perhaps healthier and stronger after primary closure,
since no sutures are placed in the midline fascia
(elastomers are placed several centimeters off the
midline fascia). This is not supported by known
data at this time.
In most circumstances, techniques used to
treat an open abdomen should rely on some
mechanism to prevent fascial retraction, split
thickness skin grafting, and planned ventral hernia repair. Due to the lack of objective data on
what techniques to use and when to attempt closure, surgeons must rely on their clinical judgment and experience. We are currently studying
objective abdominal tension measurements to
help establish guidelines to determine the appropriate time to close an abdomen and the best closure techniques to use.
Conclusions
Knowledge and experience with temporary
abdominal closure is increasingly important, as
damage control surgery and open abdomens are
more commonplace. Several different techniques
can be used for primary closure, and their use
depends on the patient’s clinical status and the
desired treatment goals. In most cases, primary
fascial closure can be achieved using sound surgical techniques and attentiveness to the patient.
Achieving primary fascial closure has evolved
from simple packing methods and planned ventral hernia repair to more dynamic means of closure. Additional study is needed to evaluate these
new methods and outcomes.
420
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W.W. Hope and W.F. Powers IV
References
1. Stone HH, Strom PR, Mullins RJ. Management of the
major coagulopathy with onset during laparotomy.
Ann Surg. 1983;197(5):532–5.
2. Teichmann W, Eggert A, Wittmann DH, Bocker
W. Zipper as a new method of temporary abdominal
wall closure in abdominal surgery. Chirurg. 1985;
56(3):173–8.
3. Wittmann DH, Aprahamian C, Bergstein
JM. Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and velcro analogue for temporary
abdominal closure. World J Surg. 1990;14(2):
218–26.
4. Wittmann DH, Aprahamian C, Bergstein JM,
Edmiston CE, Frantzides CT, Quebbeman EJ, et al.
A burr-like device to facilitate temporary abdominal
closure in planned multiple laparotomies. Eur J Surg.
1993;159(2):75–9.
5. Aprahamian C, Wittmann DH, Bergstein JM,
Quebbeman EJ. Temporary abdominal closure (TAC)
for planned relaparotomy (etappenlavage) in trauma.
J Trauma. 1990;30(6):719–23.
6. Quyn AJ, Johnston C, Hall D, Chambers A, Arapova
N, Ogston S, et al. The open abdomen and temporary
abdominal closure systems—historical evolution and
systematic review. Colorectal Dis. 2012;14(8):
e429–38.
7. Boele van Hensbroek P, Wind J, Dijkgraaf MG, Busch
OR, Goslings JC. Temporary closure of the open
abdomen: a systematic review on delayed primary
fascial closure in patients with an open abdomen.
World J Surg. 2009;33(2):199–207.
Chemical Component Separation
Using Botulinum Toxin
Manuel López-Cano
and Manuel Armengol-Carrasco
“The accuracy not necessarily leads to truth,
speculation is not incompatible with the rigor”
Thomas S. Kuhn
The Structure of Scientifi c Revolutions, 1962
Introduction
Nowadays evidence-based medicine is widely
used across many, if not all, medical disciplines.
In 1996, David Sackett [ 1 ], a pioneer in evidence-
based medicine , wrote: “ Evidence-based medi-
cine is the conscientious, explicit, and judicious
use of current best evidence in making decisions
about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best
available external clinical evidence from systematic research. By individual clinical expertise we
mean the profi ciency and judgment that individual clinicians acquire through clinical experience and clinical practice ” . Karl Popper [ 2 ]
perhaps summarized this best in an accurate
Electronic supplementary material: The online version
of this chapter (doi:
tains supplementary material, which is available to authorized users.
M. López-Cano , M.D. (*)
Abdominal Wall Surgery Unit, General and
Digestive Surgery , Hospital Universitario Vall
d’Hebron, Universitat Autònoma de Barcelona ,
Barcelona , Spain
mlpezcano@gmail.com
e-mail:
M. Armengol-Carrasco , M.D.
Department of Surgery , Hospital Universitario Vall
d’Hebron , Barcelona , Spain
10.1007/978-3-319-27470-6_41 ) con-
41
commentary: “ Evidence is information that is
used to approach truth, whereas truth is an infallible, unequivocal, immutable fact. The defi nition of knowledge … is typically used as a
representation of a person’s comprehension of a
particular subject ” . Evidence-based medicine
acquires special importance when new diagnostic and/or therapeutic indications for a particular
pathologic process become available in clinical
practice.
