Open abdomen. Evolution in management

The open abdomen (OA) strategy is accepted in the treatment of extremely ill surgical patients. Its usage has increased in the last decade as the understanding of its functions, advantages and disadvantages increases. Unfortunately, it continues to be associated with very high morbidity and mortality, and the different techniques used to protect the intra-abdominal contents cannot be standardized for all surgical circumstances. The objective is to review the origins, actual indications and controversies of the staged abdominal repair (STAR) and to report on the latest and most used techniques to ensure an optimal temporary abdominal closure (TAC). A search was done in Medline and Ovid for articles with key words of open abdomen, temporary abdominal closure and staged abdominal repair. We found the use of the technique is justified in patients with trauma, abdominal compartment syndrome and patients with severe intra-abdominal sepsis. The technique used for TAC must always be individualized for each clinical circumstance. The best reported results have been obtained with the vacuum pack technique. In our own experience and as a general rule we discouraged the use of mesh to protect intra-abdominal contents. The strategy of OA is useful in complex surgical situations in extremely ill patients. Its use must be very carefully evaluated, knowing the potentially serious complications that the patient may develop with its use.     

Surgical management of intra-abdominal hypertension and abdominal compartment syndrome

The initial management of intra-abdominal hypertension (IAH) is medical measures to reduce intra-abdominal pressure (IAP). These, in combination with percutaneous drainage of peritoneal free fluid, may serve to reduce IAH. If these measures fail, surgical decompression of the abdomen by laparotomy is necessary to control the IAP, search for and treat inciting factors, and reduce the hypertension. The abdomen is usually left open with temporary abdominal closure techniques. Surgical decompression of IAH associated with acute pancreatitis or secondary abdominal compartment syndrome has other surgical options besides a complete celiotomy. Attention to detail in surgical technique and postoperative care is essential for optimal outcome.     

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??Open abdomen technique in the management of gastrointestinal fistula complicated with severe intra-abdominal infection REN Jian-an Research Institute of General Surgery, Nanjing General Hospital of Nanjing Military Command, PLA, Nanjing 210002, China Abstract Objective To investigate the result of open abdomen technique in the treatment of gastrointestinal fistula complicated with severe intra-abdominal infection. Methods The clinical data of 73 gastrointestinal fistula patients complicated with severe intra-abdominal infection received open abdomen therapy from January 1999 to December 2008 at Nanjing General Hospital of Nanjing Military Command of PLA were analyzed retrospectively. Results Fifty-six of 73 patients (76.7%) survived to discharge. Ten patients (13.7%) died and 7 patients ( 9.6%) gave up the treatment. The main causes of death were hemorrhage of abdominal cavity (5 cases), infection and organ nonfunction (5 cases). The average APACHEII score for survivors was 13.5±4.3 before open abdomen and dropped to 9.2±4.5 and 8.1±6.2 after 5 and 15 days of open abdomen. The average APACHEII score for dead patients was 16.0±5.8 before open abdomen and dropped to 12.9±5.5 and increased to 16.3±11.8 after 5 and 15 days of open abdomen. The score of organ function changed similarly .Conclusion The open abdomen therapy is an effective treatment for gastrointestinal fistula complicated with severe intra-abdominal infection. Open abdomen could improve the severity score of severe intra-abdominal infection patients. The therapy can be divided into three stages including temporary closure of the open abdomen, skin graft of open wound and permanent closure of abdomen and resection of enteric fistula. The reconstruction operation of digestive tract and abdominal wall can be performed simultaneously.     

