Botulinum toxin A in laparocele surgery

All of the Surgeons who deal with. abdominal wall have a primary goal to achieve in their interventions: that of achieving the so-called "tension-free" repair, that is, a repair in which the means used to repair the wall defect - the sutures, the prosthesis...-are not under tension.
There is no clear agreement in the international surgical community on what "tension" is. However, it appears that at least two factors play an important role in determining tension: theIncreased pressure within the abdomen and the so-called "distractive forces" of the abdominal wall, that is, those that tend to increase the diameter of the wall defect, be it a hernia, a laparocele or a diastasis of the rectus. To balance the effect of these "tensional" forces, the Surgeon has several weapons at his disposal, which he uses according to his experience and skills: from the more classic ones, such as the separation techniques ofanal fissure, anal fissure, anal pain, botulinum toxin a, laparocele, rectus diastasis, abdominal wall surgery, abdominal wall components or the use of large prosthesis, to more modern ones, such as the preoperative use of adjuvant techniques such as the botulinum toxin A and the preoperative progressive pneumoperitoneum. On the Surgeon's side there are then some "biological" factors, such as the ability of the organism to "integrate" (i.e., to make the prostheses used become part of itself): the latter ability, however, also depends on the material of which the prosthesis is made, and the position in which it is placed. Today we know, for example, that it should be avoided as much as possible to place a mesh inside the peritoneum, in contact with the abdominal viscera, because of the damage it may cause to the latter; and that in any case, even when placing an intraperitoneal prosthesis, the wall defect should always be sutured first. This last indication - the so-called IPOM PLUS technique - Unfortunately, it is followed by very few surgeons in Italy today, as the abdominal wall surgery is not still considered an autonomous specialty, and there are very few Professionals who have specific training in this regard.

Then there are "patient-side" factors that sensitively affect repair tension: the most important isobesity-and in fact no Wall Surgeon would operate (unless in an emergency situation) on an obese patient without first getting him or her to lose weight, even resorting to bariatric surgery if necessary.
Extremely important and interesting from the point of view of surgical technique are the "distractive" forces. When a defect in the abdominal wall forms, especially if it is apost-surgical hernia (also known as an incisional hernia or laparocele) or a diastasis of the rectus, the three lateral muscles of the abdomen (external oblique, internal oblique, and transverse) lose one of their insertions, the medial one, on the fascia of the rectus muscles of the abdomen; over time the muscles go into fibrosis, shorten, thicken, and lose, at least in part, their elastic capabilities. When it comes to surgery, such profound structural changes in the muscles are one of the main causes of repair tension, especially if the defect is large. This explains why if abdominal wall defects, and especially anincisional herniaor laparocele, or even a large diastasis of the rectus, are repaired with a simple suture and without using prostheses, recurrences, 10 years after surgery, are up to 50 percent of cases.
Laparocele is always consequent to a laparotomy, i.e., surgery involving incision of the abdominal wall (e.g., after surgery for removal of the gallbladder, appendix, open bowel cancer, removal of the uterus, etc.) and is common in patients undergoing surgery for cancer. We know that if, at the time of laparotomy closure, we use a "prophylactic" mesh (i.e., a mesh implanted for the purpose of reducing the likelihood of laparocele formation), the incidence of laparocele itself, at 10 years, plummets to 5-10%. The "prophylactic" mesh is normally much smaller than those used in laparocele repair: this is because at the time of laparotomy closure, the muscles are much more elastic than those of a patient with a laparocele, and can be easily brought closer together.
From this simple but important observation, an equally simple idea was born: if the muscles of patients with a large abdominal wall defect - a laparocele, for example, as mentioned; but also a large diastasis of the rectus with a diameter of more than 8 cm - could be restored to their original length and elasticity, the tension of the sutures at the time of laparocele repair would be greatly reduced, and consequently the risk of recurrence would be reduced.
This idea was first applied to laparocele surgery by an ingenious Mexican surgeon, Dr. Tomás Ibarra Hurtado, in 2007. Dr. Ibarra Hurtado thought that the

Botulinum toxin A, laparocele, rectus diastasis, abdominal wall
Dr. Tomás Ibarra Hurtado
Dr. Ibarra Hurtado teaches us his technique with botulinum toxin A

botulinum toxin A, a drug widely used both in neurology (e.g., for the treatment of facial muscle spasms), in plastic surgery (for the treatment of facial wrinkles), and in proctology (for the treatment of anal fissures), injected into the muscles of the abdominal wall prior to laparocele surgery, could cause those muscles to relax: at this point, the pressure exerted on those muscles by the viscera contained within the abdomen would cause them to lengthen. This hypothesis was confirmed by CT studies carried out at 2 to 4 weeks of toxin administration: in patients undergoing such treatment, all of whom had large laparoceles, the lateral muscles of the abdomen were indeed significantly lengthened and thinned. This makes it much easier to bring the muscles closer together and thus repair the defect without tension.
Dr. Ibarra Hurtado's technique is now widely used throughout the world, and used by leading surgeons specializing in abdominal wall repair. In Italy, however, our group-I learned the technique directly from Dr. Ibarra, as part of a splendid seminar he held in 2018 in Madrid during the congress of the Sociedad Hispano-Americana de Hernia-is the only one to use botulinum toxin A in reconstructions of large wall defects.
The effect of botulinum toxin A persists for about 3 months; in this time frame, tissue repair processes and prosthesis integration progress to such an extent that, once the effect of the toxin has ceased, the soundness of the repair is no longer at risk.
The use of botulinum toxin A in the surgery of large wall defects has confirmed that the main risk factor for recurrences of laparoceles and other large abdominal wall defects (such as large diastases of the rectus, with diameters greater than 8 cm) is precisely suture tension. Its use, together with other preoperative strategies of preparation and optimization of the surgery (e.g., weight loss, smoking cessation, diabetes control, etc.) allows to significantly reduce recurrences and postoperative pain and to use smaller mesh sizes.
In our country, the National Health System does not recognize the use of botulinum toxin A for abdominal wall surgery; therefore, as mentioned above, its use is virtually unknown.


Dr. Salvatore Cuccomarino
Cuccomarino, MD
Dr, Cuccomarino coordinates a multidisciplinary medical team dedicated to the treatment of abdominal wall defects. He was the first in Europe to perform REPA, the minimally invasive endoscopic surgery of diastasis of the rectus.
61 Amerigo Vespucci Street
Phone +39 011 0438161


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