We have made remarkable progress and
innovation over the last few decades in the
fi eld of abdominal wall surgery not only in the
technical aspects of procedures, but also in the
preoperative preparation for operation [ 3 ]. The
recent development of the so-called Chemical
Component Separation (CCS) [ 4 ] is an example
of such innovation. CCS consists of the application of botulinum neurotoxin type A (BoNT-A)
[ 5 ] for abdominal muscular relaxation as an
aid to repairing ventral and incisional hernias
and for facilitating closure of midline abdominal wall defects [ 4 , 6 , 7 ]. BoNT-A is a potent
muscle- paralyzing agent commonly used for
various medical and cosmetic indications. The
objective of this chapter is to present current
data on CCS from a three different perspectives: (1) a general overview of botulinum neurotoxins (BoNTs); (2) the evidence available
for the use of BoNT in abdominal wall surgery,
and (3) a comprehensive summary from a personal point of view.
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_41
421© Springer International Publishing Switzerland 2016
422
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M. López-Cano and M. Armengol-Carrasco
Background: Botulinum Toxin
and Therapeutic Use
BoNTs are produced by Clostridium botulinum , a
Gram-positive, rod-shaped, anaerobic, sporeforming bacterium. BoNTs bind to specifi c receptors at nerve terminals and inhibit the release of
acetylcholine. According to the different tissues,
BoNTs may cause inactivity of muscles or glands
by blocking the release of acetylcholine in nerve
terminals of the neuromuscular junction, exocrine
glands, and smooth muscle [ 8 ]. BoNTs have been
used in the treatment of neurological conditions ,
such as blepharospasm, cervical dystonia, and other
forms of dystonia or spasticity when painful and
even incapacitating spasms are present. The indications, however, have been widened and BoNTs are
also used for treating axillary or palmar hyperhidrosis and other hypersecretory disorders, as well as a
variety of gastrointestinal, urological, dermatological, cosmetic, and painful disorders [ 9 ].
The exact mechanism of action of the nociceptive effects of BoNTs remains unclear,
although it seems to be related to a direct actioninhibiting release of pain-related neurotransmitters (pain-modulating molecules calcitonin
gene-related peptide and substance P) from the
presynaptic motor nerve terminal, as well as an
indirect action by reducing muscle contractions/
spasms [ 10 ]. The toxin requires 24–72 hours to
take effect, and the maximum paralysis is
achieved between the fi rst- and second-week
post- injection. The affected nerve terminals do
not degenerate, but the blockage of neurotransmitter release is irreversible. Function can be
recovered by formation of new synaptic contacts;
this usually takes 2–7 months in humans [ 11 ].
C. botulinum elaborates seven antigenically
and serologically distinguishable exotoxins (A, B,
C [C 1 , C 2 ], D, E, F, and G) with a similar structure
[ 12 ]. Botulinum toxin types A (BoNT-A) and B
(BoNT-B) are used in clinical practice [ 13 ]. Doses
of all commercially available botulinum toxins
are expressed in terms of units of biologic activity.
One unit of botulinum toxin corresponds to the
calculated median intraperitoneal lethal dose
(LD 50 ) in female Swiss-Webster mice [ 14 ].
However, commercial products are different and
unit doses are not interchangeable because there
are differences in the strains of C. botulinum used
in the manufacturing, formulation, and purifi cation processes [ 15 ]. To reduce potential dosing
errors and to highlight the non- interchangeability
characteristics of BoNTs, the US Food and Drug
Administration (FDA) established a single generic
name for each botulinum toxin product [ 16 ]
(Table 41.1 ). In practice, BoNT-B has very spe-
cifi c indications [ 11 ] and BoNT-A is the most
commonly used due to the multifunctional activity
and long-lasting duration of effect [ 17 , 18 ].
