Anatomically-Guided Botulism Toxin Injections for Enhanced Abdominal Muscle Relaxation Prior to Massive Inguinal Hernia Repair: A Case Report

Abstract

BACKGROUND: The use of botulism toxin A (BTA) to augment abdominal muscle relaxation for surgical hernia repair is well described. However, guidance on the anatomic considerations to facilitate safe and ideal abdominal wall BTA injection patterns is limited. CASE REPORT: A 37-year-old man presented with a 26-cm inguinal hernia and abdominal content loss of domain. Due to high risk of incomplete abdominal closure, abdominal compartment syndrome, and prolonged postoperative ventilatory support, a multidisciplinary approach to surgical closure was sought with therapeutic input from a comprehensive pain clinic. The patient was injected with BTA into the bilateral internal and external oblique muscles 2 weeks preoperatively. The injection pattern design employed anatomic considerations for points of maximum abdominal wall tension and anticipated BTA spread. Subsequent muscle paralysis facilitated successful surgery with minimal tension upon closure. CONCLUSION: This case supports the safe and effective use of BTA for enhanced abdominal wall relaxation prior to major inguinal hernia repair. When considering BTA therapy for abdominal muscle relaxation augmentation, the choice of injection pattern should include points of maximum tension and injections of close-enough proximity for BTA spread and overlap to maximize procedure benefit, regardless of the location or type of abdominal wall hernia repair. KEY WORDS: Botulism toxin, abdominal muscle relaxation, hernia repair, inguinal hernia, regional anesthesia, case report