Advertisement

Hernia Surgery pp 421-436 | Cite as

Chemical Component Separation Using Botulinum Toxin

  • Manuel López-CanoEmail author
  • Manuel Armengol-Carrasco
Chapter

Abstract

“Chemical Component Separation” is a novel concept that involves the application botulinum neurotoxin A (BoNT-A), a potent muscle-paralyzing agent, to achieve muscle relaxation of the abdominal wall muscles as an aid in the surgical repair of complex ventral and incisional hernias and for facilitating closure of midline abdominal wall defects. However, the number of clinical studies is limited and the experience with the application of BoNT-A in the field abdominal wall surgery is still preliminary. Achievement of tension- and retraction-free conditions in complex abdominal wall reconstruction is the main objective taking advantage of BoNT-A-related paralysis of abdominal wall muscles following injections in selected points on both sides of the abdomen. Better postoperative pain control and reduction of opioid analgesia are related to the antinociceptive effects of BoNT-A. Recommended techniques to guide botulinum toxin injection include electromyography, electric nerve stimulation, ultrasound, and anatomical localization. Formulations are not interchangeable. Potential applications of BoNT-A in adult patients may include complex and non-complex midline incisional hernias with loss of domain, open abdomen, or reconstructions when the abdominal wall is intact, with or without preoperative progressive pneumoperitoneum. Further studies, preferably randomized-controlled designs are necessary to clarify a number of relevant clinical questions, including patient’s eligibility, dosing of the different botulinum A formulations, optimal administration technique, or benefits of potential association with other procedures. The evidence available at the present time is still weak and a clear role of BoNT-A in abdominal wall surgery remains to be defined.

Keywords

Hernia Incisional hernia Botulinum toxin Abdominal wall reconstruction Complex incisional hernia 

Notes

Acknowledgment

The authors thank Marta Pulido, MD, for editing the manuscript and editorial assistance.

Supplementary material

Video 41.1

Botulinum neurotoxin injection before VHR, by Lopez-Cano (M4V 112,938 kb)

