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41 Chemical Component Separation Using Botulinum Toxin
®
Postoperative
decrease of pain
Antinociceptive
effects
Midline and laterals
Postoperative pain
(IHR)
and use of opioids
48 ] Zendejas [ 43 ]
Botox
®
the abdominal cavity
Ibarra-Hurtado [
hernia
hernia
alter loss of domain
427
(continued)
During surgery
(59%). Prior to
surgery 41% (mean
injection
transversus,
external, internal
oblique muscles
6 days before)
Preoperative
Anatomic landmarks US. Selective
(defi nition unknown)
Paralyzing effects
47 ]
[
7 ] Zielinski [ 4 ] Ibarra-Hurtado [ 6 ] Chávez-Tostado
Dysport
®
IH repair Reintroduction into
Botox
®
Modifi cation of
length and
abdominal muscles
Dysport
®
after OA
Botox
®
13.85 ? 14.65 14.6 – ?
or at each
side of the defect
EMG. Point of
maximal activity
US. Injection
between the
US. Selective
injection
maximal activity
TC
external and
internal oblique
muscles
transversus,
external, internal
250 (500) 150 (300) 250 (500) 50 (100) 499.95U (999.9U) 150 (300)
Preoperative
<24 hours of OA Preoperative
(defi nition
unknown)
(defi nition
unknown)
>24 hours of OA
(defi nition
unknown)
Botulinum toxin Dysport
Author (year) [reference] Ibarra-Hurtado [
Study design Observational Observational Observational Observational Case report Observational
Abdominal wall defect Midline Midline Midline Midline + fl anks Inguinoscrotal
Initial transverse mean diameter
(cm)
Indication IH after OA OA IH after OA IH Bilateral inguinal
Number of patients 12 18 17 14 1 22
Table 41.2 Clinical studies of the use of BoNTs in abdominal wall surgery
Objective IH repair Fascial closure
Injection points
Guidance technique EMG. Point of
Hemiabdomen dose (total dose),
units
Timing of administration Preoperative
428
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Antinociceptive
effects
postoperative day
injection
injection
Morphine
Changes in
Decrease
2nd to 7th
45 days alter
4 weeks after
equivalents
administered and
pain relief (VAS)
abdominal muscles
and abdominal
cavity measured by
transverse diameter
wall defect
of morphine
CT
equivalents
administered and
pain relief [VAS])
M. López-Cano and M. Armengol-Carrasco
Botulinum toxic
reduces
postoperative pain
and use of opioids
Botulinum toxic
relaxes increasing
the volume of
abdominal cavity
Botulinum toxin is
effective in the
treatment of giant
IH. Studies are
needed to
standardize the
technique
Paralyzing effects
Table 41.2 (continued)
Reduction of
injection
Fascial closure
4 weeks = 10
patients
Timing intervention/measurement 1 week = 2 patients NR 4 weeks after
Defi nition of positive effect Decrease
length and
abdominal muscles
alter OA
transverse diameter
wall defect
CT CT CT Clinical (decrease
closure)
CT, 10 patients
Assessment of effi cacy Clinical, 2 patients Clinical (fascial
Assessment of duration of action NR NR NR NR NR NR
Botulinum toxin
reduces thickness
and increases
length of
abdominal wall
Botulinum toxic
relaxes but
combined with
TAC techniques
transverse diameter
of the abdominal
wall defect
Primary midline closure (%) 50 83 23.5 78 – –
Closure by abdominoplasty (%) 50 – 76.5 22 – –
Total complications (%) 16.6 67 41 28.5 0 –
Complication toxin A 0 0 0 0 0 0
Mean follow-up (months) 9 ? 49 15 46 18
Overall mortality (%) 0 11 0 7 0 0
Toxin-related mortality 0 0 0 0 0 0
Conclusions Decrease of
HI incisional hernia, OA open abdomen, IHR incisional hernia repair, NR not reported, CT computed tomography, VA S visual analogue scale, TAC temporary abdominal closure
41 Chemical Component Separation Using Botulinum Toxin
429
procedures of similar names. In our opinion, the
use of BoNTs in abdominal wall surgery is a
technique for primarily preparing the patient, not
for repairing patient’s defect. “Chemical component paralysis” [ 43 ], or even better “chemodener-
vation of abdominal wall musculature” seems
more appropriate designations.
Although BoNTs have shown a favorable
clinical profi le in cosmetic/dermatological applications for decades, some important aspects are
still pending to be clarifi ed [ 21 ]. It is interesting
to note that uncertainties on some of these clinical questions are still present when BoNTs are
used in the fi eld of abdominal wall surgery. In
this respect, assessment of the effi cacy of botulinum toxin across studies is heterogeneous, ranging from a clinical evaluation (potential bias
related to subjectivity of the examiner) to indirect techniques, such as an abdominal
CT. Therefore, a clear criterion to defi ne a positive clinical effect of the application of botulinum toxin in the abdominal wall is lacking.