腹腔开放治疗肠瘘并严重腹腔感染73例分析

目的 研究腹腔开放治疗肠外瘘并腹腔感染的时机、方法与效果。比较不同暂时关腹技术,研究消化道与腹壁重建的时机与效果。方法 回顾性分析1999年1月至2008年12月南京军区南京总医院73例接受腹腔开放疗法的肠外瘘并严重腹腹腔感染的临床资料。结果 56例（76.7%）行腹腔开放疗法后存活（存活组）,10例（13.7%）死亡,7例（9.6%）放弃治疗（死亡及放弃治疗者统称为死亡及放弃治疗组）。死亡原因主要是腹腔出血（5例）、感染和脏器功能衰竭（5例）。腹腔开放前的APACHE II评分在存活组和死亡及放弃治疗组分别为13.5±4.3和16.0±5.8,腹腔开放后第5天时分别降至9.2±4.5和12.9±5.5;腹腔开放第15天时,存活组APACHEII评分降至8.1±6.2,而死亡及放弃治疗组评分重新升高至腹腔开放前水平（16.3±11.8）。脏器功能障碍评分亦有类似变化。结论 腹腔开放可有效治疗肠外瘘并严重腹腔感染病人。在多脏器功能严重损害前及时行腹腔开放疗法可有效改善肠瘘并严重腹腔感染的疾病严重度。腹腔开放后第15天左右的疾病严重度可提示病人的转归。行腹腔开放的病人可分为暂时关腹、创面植皮和永久重建3个阶段。消化道与腹壁重建可同时进行。     

Single incision laparoscopic surgery ovarian cystectomy in large benign ovarian cysts using conventional instruments

We describe a technique for the management of large benign ovarian cysts by single incision laparoscopic surgery (SILS) through the umbilicus. The paucity of intra-abdominal working space in large ovarian cysts poses a technical challenge. Moreover, difficult convergence of operating instruments and competition for operating space outside the abdomen during the SILS makes the procedure quite demanding, especially with the conventional instruments. The concept of providing traction by taking sutures from the abdominal wall, as done in SILS laparoscopic cholecystectomy, was applied for SILS cystectomy in large ovarian cysts. Two sutures taken through the abdominal wall and then through the cyst wall provide excellent traction and "hang" the cyst from the abdominal wall, making it convenient to dissect and operate. This technique demonstrates that SILS ovarian cystectomy is feasible, safe and technically unchallenging even in large benign ovarian cysts.     

Simple technique for proper approximation and closure of peritoneal and rectus sheath defects at port site after laparoscopic surgery.

Complex intra-abdominal surgical procedures can now be performed with laparoscopy, and laparoscopic cholecystectomy has become the gold standard in the care of patients with cholelithiasis. This and other surgically challenging procedures involve use of multiple large (10-mm-15-mm) ports. A standard laparoscopic cholecystectomy employs two 10-mm trocar incisions. Development of incisional hernia from these port sites is well recognized unless the rectus sheath is closed properly. This makes proper closure of the incisions for larger ports critical, especially 10-mm to 15-mm ports. However, securing abdominal wall bleeding and closing facial defects through a small incision can be a cumbersome task. We have developed a simple technique using the regular curved needle and sutures for closure of rectus sheath defects through a small port-site incision.     

Open abdomen management of intra-abdominal sepsis

Despite surgical advances, antimicrobial therapy, and intensive care, the morbidity and mortality of intra-abdominal sepsis remains high. The primary purpose of this study was to determine whether open abdomen management of intra-abdominal sepsis reduces intensive care unit (ICU) and hospital mortality. The records of 81 consecutive patients with open abdomen management for intra-abdominal sepsis admitted to the surgical ICU from January 1998 to April 2002 were retrospectively reviewed. Outcomes were compared to a historical control group with primary abdominal closure, also admitted to the surgical ICU with intra-abdominal sepsis and matched for sex, age, source of sepsis, and APACHE III score. ICU mortality for the open abdomen group was 25 per cent versus 17 per cent for the control group. Hospital mortality was 33 per cent and 25 per cent for the open abdomen patients and historical controls, respectively. Both ICU and hospital length of stay were significantly longer for the open abdomen group. An overall fistula rate of 14.8 per cent was demonstrated in the open abdomen patients. A significant difference in overall ICU and hospital mortality was not demonstrated between patients treated with open abdomen management and historical controls. A prospective randomized study accounting for extent of sepsis may define a role for open abdomen management in selected subgroups of patients.     