References

  1. 1.
    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–2.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Glasser SP, Duval S. Meta-analysis, evidence-based medicine, and clinical guidelines. In: Glasser SP, editor. Essentials of clinical research. 2nd ed. Berlin: Springer International; 2014. p. 203–32.Google Scholar
  3. 3.
    López-Cano M. Evidence-based surgery and incisional hernia. Rev Hispanoamer Hernia. 2013;1:18–26.CrossRefGoogle Scholar
  4. 4.
    Zielinski MD, Goussous N, Schiller HJ, Jenkins D. Chemical component separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen. Hernia. 2013;17:101–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Aoki KR. Botulinum toxin: a successful therapeutic protein. Curr Med Chem. 2004;11:3085–92.CrossRefPubMedGoogle Scholar
  6. 6.
    Ibarra-Hurtado TR, Nuño-Guzmán CM, Miranda-Díaz AG, Troyo-Sanromán R, Navarro-Ibarra R, Bravo-Cuéllar L. Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management. Hernia. 2014;18:647–52.Google Scholar
  7. 7.
    Ibarra-Hurtado TR, Nuño-Guzmán CM, Echeagaray-Herrera JE, Robles-Vélez E, de Jesús González-Jaime J. Use of botulinum toxin type A before abdominal wall hernia reconstruction. World J Surg. 2009;33:2553–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Erbguth FJ. Historical notes on botulism, Clostridium botulinum, botulinum toxin, and the idea of the therapeutic use of the toxin. Mov Disord. 2004;19 Suppl 8:S2–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Bigalke H, Dressler D, Jankovic J. Basic and therapeutic aspects of neurotonins. Mov Disord. 2004;19 Suppl 8:S1.CrossRefGoogle Scholar
  10. 10.
    Chaddock JA, Purkiss JR, Alexander FC, Doward S, Fooks SJ, Friis LM, et al. Retargeted clostridial endopeptidases: inhibition of nociceptive neurotransmitter release in vitro, and antinociceptive activity in in vivo models of pain. Mov Disord. 2004;19 Suppl 8:S42–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Nigam PK, Nigam A. Botulinum toxin. Indian J Dermatol. 2010;55:8–14.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Dolly JO, Aoki KR. The structure and mode of action of different botulinum toxins. Eur J Neurol. 2006;13 Suppl 4:1–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Klein AW, Carruthers A, Fagien S, Lowe NJ. Comparisons among botulinum toxins: an evidence-based review. Plast Reconstr Surg. 2008;121:413–22.CrossRefGoogle Scholar
  14. 14.
    Hoffman RO, Helveston EM. Botulinum in the treatment of adult motility disorders. Int Ophthalmol Clin. 1986;26:241–50.CrossRefPubMedGoogle Scholar
  15. 15.
    Aoki KR, Guyer B. Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions. Eur J Neurol. 2001;8 Suppl 5:21–9.CrossRefPubMedGoogle Scholar
  16. 16.
    U.S. Food and Drug Administration.Google Scholar
  17. 17.
    Aoki KR, Ranoux D, Wissel J. Using translational medicine to understand clinical differences between botulinum toxin formulations. Eur J Neurol. 2006;13:10–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Kranz G, Paul A, Voller B, Posch M, Windischberger C, Auff E, Sycha T. Long-term efficacy and respective potencies of botulinum toxin A and B: a randomized, double-blind study. Br J Dermatol. 2011;164:176–81.CrossRefPubMedGoogle Scholar
  19. 19.
    Esquenazi A, Mayer N. Botulinum toxin for the management of muscle overactivity and spasticity after stroke. Curr Atheroscler Rep. 2001;3:295–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Pathak MS, Nguyen HT, Graham HK, Moore AP. Management of spasticity in adults: practical application of botulinum toxin. Eur J Neurol. 2006;13 Suppl 1:42–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Bonaparte JP, Ellis D, Quinn JG, Ansari MT, Rabski J, Kilty SJ. A comparative assessment of three formulations of botulinum toxin A for facial rhytides: a systematic review and meta-analyses. Syst Rev. 2013;2:40.Google Scholar
  22. 22.
    Borodic G. Immunologic resistance after repeated botulinum toxin type A injections for facial rhytides. Ophthal Plast Reconstr Surg. 2006;22:239–40.CrossRefPubMedGoogle Scholar
  23. 23.
    Dressler D, Wohlfahrt K, Meyer-Rogge E, Wiest L, Bigalke H. Antibody-induced failure of botulinum toxin: a therapy in cosmetic indications. Dermatol Surg. 2010;36 Suppl 4:2182–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Ranoux D, Gury C, Fondarai J, Mas JL, Zuber M. Therapy with botulinum toxin. J Neurol Neurosurg Psychiatry. 2002;72:459–62.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Panjwani N, O’Keeffe R, Pickett A. Biochemical, functional and potency characteristics of type A botulinum toxin in clinical use. Botulinum J. 2008;1:153–66.CrossRefGoogle Scholar
  26. 26.
    Kranz G, Haubenberger D, Voller B, Posch M, Schnider P, Auff E, et al. Respective potencies of Botox and Dysport in a human skin model: a randomized, double-blind study. Mov Disord. 2009;24:231–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Jandhyala R. Relative potency of incobotulinum toxin A vs onabotulinum toxin A: a meta-analysis of key evidence. J Drugs Dermatol. 2012;11:731–6.PubMedGoogle Scholar
