Chemical Components Separation: Concepts, Evidence, and Outcomes

Abstract

Ventral hernias with loss of domain pose a significant challenge to the hernia surgeon. Techniques such as advancement flaps, component separation, progressive pneumoperitoneum, and preoperative injection of botulinum toxin A (BTA) aim to alter the abdominal wall length or form to achieve tension-free primary fascial repair in abdominal wall reconstruction (AWR). Here, we review the current literature on BTA injection as an adjunct to AWR. A literature review identified 22 articles discussing the use of BTA associated with ventral hernia repair. Six primary studies reported preoperative use of BTA. Treatment regimens are not standardized, varying from 300 to 500 u injection on 3-5 sites per laterality, from 4 weeks before the day of surgery. After injection, computed tomography scans demonstrate elongated and thinned abdominal wall muscles with decreased mean defect size and hernia size. Primary fascial closure is usually achieved. Postoperative pain control may be improved with perioperative administration of BTA, and no adverse events associated with BTA injection were reported. Preoperative BTA injection is a promising adjunct to AWR, creating abdominal wall laxity and enabling primary fascial repair. Further investigation will be needed to determine the ideal dosage, timing, and patient population.

Successful Administration of Preoperative Botox for Giant Omphalocele Repair With Ultrasound Guidance

“…BTA acts by inhibiting the release of acetylcholine, resulting in muscular flaccid paralysis. The toxin takes effect within two weeks, with peak effect in four to six weeks and a gradual decline over three months [4,5]. BTA has also been shown to reduce inflammation and scarring by inhibiting the release of glutamate and substance P [5].…”

“…This mechanism may help to reduce postoperative pain. Several studies have reported the safe and effective use of BTA as an adjunct in the repair of complex abdominal wall defects in both adult and pediatric patients [1][2][3][4][5]. BTA injections result in a reversible flaccid paralysis of the lateral abdominal wall musculature allowing for apposition of midline fascia and reducing tension on the fascial repair, decreasing intraabdominal pressure, and mitigating the risk of postoperative complications [4].…”

“…Recently, Botox (botulinum toxin A [BTA]) has been safely used for abdominal wall reconstruction in pediatric patients [2,3]. Botox administration causes laxity of the abdominal wall musculature and decreases tension on the fascial closure, facilitating midline abdominal wall closure [4]. To our knowledge, this is the first description of a combined preoperative sub-fascial tissue expander and BTA injection for definitive GO repair.…”

Incisional hernia repair with plication and utilization of Botox injections: First case report from Saudi Arabia for a 19‐year‐old female

“…It's now evident that its flaccid paralysis inducing properties could provide a temporary decreased midline abdominal wall tension. This allows for a pharmacologically safe, reversible alternative for CST while avoiding permanent division to aponeurotic tissue to perform primary fascial closure …”

“…This allows for a pharmacologically safe, reversible alternative for CST while avoiding permanent division to aponeurotic tissue to perform primary fascial closure. 16 The potential use of BTA as an adjunct for abdominal wall closure was first theorized in 2006 when a study on rats successfully increased intra-abdominal volume and decreased pressure by paralyzing abdominal wall muscles, thus diminishing transverse hernia defect. 17 The attempted use of novel technique involving the application of BTA before abdominal wall hernia reconstruction was first reported in 2009, in a study involving 12 patients.…”