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Chemical Component Separation with Botox


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Clinical Anatomy

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    Comprehensive knowledge of the lateral abdominal wall muscles is required to understand the function of these muscles and to ensure adequate coverage with botulinum toxin (BTX).

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    External oblique fibers run inferomedially to provide lateral flexion and rotation.

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    Internal oblique fibers run superomedially, directly perpendicular to the external oblique fibers, to provide abduction and rotation.

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    Transversus abdominis fibers run medially to laterally to provide pelvic and lower back stabilization.

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    These muscles produce tension on midline hernia repairs in the direction of their fibers. In addition, they are considered accessory muscles of breathing.

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    BTX type A (Botox; Allergan, Irvine, CA), as a neuromodulating agent, blocks the release of acetylcholine and other pain-modulating substances to produce flaccid paralysis ( Fig. 12.1 ).

    Fig. 12.1

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    The maximum effect of BTX is reached at approximately 3 weeks, providing a benefit for 3-6 months after the procedure.

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Preoperative Considerations

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Patient Selection

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    There are currently four indications for BTX injections of the lateral abdominal wall.

    • Planned abdominal wall reconstruction in the setting of a large ventral hernia

    • Preoperative or postoperative pain secondary to lateral abdominal wall muscle spasms

    • Open abdomen after damage control laparotomy

    • Massive intrathoracic herniation of abdominal contents

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    Severe chronic obstructive pulmonary disease is a relative contraindication to chemical component separation because of the flaccidity of accessory breathing muscles.

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    Contraindications to BTX include preexisting pareses (amyotrophic lateral sclerosis, myopathies, motor polyneuropathies), impaired neuromuscular transmission (myasthenia gravis, Lambert-Eaton syndrome), and concurrent aminoglycoside use.

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    Although the planned abdominal wall reconstruction is a major operative intervention, BTX injections are an outpatient procedure with minimal physiologic sequelae. If a patient is optimized for the major procedure, no further preoperative optimization except for consideration of anticoagulation cessation is required.

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