Administration, Immunological
Considerations, and Formulation
BoNTs are administered intramuscularly with the
adequate aseptic measures [ 19 ]. The number of
injections and characteristics of the needle are
tailored to the mass of the muscle or muscle
groups being injected [ 19 , 20 ]. Recommended
techniques to guide botulinum toxin injection
include electromyography, electric nerve stimulation, ultrasound, and anatomical localization
(anatomical landmarks) [ 20 ]. Localization of
injection, availability of technical equipment,
and the clinician’s experience are important factors for the choice of the guidance procedure.
Injection of BoNT-A may lead to the development of neutralizing antibodies and secondary nonresponsiveness [ 11 , 21 ]. Although development of
neutralizing antibodies occur in a small percentage
of patients, especially in cosmetic indications,
patients who receive higher individual doses or frequent booster injections seem to have a higher risk of
developing antibodies [ 22 , 23 ]. Therefore, using the
lowest dose of toxin necessary to achieve the desired
clinical effect and avoiding reinjection within 1
month appear prudent in an effort to keep antibody
formation as low and unlikely as possible [ 11 ].
There are three commercially available serotype A formulation s (Table 41.1 ): onabotulinum
toxin A (Botox ® , Allergan Inc., Irvine, CA,
USA), abobotulinum toxin A (Dysport ® , Ipsen
Ltd., Slough, Berkshire, UK), and incobotulinum
toxin A (Xeomin ® , Marz Pharmaceuticals,
Frankfurt, Germany).
41 Chemical Component Separation Using Botulinum Toxin
Table 41.1 Generic name for each botulinum toxin by the U.S. Food and Drug Administration (FDA)
Commercial name
Generic name
OnaBotulinumtoxin A Botox ® (Allergan, Inc.)
AboBotulinumtoxin A Dysport
Incobotulinumtoxin A Xeomin
RimaBotulinumtoxin B Myobloc
a
Brand name in Europe
(manufacturer)
®
(Ipsen
Pharmaceuticals)
®
(Merz)
®
/NeuroBloc ®a
(Solstice Neurosciences)
Distribution
licence Indications
Worldwide
USA, UK, and
Europe
Europe, USA
USA, Europe,
and Japan
Cervical dystonia, strabismus,
blepharospasm, hemifacial spasm,
hyperhidrosis, post-stroke
spasticity, overactive bladder,
improved appearance of glabellar
lines
Cervical dystonia. In clinical trials
in USA for other conditions
Cervical dystonia, blepharospasm,
glabellar lines
Cervical dystonia
423
Onabotulinum toxin A (Botox ® ) is available in
100 or 200 unit vials. One 100 unit vial is diluted
with 1, 2, 4, or 8 mL of preservative-free 0.9%
saline, yielding preparations of 10.0, 5.0, 2.5, or
1.25 units/0.1 mL, respectively. However the fi nal
dilution of BOTOX ® is mostly a matter of personal preference [ 11 ]. Botox ® is denatured easily
by bubbling or agitation; gently inject the diluent
onto the inside wall of the vial and discard the
vial if a vacuum does not pull the diluent in.
Reconstituted Botox ® should be stored in a refrigerator 2–8 °C and used within 24 hours [ 24 ].
Abobotulinum toxin A (Dysport ® ) is available
in 300 or 500 unit vials. For the treatment of
some neurological disorders, such as cervical
dystonia, one 500 unit vial is diluted with 1 mL
preservative-free 0.9% saline, yielding a preparation of 500 units/mL. Reconstituted Dysport
®
should be used within 4 hours and should be
stored in a refrigerator at 2–8 °C.
Incobotulinum toxin A (Xeomin ® ) is available
in 50 and 100 unit vials and reconstituted with
0.9% saline. Reconstituted Xeomin
®
should be
used within 24 hours and should be stored at 2–8
°C. Unopened vials can be stored at room temperature, refrigerated or frozen.
Reconstituted products should be clear and
free from suspended particles. All vials, including expired vials, or equipment used with the
drug should be disposed of carefully as is done
with all medical waste.
Manufacturers of botulinum toxin produce
their product as 150 kDa protein (incobotulinum
toxin A), 500–700 kDa (abobotulinum toxin A),
and 900 kDa (onabotulinum toxin A). This protein includes both the primary active component
as well as complexing proteins. Although it has
been suggested that these proteins are responsible for the development of anti-toxin antibodies,
it is unclear whether clinically there is a
signifi cant effect of these molecular differences
in terms of both antigenicity and effi cacy [ 21 ].
