Chemical Component Separation Technique in Hernia Repair

Abstract

AbstractGiven the limitations of CST, additional surgical adjuncts have been developed to aid in fascial closure, most commonly the preoperative injection of botulinum toxin A (BTA) or the use of progressive preoperative pneumoperitoneum. BTA works by causing functional denervation of the abdominal wall by blocking the release of the neurotransmitter acetylcholine, which is an excitatory neurotransmitter that acts at neuromuscular junctions. BTA was first injected into the lateral abdominal wall of rats and determined to significantly increase abdominal wall laxity after injection. As a form of chemical component separation, its use in AWR was first described in 2009. Preoperative injection of BTA allows the muscles of the abdominal wall to elongate and become more compliant therefore assisting in achieving primary fascial closure. This is particularly useful in patients with large ventral hernias with LOD, or in patients with contaminated fields where implantation of synthetic mesh is not possible or development of tissue planes for component separation would yield even higher wound complication rates. Although its on-label use is in different muscles of the body with the same therapeutic goal, the use of BTA injection in the lateral abdominal wall is currently considered off-label by the Food and Drug Administration. Nonetheless, fascial closure, recurrence rates, and other outcomes of its use in large hernia repair have been thus far excellent making BTA a promising part of the future of complex AWR.