One-Year Follow-up After Open Abdomen Therapy With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction

Background

Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure.

Methods

A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006–2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted.

Results

The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm², respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2–68.8) was the only independent factor associated with an incisional hernia.

Conclusions

Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.     

Early Results after Treatment of Open Abdomen after Aortic Surgery with Mesh Traction and Vacuum-Assisted Wound Closure

ObjectivesThis study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery.DesignProspective clinical study.Material and methodsFrom October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC.ResultsAll wounds could be closed following a median interval of 10.5 (range: 6–19) days after laparostomy. A median of four (range: 2–7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2–36) months.ConclusionVAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.     

Study of Two Techniques for Midline Laparotomy Fascial Wound Closure

To study the results of two techniques, simple interrupted closure and continuous with intermittent Aberdeen knot technique for midline laparotomy fascial wound closure. A random selection of 200 midline laparotomy cases was done. In one group (group A) of 100 cases, midline fascial wound closure was done with continuous sutures with intermittent Aberdeen knot technique using Prolene No. 1 suture material. In the other group (group B) of 100 cases, closure was done with the technique of simple interrupted sutures with Prolene No.1 suture material. Comparison of both the techniques regarding preoperative status and postoperative complication such as incisional hernia, wound dehiscence, suture sinus formation, stitch granuloma, and chronic wound pain was done according to clinical examination and recorded in the pro forma prepared. In group A, postoperative complications were incisional hernia 3 %, wound dehiscence 4 %, and suture sinus formation 1 %. In group B, postoperative complication were incisional hernia 5 %, wound dehiscence 4 %, and suture sinus formation 1 %. All these complications were statistically insignificant, in both group comparisons. While the complication such as stitch granuloma 3 %, chronic wound pain 3 %, and wound infection 4 % in group A was significantly less than in group B where the complication of stitch granuloma was 12 %, chronic wound pain 13 %, and wound infection 13 % (P value 0.03, P value 0.018, and P value 0.048, respectively). Both the techniques, simple interrupted suture closure and continuous with intermittent Aberdeen knot closure for midline laparotomy fascial wounds, show a similar rate of postoperative complication such as incisional hernia, wound dehiscence, and suture sinus formation. But the continuous suturing with intermittent Aberdeen knot technique is a better option to prevent complications such as stitch granuloma, chronic wound pain, and wound infection, which are higher in the simple interrupted fascial wound closure technique.     

Vacuum-Assisted Closure of Postoperative Abdominal Wounds: A Prospective Study

Background

We aimed to study outcome in patients with an open abdomen in whom the abdominal vacuum-assisted closure system (V.A.C.^® Therapy^?) was used to provide temporary cover and achieve wound closure.

Methods

All patients in whom V.A.C. Therapy was used to manage laparotomy wounds between February 2006 and May 2007 at a University Teaching Hospital were followed up prospectively until successful completion or stoppage of V.A.C. Therapy.

Results

Of the 51 consecutive patients (33 male), V.A.C. Therapy was used to manage a laparostomy in 10 patients and abdominal wound dehiscence in 41. Median (IQR) duration of V.A.C. Therapy was 17 (7–26) days. Wound healing was achieved in 31 (61%) patients, four of whom had additional surgery to assist wound closure. The rest healed by secondary intention. Treatment was withdrawn due to therapy-related complications in nine patients and due to medical or logistical reasons in seven. Four patients died while on therapy. While most V.A.C. Therapy-related problems were minor, two patients developed enteric fistulae that necessitated surgical repair. At a median (IQR) follow-up of 8 (4–13) months, 18 patients had stable cutaneous coverage with no incisional hernia, 12 developed an incisional hernia, 9 were lost to follow-up, and 12 died.

Conclusions

V.A.C. Therapy is a useful adjunct in the management of the open abdomen and should be considered in the treatment of this problem. Restoration of cutaneous and fascial integrity of the abdominal wall, the risk of fistulisation, and the cost-effectiveness of this therapy require further evaluation.

     

Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems

Management of the post-traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure. Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero-atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration. We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero-atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = − 0.294, p = 0.036). For the post-traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.     

Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen

Background  This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This “open abdomen” must then be temporarily closed. However, the FC rate varies between techniques. Methods  The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) “open abdomen,” “fascial closure,” “vacuum,” “reapproximation,” and “ventral hernia.” Open abdomen was defined as “the inability to close the abdominal fascia after laparotomy.” Two reviewers independently extracted data from original articles by using a predefined checklist. Results  The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). Conclusions  These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.     