Presumed clinical effects of 1 unit are not interchangeable between formulations, and the dose
ratio between onabotulinum and abobotulinum is
25 – 27 ].
1:3 [
In both dermatocosmetological and neurological applications, BoNT-A doses vary according
to the muscle mass to be treated, degree of spasticity or the patient’s body weight. In successive
sessions, doses and injection points are usually
individualized according to results obtained with
the starting dose [
21 , 28 ]. Doses of Botox ® should
not exceed 400–600 units per session but maximum absolute doses of Dysport ® are unknown,
although a maximum dose should probably not
exceed 2000 units. Maximum doses of Xeomin ®
have not been established [ 20 ]. Also, different
formulations of BoNT-A are not identical and
may behave differently in clinical practice, partly
due to differences in the degree of migration of
the neurotoxin–protein complex from its injec-
424
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M. López-Cano and M. Armengol-Carrasco
tion site [ 29 , 30 ]. The lower potential of onabotu-
linum to migrate promotes more precise
localization of clinical effects, thereby helping to
optimize the risk/benefi t ration [ 31 ].
Tolerability and Contraindications
Injections of BoNT-A are generally well tolerated
[ 11 ]. Side effects are rare, but adverse effects may
be both local or systemic [ 9 , 11 ]. Local unwanted
weakness/paralysis is commonly related to spread
of the botulinum toxin from the injection site to
nearby muscles or other secretion and sensory
systems. It usually resolves in several months
depending on the site, strength of the injections,
and the muscles made excessively weak [ 11 ].
Occasionally autonomic effects (e.g., dry mouth)
and local effects at the injection site, such as pain,
bruising, infection, or rash may occur. In some
cases, local effects are related to an enhanced
response of the injected muscles. Most of these
local side effects may be prevented using the lowest effective dose and accurately selecting the site
of injection in the selected muscle.
Systemic adverse events may include a transient generalized reaction with headache, discomfort, or mild nauseas. Direct intravascular
puncture should be avoided and the presence of
botulinum toxin in the bloodstream may cause a
generalized botulism-like syndrome [ 32 ]. Other
side effects, such as brachial plexopathy [ 33 ],
gallbladder dysfunction [ 34 ] or necrotizing fasci-
itis [ 35 ] have been reported as a complication of
botulinum toxin treatment.
Satisfactory results are generally obtained
with the use of BoNT-A in cosmetic and/or neurological indications [ 36 ], but applicability to
abdominal wall surgery remains to be established. However, lack of response can be observed
in 10% of patients [ 37 ]. In contrast to primary
non-responders, development of secondary resistance after an initial response has also been
reported in up to 10% of patients [ 38 ]. Technical
factors such as incorrect storage or reconstitution
of the toxin may be responsible for isolated secondary treatment failures. Sustained late failure
of response include underdosing, injection of
inappropriate muscles, a worsening or change in
the pattern of dystonia or underlying disorder,
muscular atrophy, altered perception of atrophy,
and development of immunity [ 39 ]. Risk factors
for the development of antibodies seem to be
higher frequency of injections, the use of
“booster” injections, and higher doses of Botox ®
per treatment [ 40 ].
Absolute contraindications to the use of
BoNTs include known hypersensitivity to components of the product formulation, neuromuscular diseases, myasthenia gravis, Lambert-Eaton
syndrome, neuropathies, brain tumors, aneurysms, heart, renal or liver failure, psychiatric
disorders, pregnancy, lactation, and drugs affecting the muscle tone, and infections in the site of
injection. The relative contraindications include
concurrent treatment with aminoglycosides (may
increase the effect), penicillamine, quinine, chloroquine and hydroxychloroquine (may reduce the
effect), calcium channel blockers, and platelet
antiaggregants or anticoagulants (which may
increase the risk of hematoma) [ 11 ]. Treatment
with BoNTs seems to be contraindicated in
patients with severe chronic obstructive
pulmonary disease [ 4 , 43 ] for the possibility of
botulinum toxin to affect respiratory dynamics.