Abdominal wall reconstruction after open management of the septic abdomen

The increasing popularity of open management of the septic abdomen has generated a challenge that the surgeon is forced to face more frequently. The typical presentation is that of a patient with a full-thickness abdominal wall defect occurring after a protracted, severe illness. The various methods of reconstruction of the abdominal wall are reviewed and evaluated. The reconstruction should only be attempted once intra-abdominal sepsis is controlled, re-exploration of the peritoneal cavity is no longer necessary and organ support is discontinued. Although various methods of reconstruction are described, the recommended technique consists of either medial advancement of the rectus abdominis muscle or direct application of split-thickness skin grafts. Mid-line abdominal defects may also be repaired with tensor fasciae latae or rectus femoris flaps.     

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腹腔开放是损伤控制外科的重要组成部分,不但用于腹部外伤和感染等普外科疾病的救治,也用于救治烧伤或液体复苏过程中产生的腹腔高压。腹腔开放包括两大要素:开放腹腔和暂时性腹腔关闭,二者缺一不可。开放腹腔的主要目的是降低腹内压,暂时性腹腔关闭技术能够保护腹内脏器、引流腹腔液体,减少或避免腹壁回缩和并发症的发生。暂时性腹腔关闭方法分三类,分别为关闭皮肤法,关闭筋膜法和负压辅助关腹法。关闭皮肤法简单方便,但后期修复腹壁困难较大。负压辅助关腹技术并发症少,早期确定性腹腔关闭成功率高,应用越来越广泛。     

Outcome of reconstructive surgery for intestinal fistula in the open abdomen

OBJECTIVE: To determine factors which influence the outcome of surgical techniques to close enterocutaneous fistulas within the open abdomen. SUMMARY BACKGROUND DATA: Enterocutaneous fistulation within an open abdominal wound is associated with considerable morbidity and mortality. The factors that influence the outcome of reconstructive surgery are unclear. METHODS: Sixty-one patients undergoing 63 operations to close enterocutaneous fistulas associated with open abdominal wounds were referred to a national center for further management. Once sepsis had been eradicated, nutritional status restored and local conditions in the abdomen judged to be suitable, fistulas were resected and the abdominal wall reconstructed by suture repair with and without component separation, or by suture repair in combination with absorbable or nonabsorbable prosthetic mesh. Patients were followed up for 16 to 84 months postoperatively. RESULTS: There were 3 postoperative deaths (4.8%). Major complications, including postoperative respiratory and surgical site infection occurred in 52 of 63 (82.5%) procedures. Refistulation occurred in 7 cases (11.1%) but was more common when the abdominal wall was reconstructed with prosthetic mesh (7 of 29, 24.1%) than with sutures (0 of 34, 0%). Porcine collagen mesh was associated with a particularly high rate of refistulation (5 of 12, 41.7%). CONCLUSIONS: Simultaneous reconstruction of the intestinal tract and abdominal wall remains associated with a high complication rate, justifying the management of such patients in specialized units. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation and should be avoided if possible.     

Percutaneous endoscopic gastrostomy in patients with an open abdomen

Percutaneous endoscopic gastrostomy is a commonly performed procedure for enteral access. In the past decade surgeons have used the open abdomen technique with increased frequency for the treatment of intra-abdominal compartment syndrome. Because these patients often have associated malnutrition long-term enteral access is complicated by the massive ventral hernia. We reviewed the records of two patients with an open abdomen who needed long-term enteral access. Both patients had a large midabdominal soft tissue defect, which posed a concern about the technique for gastrostomy creation. Both patients underwent percutaneous endoscopic gastrostomy. In each case the entrance site was located on a portion of intact abdominal wall lateral to the open abdomen tissue defect. No intraoperative or postoperative complications were noted. We conclude that percutaneous endoscopic gastrostomy can be safely performed in patients with an open abdomen. Adherence to standard principles of performing percutaneous endoscopic gastrostomy allows for enteral access in these patients.     

