Natasza M Posielski, BS, Clayton C Petro, MD, Yuri W Novitsky, MD, Hooman T Soltanian, MD, Michael J Rosen, MD. University Hospitals Case Medical Center.
Introduction: A 58-year-old male with gallstone pancreatitis developed abdominal compartment syndrome requiring a decompressive laparotomy at an outside hospital. Ten days later his fascial defect remained >30cm wide and he was transferred to our institution for further management. Skin grafting was deferred due to malnutrition (albmin 1.2 mg/dL) and the decision was made to attempt chemical components separation with onabotulinumtoxin A (Botox®).
Methods: Ultrasound guidance was used to inject 8mL of Botox solution (2 IU/mL) into each layer of the abdominal wall musculature at 3 sites lateral to the linea semilunaris on each side (300 IU total). A continuous tissue expander device was then applied to support subcutaneous tissue medialization followed by a wound vacuum dressing. The patient remained paralyzed and the tissue expander and vacuum dressings were changed two days later. Five days after the Botox injection, the patient returned to the operating room for primary skin closure. Systemic paralysis was withdrawn 3 days after skin closure.
Results: The patient began tolerating tube feeds two days after his last operation and was liberated from the ventilator 10 days after skin closure. He was discharged from the hospital to home 50 days after his initial presentation. Four weeks after discharge his incision is almost entirely healed and he has resumed normal activity.
Conclusion: Use of chemical components separation with Botox and tissue medialization supported by a tissue expander device is a valid technique to achieve primary closure of a difficult open abdomen.