The preceding paragraphs present relevant
information that, in our opinion, should be known
by a general surgeon interested in the use of botulinum toxin for the repair of abdominal wall
defects rather than to provide an exhaustive
description of the clinical application of BoNTs.
Most of the aforementioned data have been
obtained from a large clinical experience with the
use of BoNTs in cosmetics and motor disorders,
although there are limitations in the consistence
of the evidence.
Botulinum Toxin in Abdominal Wall
Hernia: Evidence and Outcome
The application of BoNTs in abdominal wall surgery is a special fi eld of increasing interest.
However, at the time of writing this chapter,
information on the use of BoNTs in this particular context is limited [ 4 – 7 , 41 – 48 ]. Two refer-
41 Chemical Component Separation Using Botulinum Toxin
425
ences are comments to clinical studies [ 44 , 45 ]
and two publications were experimental studies
[ 41 , 46 ]. The fi rst experimental study [ 41 ]
assessed the effect of botulinum A toxin-induced
paralysis of abdominal muscles on intraabdominal volume and pressure at 3 days after
injection of 2 mL (5 U/mL) of onabotulinum
toxin A (BOTOX ® ) into the abdominal muscles
at 16 different points (right, left, upper and lower
quadrants, and rectus muscles) in Sprague–
Dawley rats. It was found that botulinum A toxin
injection to abdominal muscles of the rats
increased intra-abdominal volume which therefore decreased the pressure. According to these
fi ndings it was suggested that this application
may be used as an adjunct in abdominal wall closure in selective cases. In the second experimental study carried out in a porcine model [ 46 ],
advance of the abdominal wall toward the midline was analyzed after randomly-assigned injections of 150–200 U of onabotulinum toxin A (the
brand name was not specifi ed) in the external
oblique muscle in one side and placebo in the
contralateral side. Botulinum A injection
achieved 68% advance of the abdominal wall as a
result of open component separation.
Clinical studies are mainly based on (a) the paralyzing effects of BoNTs on the abdominal wall
lateral muscles (oblique and transverse) to facilitate
repair of ventral defects, and (b) the direct (inhibition of pain-related neurotransmitters) and indirect
(reduction of muscular contraction) antinociceptive effects of BoNTs as an adjuvant technique for
the relief of pain after surgery.
Paralyzing Effects of BoNTs
The fi rst clinical study to propose botulinum
toxin type A before abdominal Hernia repair to
reduce muscle tension and lateral retraction was
published in 2009 [ 7 ]. In this study, 12 patients
with midline incisional hernias secondary to
intentional open abdomen [ 49 ] were treated with
injections of abobotulinum toxin A (Dysport ® ) in
fi ve different points of the lateral abdominal wall
(two over the mid- axillary line, between the costal border and the superior iliac crest, and three
over the external oblique muscle). Bilateral application of abobotulinum toxin A was performed
under electromyographic guidance. A total of
500 units were injected (250 units for each hemiabdomen, 5 units per point). Transverse abdominal wall defect measurement was practiced at
weekly intervals (clinically in 2 patients and with
computed tomography scan [CT] in 10). At 4
weeks after treatment, a signifi cant overall mean
reduction of the transverse defect was observed,
and hernia repair was successfully performed
with no recurrence after a mean follow-up of 9
months. This fi rst report of botulinum A toxin
application before abdominal wall hernia reconstruction showed that the lateral muscles paralysis can be achieved and transverse hernia defect
reduction can subsequently be accomplished
with minimal tension closure.
In 2013, Zielinski et al. [ 4 ] developed the novel
technique of CCS which incorporates injection of
botulinum toxin A (Botox ® ) into the lateral
abdominal wall musculature to avoid extensive
dissection in critically ill patients with extensive
infected/contaminated abdominal domains. The
study was a retrospective review of 18 patients
with open abdomen who underwent ultrasoundguided Botox ® injections into six separate injection sites (right/left subcostal, right/left anterior
axillary, and right/left lower quadrants) of the
external oblique, internal oblique, and transversus
abdominis muscles (50 units per point, 150 units
for each hemiabdomen, total 300 units). The primary fascial closure rate was 83% with a fascial
dehiscence rate of 11%. The technique of CCS
described by the authors was safe and feasible,
and created less tension at the midline throughout
the duration of the open abdomen surgery.
