Keywords:
Abdomen, Ultrasound, Surgery, Experimental investigations, Hernia
Authors:
A. Walker, S. Deshmukh; Chicago/US
DOI:
10.26044/essr2019/P-0014
Imaging findings OR Procedure Details
Lateral abdominal wall muscular anatomy and general approach for ultrasound guided botox injection prior to ventral hernia repair surgery is shown in Figure 1. Abdominal muscular anatomy on computed tomography (CT) in a patient with ventral hernia is shown in Figure 2. At our institution,
ultrasound guided botox injection of the lateral abdominal wall muscles is commonly performed 3-4 weeks prior to the date of surgery for ventral hernia repair (Figure 3).
Our procedural technique: Pre-procedural ultrasound should be obtained to clearly identify the three lateral abdominal wall muscles and to mark the injection site(s). Ultrasound of the lateral abdominal wall musculature can adequately delineate the three layers of muscular anatomy: from superficial to deep,
the external oblique,
internal oblique,
and transversus abdominis muscles are visualized,
with thick hyperechoic fascial planes of separation (Figure 4). At our institution,
one injection site is typically selected per side,
generally at the level of the umbilicus and along the mid-axillary line.
However,
multiple target sites ranging from 37,8 to 59,10 per side have been described in the literature. The skin over the target areas is prepped and draped in sterile fashion.
Next,
1% lidocaine is injected subcutaneously as a local anesthetic.
Under sonographic guidance,
a 22-gauge spinal needle is inserted into the target muscles and the appropriate volume of botox diluted in saline (Figure 5) is administered.
Typically,
at our institution,
we administer 100 units of botox diluted in saline on each side. Generally speaking,
a patient may receive up to 400 units of botox over a 3 month period.
The technique for preoperative lateral abdominal wall botox injections may be dependent on the case since some patients with ventral hernias may have a complex medical and past surgical histories.
Potential alternative techniques include unilateral lateral abdominal wall muscular injection or even rectus abdominis muscle injection. The exact site of injection should be discussed with the ordering surgeon.
Ultrasound-guided intra-muscular botox injections can also be used for treatment of chronic pain secondary to muscle spasticity.
For instance,
in patients with epilepsy,
muscle pain may result from chronic seizure-induced contraction. Muscle spasticity resulting from trauma or other conditions may also be treated with botox injections (Figures 6 and 7). Imaging technique is the same as with lateral abdominal wall muscle injections. At our institution,
dosing ranges from 100-200 units per muscle with a total botox injection dose not to exceed 400 units over 3 months. Repeat injections are performed at 3 month intervals as needed for pain management.