Injection strategies, including timing, which is
important to determine the onset of action, duration of effect and, ultimately, the impact of
BoNTs on the abdominal wall muscular function, remain unclear. A better defi nition of these
aspects would contribute to our understanding of
which type of botulinum toxin may be the most
appropriate for its application in different scenarios of abdominal wall surgery, given the characteristics of abdominal muscles and
formulations. Formulations are not interchangeable and differ in relation to their molecular
structure, mode of action, dosing, migration
characteristics, and potential adverse effects.
Clinical studies of the application of BoNTs
in abdominal wall surgery are still preliminary
experiences based on observational designs and
carried out in small study populations. Therefore,
results of these studies should be interpreted
taking into account these limitations. At the
present time, there is only one ongoing registered clinical trial (NCT01495962) aimed to
determine whether botulinum toxin A (Botox ® )
will facilitate fascial closure after damage con-
trol laparotomy (DCL) [ 50 ]. The primary end-
point is the rate of delayed primary fascial
closure. Delayed primary fascial closure will be
considered when the rectus abdominus fascia is
directly approximated in the midline during the
same hospitalization as the initial DCL without
the use of mesh.
Potential applications of the paralyzing and
antinociceptive effects of BoNTs in the abdominal wall in adult patients may include complex
and non-complex midline incisional hernias,
open abdomen, or reconstructions when the
abdominal wall is intact. Although a clear defi nition of “complex” abdominal hernia is missing, recently, consensus on criteria used to
defi ne a patient with complex hernia was
reached [ 51 ]. Such consensus includes 22
patients and hernia variables for “complex” hernia criteria inclusion which were grouped under
four categories: “Size and location,”
“Contamination/soft tissue condition,” “Patient
history/risk factors,” and “Clinical scenario.”
These variables were further divided into three
patient severity classes (“Minor,” “Moderate,”
and “Major”) to provide guidance for perioperative planning and measures, the risk of a complicated postoperative course, and the extent of
fi nancial costs associated with treatment of
these hernia patients [ 51 ].
On the basis of previous considerations and
taking into account that each case treatment
should be individualized, the paralyzing effect
of BoNT-A could be indicated, with or without
preoperative progressive pneumoperitoneum
(PPP), in patients with complex midline incisional hernia with a loss of domain (hernia sac
can form a second abdominal cavity), small or
large defects and minor or moderate severity
class. Our group has a short experience with
excellent results in a small clinical series of fi ve
patients with complex midline incisional hernia
and loss of domain (large/small defects, minor/
moderate severity class), which have been
treated with a combination of onabotulinum
toxin A (Botox ® ) and PPP. Two weeks prior to
starting PPP, botulinum toxin A is injected. The
430
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M. López-Cano and M. Armengol-Carrasco
injection technique used in our patients is based
on the method described by Ibarra-Hurtado
et al. [ 7 ], in 2009, with the difference that we
use onabotulinum toxin A (Botox ® ). Briefl y,
after preparing the sterile material (gloves,
gauzes, syringes, etc.,) and a mioject needle
of 75 mm length (TECANeedles, MyoJect
Disposable Hypodermic Needle Electrode,
VIASYS Healthcare, Madison, WI, USA), 100
units of BoNT-A (Botox ® ) are diluted with
5 cm 3 of preservative-free 0.9% saline and a
total of fi ve syringes of 1 cm 3 is obtained (20
units of BoNT-A). Five points are identifi ed at
each side of lateral abdominal wall. Two points
over the mid-axillary line (between the costal
border and the superior iliac crest) and three
points over the external oblique muscle. The
skin is cleaned with alcohol and no local anesthesia is used. The mioject needle is applied and
under electromyographic guidance, the needle
is used to identify the maximal electromyographic recording points in the fi ve points of the
lateral abdominal wall. The depth of injection
will depend on the anthropometric characteristics of the individual and the location of the
point of maximum electromyographic activity.
Then, 20 units (1 cm 3 ) per point (100 units for
each hemiabdomen) are injected. The procedure
is performed in the outpatient setting. The purpose of this combined approach was to increase
elongation of the lateral abdominal wall muscles (i.e., increase of the abdominal cavity/
capacity) adding the effect of BoNT-A with the
effect of PPP. Alternatively, the injections may
be performed under ultrasound guidance, with
each of the lateral abdominal muscles injected
separately.
The algorithm for the management of midline
incisional hernias with suspicion of loss of
domain currently used by our group is shown in
Fig. 41.1 . Details of our technique of BoNT-A
injection are presented in the video supplement.