Vacuum-Assisted Closure for Successful Treatment of a Major Contaminated Gunshot Chest-Wound: A Case Report

Vacuum-assisted closure (VAC) is a well-established treatment for complicated wound infections and chronic wounds, including poststernotomy mediastinitis. The use of VAC in treating high-energy trauma has been more limited. We present a case where VAC was successfully used to treat a contaminated self-inflicted gunshot-wound of the chest and abdomen.     

Suture-Tool: A Mechanical Needle Driver for Standardized Wound Closure

World Journal of Surgery - A laparotomy is commonly required to gain abdominal access. A safe standardized access and closure technique is warranted to minimize abdominal wall complications like...     

Endoscopic Plantar Fasciotomy; Deep Fascial Versus Superficial Fascial Approach: A Prospective Randomized Study

In the present randomized prospective study, 2 different surgical techniques of endoscopic plantar fascia release were compared. Of 547 patients with a diagnosis of plantar fasciitis, 46 with no response to conservative treatment for ≥6 months were included. Of the 46 patients, 5 were lost to follow-up. In group 1 (n = 21), plantar fascia release was performed using a deep fascial approach (DFA), and in group 2 (n = 20), the superficial fascial approach (SFA) with a slotted cannula technique was used. Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale and visual analog scale at baseline and 3 weeks and 3, 6, and 12 months after the initial surgery. At the final follow-up appointment, the Roles-Maudsley score was used to determine patient satisfaction. At the final follow-up examination, the mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale scores had increased from 53.12 to 83.68, with a decrease in the mean visual analog scale score from 7.95 to 1.65 noted. According to the Roles-Maudsley score, the success rate after 1 year was 90.47% for DFA group, 95% for the SFA group, and 92.68% for all patients. Although no significant difference was found between the final functional scores, better early postoperative scores were found in the SFA group. The mean duration of the procedure was measured as 27.22 ± 9.41 minutes overall, 35 ± 5.62 minutes in the DFA group, and 19.05 ± 4.01 minutes in the SFA group. Two early and two late complications occurred in the DFA group with none reported in the SFA group. In conclusion, the SFA is a faster and safer method of endoscopic plantar fascia release with better early postoperative scores.     

Treatment of Chronic Osteomyelitis: A Prospective Study of 55 Cases Treated with Radical Surgery and Primary Wound Closure

A prospective and consecutive series of 55 patients were treated for chronic osteomyelitis occurring mainly in the lower extremity and after fractures treated with internal fixation. The mean duration of osteomyelitis was 27 months. Sixty- five per cent had previously undergone operations and had been hospitalized for an average of 131 days. Staphylococcus aureus was cultured in 72 per cent of the cases as the solitary agent. In 6 cases no bacteria were found. The remaining cases had more than one species. The treatment consisted of radical operation, removal of all internal fixation, sequestrectomy, partial decortication and primary wound closure with suction drainage. External fixation was used for bone stabilization. In 13 cases plastic procedures were carried out. Antibiotics appropriate for the sensitivity patterns were given for a maximum of 3 months. Primary wound healing was obtained in 98 per cent of the cases. In practically all cases the sedimentation rate normalized within 4 weeks after the operation. The results in the available literature indicate that radical operation is effective in the treatment of osteomyelitis and this treatment seems economical as regards hospitalization time and quantity of antibiotics required     

脊柱侧凸患者对不同牵引方法依从性的比较研究

目的 评价脊柱侧凸患者对自行设计的滑动式脊柱侧凸牵引床应用的依从性.方法 将41例特发性脊柱侧凸患者按入院顺序分为观察组(22例)和对照组(19例).对照组采用自身悬吊牵引,观察组应用自行设计的滑动式脊柱侧凸牵引床牵引.结果 观察组对牵引认知、牵引舒适情况、牵引耐受时间、牵引方式选择和主观评价优于对照组.观察组100%患者按计划完成牵引,而对照组仪为21.1%.结论 特发性脊柱侧凸患者应用自制滑动式脊柱侧凸牵引床可提高患者牵引依从性,为脊柱侧凸的术前准备提供保障.     

