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

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. This is a retrospective review of all OA patients (age a parts per thousand yen18) 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. 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 %). 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.