913 Role of Botulinum Toxin in the Medical Management of Respiratory Distress Secondary to Suspected Intraabdominal Hypertension After Abdominal Wall Reconstruction

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Abstract Introduction Botulinum toxin (BTX) is a neurotoxin which causes functional denervation of muscles. Botulinum toxin type A (BTX) has been approved for a wide range of clinical applications. In addition, off-label preoperative injection of BTX is increasingly used for chemical component relaxation of the lateral abdominal wall muscles prior to abdominal wall reconstruction. Rationale Postoperative intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) with consequent organ dysfunction can be a potential complication after abdominal wall reconstruction. The IAH and ACS clinical practice guidelines suggest improving abdominal wall compliance in their medical management algorithm including neuromuscular blockade. Method Following an open retrorectus mesh repair with left component separation via transversus abdominis release of a midline incisional hernia, we report a case of postoperative respiratory distress and acute kidney injury suspected secondary to increasing intraabdominal hypertension due to ileus unresponsive to standard conservative measures including nasogastric tube insertion, use of prokinetic agents and judicious fluid management. We performed Botox A injection under ultrasound guidance to the lateral abdominal wall musculature. This resulted in improved abdominal wall compliance, consequent resolution of respiratory symptoms and reversal of acute renal injury with eventual resolution of ileus and a good post operative outcome. There was an increase in length of stay by 2 days compared to our average. The patient remains well at 3 months post operatively. Conclusions Botulinum Toxin A injection can be considered as adjunct in the medical management of IAH and ACS if it has not been used in the pre-operative setting.

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