Treatment of Chronic Osteomyelitis: A Prospective Study of 55 Cases Treated with Radical Surgery and Primary Wound Closure

A prospective and consecutive series of 55 patients were treated for chronic osteomyelitis occurring mainly in the lower extremity and after fractures treated with internal fixation. The mean duration of osteomyelitis was 27 months. Sixty- five per cent had previously undergone operations and had been hospitalized for an average of 131 days. Staphylococcus aureus was cultured in 72 per cent of the cases as the solitary agent. In 6 cases no bacteria were found. The remaining cases had more than one species. The treatment consisted of radical operation, removal of all internal fixation, sequestrectomy, partial decortication and primary wound closure with suction drainage. External fixation was used for bone stabilization. In 13 cases plastic procedures were carried out. Antibiotics appropriate for the sensitivity patterns were given for a maximum of 3 months. Primary wound healing was obtained in 98 per cent of the cases. In practically all cases the sedimentation rate normalized within 4 weeks after the operation. The results in the available literature indicate that radical operation is effective in the treatment of osteomyelitis and this treatment seems economical as regards hospitalization time and quantity of antibiotics required     

A New Method for Surgical Abdominal Mass Closure After Abdominal Fascial Dehiscence Using Nasogastric Tube and Hemovac Perforator: A Case-Series Study

Background

As the challenge for finding the best abdominal incision closure technique continues, surgeons are aiming to minimize postoperative wound complications such as wound dehiscence and hernia as an acute or late manifestation. In order to achieve this goal, several abdominal opening and closure techniques have been tried. In this article, we describe a method in which we used a nasogastric tube (NGT) in mass closure for patients with fascial dehiscence.

Methods

In this case-series study, a total number of 25 patients participated. All of the patients had abdominal dehiscence after a surgery and had to undergo for another. An NGT was used for abdominal closure. The patients were followed for a month and were examined for any signs and symptoms of fever, infection, pain, material expenses, closing time, and laboratory data. The data were analyzed using SPSS software V.22. Mean?±?SD and frequencies were used for describing the variables.

Results

The mean NGT mass closure material expenses for each patient were 8400.00?±?0.00 IRR (around 0.25 US dollars). The mean closure time after the operation was 13.08?±?3.09 min. There was no evidence of infection among the patients as well as no other complications after the surgery in the 1-month study period.

Conclusion

Abdominal mass closure with NG tube suturing technique is associated with reduced time required for closure of the incision, incidence of wound dehiscence, and the incidence of incisional hernia as well as infection, with a considerable low cost.

     

Barbed Versus Traditional Sutures: Closure Time,Cost, and Wound Related Outcomes in Total Joint Arthroplasty

The purpose of this study was to compare barbed sutures to traditional sutures in three domains: time, cost, and wound related outcomes in total knee arthroplasty (TKA) and total hip arthroplasty (THA). A total of 34 patients were enrolled in a prospective randomized controlled trial to assess time to wound closure and cost. In addition, a retrospective chart review of an additional 100 patients was conducted to further assess wound-related outcomes. On average, barbed sutures decreased time to wound closure by 9.72 min (P < 0.05) after controlling for length of incision, patient's BMI and number of physicians closing. Further, using barbed sutures saved an average of $549.59 per case. However, increased frequency and severity of wound complications were associated with barbed sutures.     

Outcome of Negative-Pressure Wound Therapy for Open Abdomen Treatment After Nontraumatic Lower Gastrointestinal Surgery: Analysis of Factors Affecting Delayed Fascial Closure in 101 Patients

Background

Few studies have focused on the risk factors for failure to achieve fascial closure after use of negative-pressure wound therapy (NPWT) in an open abdomen (OA). We aimed at analyzing possible risk factors for failure of fascial closure and the risk of fistulas after nontrauma lower gastrointestinal (GI) tract surgery treated with OA.

Methods

This retrospective study included 101 nontrauma patients treated with OA from 2007 to 2011. Multivariate analyses of risk factors were performed.

Results

Indications for OA were diffuse peritonitis (n = 47), need for second look (n = 26), failure to achieve fascial closure (e.g., bowel edema) at primary laparotomy (n = 24), and fascial necrosis (n = 4). Of the 101 patients, 61 (60 %) were alive at discharge, with one death possibly related to OA (fistula from an iatrogenic perforation). Delayed fascial closure was obtained in 40 (66 %) of the surviving patients, with 80 % when the indications for OA was need for second look and 72 % in cases of diffuse peritonitis. Compared with need for second look [hazard ratio (HR = 1), 95 % CI], proportional HR for failure of delayed fascial closure were peritonitis 1.96 (1.10–3.49) and failure to achieve fascial closure at primary laparotomy 4.70 (2.17–10.2). In the presence of a stoma the HR was 2.02 (1.13–3.63).

Conclusions

OA using NPWT seems to be a safe procedure, with few procedure-related complications. Failure of fascial closure is related to the indication of OA and the presence of a stoma. Prospective multicenter studies are needed to establish which patients with lower GI surgery benefit from OA.