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01.02.2013 | Original Article | Ausgabe 1/2013

Hernia 1/2013

Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen

Zeitschrift:
Hernia > Ausgabe 1/2013
Autoren:
M. D. Zielinski, N. Goussous, H. J. Schiller, D. Jenkins
Wichtige Hinweise
A comment to this article is available at http://​dx.​doi.​org/​10.​1007/​s10029-012-1021-3.

Abstract

Introduction

Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the “chemical components separation,” which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature.

Methods

This is a retrospective review of all OA patients (age ≥18) from December 2009–June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus.

Results

A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %).

Conclusion

The “chemical components separation” technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.

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ACKNOWLEDGEMENT TO REFEREES

Acknowledgement to referees 2012

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