Our strategy to measure BoNT-A effects is based
on radiological evidence of a reduction of muscle
thickness on post-injection CT and a shorter time
of pneumoperitoneum (usually without BoNT-A
Fig. 41.1 Management algorithm of midline incisional
hernias with potential loss of domain CT computed
tomography, HV/PV hernia volume/peritoneal volume
ratio, PPP preoperative progressive pneumoperitoneum,
BoNT - A botulinum neurotoxin A, in our experience
®
)
Botox
41 Chemical Component Separation Using Botulinum Toxin
431
Fig. 41.2 ( a ) Complex midline incisional hernia with loss of domain, ( b ) Botox ® injection with electromyographic
guidance
Fig. 41.3 ( a ) Complex midline incisional hernia with loss of domain standing up, ( b ) Lying fl at (hernia is not reduced)
it takes between 2 and 3 weeks and with BoNT-A
is reduced to 1–2 weeks). Illustrative cases of the
combined use of BoNT-A and PPP are presented
in Figs. 41.2 , 41.3 , and 41.4 .
Patients with a complex midline incisional
hernia without loss of domain (large/small
defects, minor/moderate severity class) may be
candidates for BoNT-A application (Fig. 41.5 ).
In these cases, the laparoscopic approach together
with BoNT-A injection would be only considered
in the absence of trophic cutaneous lesions, when
defects are small and closed with or without asso-
432
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M. López-Cano and M. Armengol-Carrasco
Fig. 41.4 ( a , b ) Complex midline incisional hernia with
loss of domain standing up. This patient may be candidate
for combined preoperative progressive pneumoperitoneum and botulinum toxin A application. ( c ) CT previous
Fig. 41.5 Complex midline incisional hernia without
loss of domain and large defect
to BoNT-A + PPP, highlighted in yellow wide lateral
abdominal wall muscles. ( d ) CT after BoNT-A + PPP,
highlighted in yellow narrow lateral abdominal wall
muscles
ciated endoscopic component separation (ECS).
The use of BoNT-A should not be indicated as a
preoperative preparation of a non- complex midline incisional hernia (5–10 cm of transverse
diameter), unless a laparoscopic approach with
closure of the defect, with or without ECS would
be chosen.
The open abdomen may be a reasonable indication for BoNT-A in patients with an abdominal
temporal closure technique with vacuum-assisted
negative pressure [ 52 ] (Fig. 41.6 ).
In cases of abdominal defects with intact
abdominal wall, BoNT-A application could be
used in inguinal hernia with loss of domain, with
41 Chemical Component Separation Using Botulinum Toxin
433
Fig. 41.6 Temporary abdominal closure of open abdomen with non-absorbable synthetic mesh traction (pleating or serial excision of the mesh as the fascial edges are
Fig. 41.7 Inguinal hernia with loss of domain
or without associated PPP (Fig. 41.7 ). Other rare
cases may be treated with BoNT-A without PPP,
such as a giant diaphragmatic hernia.
re-approximated) ( a ) with combined negative pressure
wound therapy ( b , c )
Potential separation of the paralyzing and
antinociceptive effects of BoNTs is artifi cial and,
theoretically, indications related to one effect
may favor the other, and vice versa. For this reason, potential indications of the antinociceptive
effects of BoNTs are the same than those previously described (Table 41.3 ).
Concluding Remarks
Potential applications of BoNT-A here described
to achieve tension- and retraction-free conditions
in abdominal wall reconstruction are exclusively
based on the author’s opinion and experience.
Further studies (preferably randomizedcontrolled designs) are necessary to clarify a
number of relevant clinical questions, including
patient’s eligibility, dosing of the different botulinum toxin A formulations, optimal administration technique, or benefi ts of potential association
with other procedures (such as PPP or ECS).
Injections of BoNT-A into the abdominal wall
muscles to facilitate complex hernia repair is a
promising technique, but the evidence available
at the present time is still weak and a clear role of
BoNT-A in abdominal wall surgery remains to be
defi ned.
434
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Potential indication antinociceptive effect
defect
Closing defect Without closing
M. López-Cano and M. Armengol-Carrasco
a
a
defect
Yes No
a
Closing defect Without closing
No
Potential indication paralyzing affect (preparation for
surgery)
Open surgery Laparoscopic surgery Open surgery Laparoscopic surgery
Small defect Yes (with or
With loss of
No Yes
Yes No
a
No
without PPP)
without PPP)
Large defect Yes (with or
Small defect Yes Yes (with or
domain
Without loss of
No Yes
Yes
a
without ECS)
without ECS)
Large defect Yes No
domain
Yes
Yes
a
a
No
Inguinal hernia Yes (with or
With loss of
Yes
a
without PPP)
Yes No
No No
†
†
Other
Inguinal hernia No No
Other
domain
Without loss of
domain
Diaphragmatic hernias; PPP preoperative progressive pneumoperitoneum, ECS endoscopic component separation
†
Non-complex midline incisional hernias No Yes (with or
Open abdomen Yes No
Intact abdominal
Complex midline
incisional hernias
Risk minor/
Table 41.3 Potential indications of botulinum toxins in abdominal wall surgery
moderate
wall
No indication for laparoscopic surgery;
a
41 Chemical Component Separation Using Botulinum Toxin
435
Acknowledgment The authors thank Marta Pulido, MD,
for editing the manuscript and editorial assistance.
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