In 2014, the results of a clinical trial in 17
male trauma patients with abdominal wall hernia
secondary to open abdomen management were
reported [ 6 ]. The aim of the study was to evaluate
if botulinum toxin type A application in the lateral abdominal wall muscles could modify its
thickness and length. An injection of 50 units of
Dysport ® between the external and internal
oblique muscles was performed under ultrasonographic guidance at fi ve application sites (two at
the middle axillary line between costal margin
426
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M. López-Cano and M. Armengol-Carrasco
and iliac crest level, and three between anterior
axillary line and middle clavicular line between
costal margin and iliac crest level) in both sides
of the abdomen (250 units for each hemiabdomen, total 500 units). Four weeks after NoBT-A
injection, a CT scan was performed and the thickness and length of the lateral abdominal wall
muscles were compared with previous measures.
The abdominal wall reconstruction surgery was
scheduled afterwards. In all patients, a statistically signifi cant reduction of left and right muscle thickness and length was achieved.
Botulinum toxin A has recently been used in
patients with incisional hernia. In one study [ 47 ],
14 patients with giant incisional hernias were
infi ltrated with 10 units of botulinum toxin A
(Botox ® ) in fi ve points of each side of the
abdominal wall under electromyographic guidance (50 units per side, total 100 units). Four
weeks later they were submitted to surgery. A
reduction in the hernia diameter was found in
50% of the patients. The authors concluded that
the use of preoperative botulinum toxin A markedly reduces tension during surgical repair and
increases the rate of primary closure. Moreover,
in a single patient with bilateral inguinoscrotal
hernia with loss of domain, and remaining
abdominal wall intact, the use of 55.55 units of
abobotulinum toxin A (Dysport ® ) injected into
fi ve different points of the lateral abdominal wall
and four points of the ipsilateral rectus abdominus muscle under anatomic guidance (499.95
units per each abdominal side, total 999.9 units)
was useful to relax the abdominal wall muscles
and facilitated performing the surgery [ 48 ].
Although the evidence is still anecdotal, the
authors concluded that this adjunct treatment
should be considered as a new alternative for
hernias with loss of domain.
Antinociceptive Effects of BoNTs
side of the abdominal wall. All three muscles
(external oblique, internal oblique, and transversus) were identifi ed by ultrasound. A total of 300
units of Botox ® were utilized (50 units per point,
150 units for each abdominal side). Pain scores
improved from 10/10 to 2/10 and were durable at
3-month follow-up.
In 2013, Zendejas et al. [ 43 ] evaluated the
usefulness of botulinum toxin A injection to
reduce postoperative pain and the consumption
of opioid analgesia in 22 patients undergoing
elective incisional hernia repair compared to
concurrent matched controls. The primary outcome measure was in-hospital mean morphine
equivalents (MEs) on hospital day (HD) 2, considering the operative day to be HD1. Secondary
outcome measures included in-hospital ME per
day for HD3 through HD7, in-hospital daily
patient reported pain scores (visual analogue
scale [VAS] 1-10), duration of hospital stay,
perioperative complications, opioid-related
adverse effects, surgical-site occurrences, and
hernia recurrence. The technique of Botox ®
injection also included three injection sites
(right/left subcostal, right/left anterior axillary,
right/left lower quadrants) on each side of the
abdominal wall, with ultrasound identifi cation
of the external oblique, internal oblique, and
transversus muscles, with a dose of 50 units per
injection (150 units for each hemiabdomen,
total 300 units). Patients in the active treatment
group used signifi cantly less opioid analgesia on
HD2 and 5, and reported signifi cantly less pain
on HD2 and 4, as compared to controls.
Differences in secondary outcome measures
were not observed. The authors concluded that,
patients who underwent chemical component
paralysis reported less pain and required signifi cantly less opioid analgesia.
A summary of these studies is shown in Table
41.2 .
In 2011, Botox ® was used for the fi rst time for
Personal Comprehension
postoperative pain control after laparoscopic
ventral hernia repair [ 42 ]. Three injection sites
(right/left subcostal, right/left anterior axillary,
right/left lower quadrants) were chosen on each
The terms CCS [ 4 ] or chemical myotomy [ 46 ]
should be abandoned because they may cause
confusion with results obtained from surgical
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