  28. 28.
    Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013;4:10.Google Scholar
  29. 29.
    Borodic GE, Ferrante R, Pearce LB, Smith K. Histologic assessment of dose-related diffusion and muscle fiber response after therapeutic botulinum A toxin injections. Mov Disord. 1994;9:31–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Hsu TS, Dover JS, Arndt KA. Effect of volume and concentration on the diffusion of botulinum exotoxin A. Arch Dermatol. 2004;140:1351–4.CrossRefPubMedGoogle Scholar
  31. 31.
    Cliff SH, Judodihardjo H, Eltringham E. Different formulations of botulinum toxin type A have different migration characteristics: a double-blind, randomized study. J Cosmet Dermatol. 2008;7:50–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Bakheit AM, Ward CD, McLellan DL. Generalised botulism-like syndrome after intramuscular injections of botulinum toxin type A: a report of two cases. J Neurol Neurosurg Psychiatry. 1997;62:198.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Glanzman RL, Gelb DJ, Drury I, Bromberg MB, Truong DD. Brachial plexopathy after botulinum toxin injections. Neurology. 1990;40:1143.CrossRefPubMedGoogle Scholar
  34. 34.
    Schnider P, Brichta A, Schmied M, Auff E. Gallbladder dysfunction induced by botulinum A toxin. Lancet. 1993;342:811–2.CrossRefPubMedGoogle Scholar
  35. 35.
    Latimer PR, Hodgkins PR, Vakalis BRE, Evans AR, Zaki GA. Necrotising fasciitis as a complication of botulinum toxin treatment. Eye. 1998;12:51–3.CrossRefPubMedGoogle Scholar
  36. 36.
    Dressler D. Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Mov Disord. 2004;19 Suppl 8:S92–100.CrossRefPubMedGoogle Scholar
  37. 37.
    Greene P, Fahn S, Diamond B. Development of resistance to botulinum toxin type A in patients with torticollis. Mov Disord. 1994;9:213–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Jankovic J, Schwartz KS. Clinical correlates of response to botulinum toxin injections. Arch Neurol. 1991;48:1253–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Sheean GL, Lees AJ. Botulinum toxin F in the treatment of torticollis clinically resistant to botulinum toxin A. J Neurol Neurosurg Psychiatry. 1995;59:601–7.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Dressler D, Dirnberger G. Botulinum toxin therapy: risk factors for therapy failure. Mov Disord. 2000;15 Suppl 2:51.Google Scholar
  41. 41.
    Cakmak M, Caglayan F, Somuncu S, Leventoglu A, Ulusoy S, Akman H, et al. Effect of paralysis of the abdominal wall muscles by botulinum A toxin to intraabdominal pressure: an experimental study. J Pediatr Surg. 2006;4:821–5.CrossRefGoogle Scholar
  42. 42.
    Smoot D, Zielinski M, Jenkins D, Schiller H. Botox A injection for pain after laparoscopic ventral hernia: a case report. Pain Med. 2011;12:1121–3.CrossRefPubMedGoogle Scholar
  43. 43.
    Zendejas B, Khasawneh MA, Srvantstyan B, Jenkins DH, Schiller HJ, Zielinski MD. Outcomes of chemical component paralysis using botulinum toxin for incisional hernia repairs. World J Surg. 2013;37:2830–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Rosin D. Outcomes of chemical component paralysis using botulinum toxin for incisional hernia repairs. World J Surg. 2013;37:2838.Google Scholar
  45. 45.
    Ibarra-Hurtado TR, Nuño-Guzmán CM. Comment to: chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen by Zielinski et al. Hernia. 2013;17:109–10.CrossRefPubMedGoogle Scholar
  46. 46.
    Harth K, Rosen M, Blatnik J, Schomisch S, Cash A, Soltanian H. Chemical myotomy with botulinum toxin for abdominal wall reconstruction: results of a porcine pilot study. Plast Reconstruct Surg. 2011;127 Suppl 5:S99.CrossRefGoogle Scholar
  47. 47.
    Chávez-Tostado KV, Cárdenas-Lailsonb LE, Pérez-Trigosb H. Results of preoperative application of botulinum toxin type A in treatment of giant incisional hernias. Rev Hispanoam Hernia. 2014;2:145–51.CrossRefGoogle Scholar
  48. 48.
    Ibarra Hurtado TR, Negrete Ramosa GI, Preciado Hernández F, Nuño Guzmán CM, Tapia Alcalá E, Bravo CL. Botulinum toxin type A as an adjuvant in bilateral inguinoscrotal hernia with loss of domain. First case report and literature review. Rev Hispanoam Hernia. 2014;2:139–44.CrossRefGoogle Scholar
  49. 49.
    López-Cano M, Pereira JA, Armengol-Carrasco M. “Acute postoperative open abdominal wall”: Nosological concept and treatment implications. World J Gastrointest Surg. 2013;5:314–20.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
  51. 51.
    Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, et al. Criteria for definition of a complex abdominal wall hernia. Hernia. 2014;18:7–17.CrossRefPubMedGoogle Scholar
  52. 52.
    Petersson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction—a novel technique for late closure of the open abdomen. World J Surg. 2007;31:2133–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Abdominal Wall Surgery Unit, General and Digestive SurgeryHospital Universitario Vall d’Hebron, Universitat Autònoma de BarcelonaBarcelonaSpain
  2. 2.Department of SurgeryHospital Universitario Vall d’HebronBarcelonaSpain

Personalised recommendations