Open treatment of postoperative peritonitis

Results of using the open method of treatment of postoperative peritonitis in 26 patients are presented. Relaparotomy technique is described when "open abdomen" was used as a typical operation irrespective of causes of progressing peritonitis. In addition to surgical measures the authors stress the importance of intensive therapy. In relation with the character of postoperative peritonitis the abdominal cavity was closed by primary-delayed or secondary sutures on the 5-12th day. Lethality after using the open method of treatment of postoperative peritonitis was 30.7%.     

Abdominal compartment syndrome as a consequence of rectus sheath hematoma

Abdominal compartment syndrome is a well-documented entity arising from multiple and various causes. The rise of intra-abdominal pressure by the increase in volume of the peritoneal and retroperitoneal contents has been shown in the resuscitation and evaluation of surgical patients. However, the incidence of constriction of the abdomen causing intra-abdominal hypertension is unknown. Previously limited to burn eschar and externally applied devices (such as MAST trousers), external compression leading to abdominal compartment syndrome has been a limited entity. We report the first documented case of an expansive abdominal wall mass, a rectus sheath hematoma, leading to impending abdominal compartment syndrome.     

Use of a non-cross-linked porcine dermal scaffold in abdominal wall reconstruction

Background

Reconstruction of complex abdominal wall defects is challenging. The use of prosthetic mesh can be associated with surgical site infection, fistula formation, and adhesions. This study presents our experience using a non-cross-linked porcine dermal scaffold (NCPDS) in abdominal wall reconstruction.

Methods

Patients undergoing abdominal wall reconstruction with NCPDS between May 2006 and January 2008 underwent a retrospective chart review. Demographics, indications for NCPDS placement, surgical technique, complications, and follow-up data were evaluated.

Results

Sixteen patients were identified in whom NCPDS was implanted into complex abdominal wall defects. These included 13 planned and 3 emergency surgeries. Indications for surgery included delayed reconstruction of giant ventral hernia secondary to decompressive laparotomy and open management of abdominal trauma, recurrence of large incisional hernia, temporary coverage of open abdomen secondary to intra-abdominal catastrophes, and open abdominal closure owing to compartment syndrome secondary to necrotizing fasciitis. In all, NCPDS was positioned in a subfascial underlay technique. Forty-four percent required a combination of components separation and NCPDS insertion. At a mean follow-up period of 16.5 months, the majority had desirable outcomes. Complications included seroma (21%), superficial wound dehiscence (7%), recurrence (7%), and infection (7%). Two patients died from multiorgan failure unrelated to NCPDS placement. The material only had to be removed in 1 patient because of wound infection and superficial wound dehiscence.

Conclusions

NCPDS seems to be a safe and effective alternative to prosthetic mesh in the reconstruction of complicated abdominal wall defects.     

Pathophysiology and clinical significance of the abdominal compartment syndrome

Different causes, for example posttraumatic and postoperative complications, can lead to an elevated intra-abdominal pressure. Increased intraabdominal pressure effects cardiovascular, pulmonary and renal systems. The abdominal compartment syndrome can be defined as organ failure caused by an increased intra-abdominal pressure. Clinically the syndrome is characterised by a tensely distended abdomen, oliguria or anuria and/or inadequate ventilation. Early decompression by simple laparotomy and delayed closure is the treatment of choice. If untreated the abdominal compartment syndrome is lethal. Even treated it has a high morbidity and mortality as shown in our series where 2 out of 7 patients with this syndrome died despite surgical decompression.     

Serial abdominal closure technique (the "SAC" procedure): a novel method for delayed closure of the abdominal wall

Abdominal compartment syndrome may occur after any elective or emergent abdominal operations that are complicated by postoperative hemorrhage or in the trauma patient who has massive fluid replacement for intra-abdominal bleeding. Once the abdomen is decompressed the type of closure varies as much as the surgeon performing the procedure. We have devised a simple, reproducible, inexpensive, and safe method to close the abdomen at the bedside. Serial abdominal closure (SAC) was performed on three patients 45, 54, and 14 years of age who had developed abdominal compartment syndrome secondary to an upper gastrointestinal bleed requiring massive transfusion, a tear of the superior mesenteric vein, and a grade 4 liver laceration respectively, all necessitating abdominal decompression. All three patients had their abdominal wounds closed at the bedside over the course of several days with our SAC technique. Subsequent postoperative course was uneventful and the abdominal wall was free of defects at one-year follow-up. SAC is an efficient, inexpensive, and easily reproducible method of managing the open abdomen. The use of SAC prevented abdominal closure-related complications such as enteric fistula and hernia formation in our three patients.     

