Botulinum toxin abdominal wall injection and post-omphalocele ventral hernia repair: database and proposal of a protocol

Abstract

Background Post-omphalocele ventral hernias (POVH) are common after giant omphaloceles. Abdominal wall botulinum toxin injections (BTI) are useful to treat complex incisional hernias (CIH) in adults, which may also apply to POVH. We review BTI data in the treatment of CIH and POVH and propose an algorithm applicable to POVH. Results Sixteen papers which described the treatment of CIH on the treatment of POVH in adults (n = 15) and children (n = 1) were reviewed. BTI elongates the lateral abdominal wall and reduces the hernia defect, with a lower incidence of compartment syndrome and respiratory complications. Doses and injection volumes vary. Effects start after 3 days, peak after 10–15 days, stabilize for 2–3 months, and decline after 4–6 months, disappearing after 6–9 months. Patients should be operated on 3–4 weeks after injection. Post-operative complications are uncommon. BTI may be associated with pre-operative pneumoperitoneum (PPP). Children presenting POVH differ from adults presenting CIH. Associated congenital cardiac malformations, genetically determined syndromes, pulmonary hypoplasia, abdominal wall hypoplasia, and thoracic dysmorphism, are common; children need sedation for any procedures; non-absorbable reinforcing meshes are not indicated; and POVH limits are frequently near to the costal margin. Conclusion BTI to induce preoperative muscular relaxation in preparation of CIH repair in adults is effective and safe. Experience with the method in children with POVH is limited, but the proposal is logical and probably safe. POVH differs from CIH in some aspects, especially abdominal wall hypoplasia, proximity to the rib cage, and diaphragmatic biomechanics.

Utilización de Toxina Botulínica en el manejo de onfalocele gigante en un lactante. Informe de Caso

“…La dosis pediátrica recomendada por la FDA propone 8 UI/kg hasta un máximo de 300 unidades 14 . Aunque la mayoría de revisiones describe la utilización de 2 -5 UI/kg decidimos utilizar la dosis de 5UI/kg según la recomendación de Eyer de Jesus et al 15 . No existe una forma específica descrita de cómo realizar las aplicaciones de toxina botulínica en estos pacientes, la literatura reporta entre 3 a 5 inyecciones por lado para tratar esta patología, Eyer de Jesus et al realiza una comparación con las publicaciones reportada hasta el 2020 15 .…”

“…Aunque la mayoría de revisiones describe la utilización de 2 -5 UI/kg decidimos utilizar la dosis de 5UI/kg según la recomendación de Eyer de Jesus et al 15 . No existe una forma específica descrita de cómo realizar las aplicaciones de toxina botulínica en estos pacientes, la literatura reporta entre 3 a 5 inyecciones por lado para tratar esta patología, Eyer de Jesus et al realiza una comparación con las publicaciones reportada hasta el 2020 15 . En nuestro caso se utilizaron 5 inyecciones por lado para abarcar un mayor una mayor área de pared abdominal con el efecto de la toxina, la literatura describe las aplicaciones de inyecciones bajo guía ecográfica, en nuestra institución no contamos con ecografía a disponibilidad por lo que se aplicó sin guía ecográfica al paciente en sala de operaciones bajo anestesia general.…”

Successful Administration of Preoperative Botox for Giant Omphalocele Repair With Ultrasound Guidance

“…Giant omphalocele (GO), defined as a defect >5-6cm that involves most or all of the liver, typically requires staged surgical closure and nonoperative delayed closure. However, these methods have frequent hernias (12-56%), morbidity (respiratory and wound complications), and high cost [2].…”

“…Recently, Botox (botulinum toxin A [BTA]) has been safely used for abdominal wall reconstruction in pediatric patients [2,3]. Botox administration causes laxity of the abdominal wall musculature and decreases tension on the fascial closure, facilitating midline abdominal wall closure [4].…”

Editorial Comment: Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results

“…The authors ingeniously associate techniques of rectus muscle releasing and myofascial compartment mobilization. We wonder whether associating intramuscular pre-operative botox injections would also help (2). This would be easy to accomplish, as surgeries are usually programmed electively after 3 months of age.…”