Surgical approach to the intraabdominal infections

AIM: The term intraabdominal infectioncomprises a broad of variety of pathological conditions which are characterized by signs of systemic infection as a response to an abdominal source of infection and ranges from a confined problem to a devastating disease regarding all organ systems. Septic abdomen is an interesting challenge in general surgery: to decide when and how to treat septic abdomen lacks of a general consensus and has not been standardized yet. METHODS: A total of 1 110 patients underwent surgical treatment for abdominal infection in a period of 10 years in the Department of Surgery of San Gerardo Hospital, Monza, Italy. We focused our attention on 94 patients who required re-exploration for residual or recurrent intra-abdominal infection. RESULTS: The procedure was associated with a mortality rate of 40%. The median number of re-explorations was 5.1. CONCLUSION: Planned multiple relaparotomies with temporarily abdomen closure are performed only in a selected high mortality risk group of elderly patients with surgical evidence of diffuse peritonitis, presence of primary infectious process of more than 72 hours, and a APACHE II score > 20. Relaparotomy on demand is required instead in those patients who develop a clinical deterioration after a first safe surgical control of the source of infection. Lack of improvement is not considered a condition to reoperate. Early detection of persisting infection, < 24-36 hours, is an important prognostic factor of outcome.     

Use of double-layer autologous dermal flap in the treatment of recurrent and/or infected incisional hernias: presentation of the surgical technique and the results of 1-year follow-up—a prospective,consecutive cohort study

Introduction

The difficulties of treating recurrent and/or infected incisional hernias are well known in surgical practice. Several surgical techniques and various types of grafts are available for surgeons. This study presents a new surgical technique option together with the results of the 1-year follow-up.

Purpose

The primary aim of the study is to present the surgical technique of the procedure suitable for the treatment of recurrent and/or infected incisional hernias. The secondary aim is to determine the recurrence rate and analyse the surgical complications. The tertiary aim is to present the quality of life test results performed 3, 6 and 12 months after the surgery.

Patients and method

The authors evaluated the results of 36 recurrent and/or infected incisional hernia surgeries (11 men, average age 60.6 years; 25 women, average age 58.9 years) performed with their own surgical method in the framework of a tightly controlled, prospective, interventional and observational consecutive cohort study conducted between 1 January 2011 and 31 December 2013 at a university surgical department. The study evaluates the results of the 1-year follow-up period. All 36 patients had at least one recurrence of abdominal wall hernia; 12 of them also had concurrent infection of the synthetic graft and a complicating fistula. The mean BMI was 31.82 kg/m² (25.2–43.5 kg/m²). The average size of the abdominal wall defect was 145.9 cm² (59–275 cm²). The abdominal wall reconstruction was performed using an autologous, double-layer dermal flap. The grafts, which had been inserted during previous surgeries, were removed completely. The autologous dermal tissue was prepared using the flap harvested during dermolipectomy. The reconstruction was achieved using a tension-free technique. The essence of the abdominal wall reconstruction is the completion of the abdominal wall defect by a double-layer autologous dermal flap. The original abdominal wall defect was not closed by direct sutures. The quality of the prepared dermal flap was histologically evaluated. IAPMS (intra-abdominal pressure monitoring set) was applied to verify intra-abdominal pressure in the post-operative period. The result of the surgeries was assessed using a quality of life questionnaire.

Results

No recurrence of the abdominal wall hernia was registered during the 1-year follow-up period. Abdominal bulking was observed in case of three patients (8.3 %). Wound infection occurred in one patient (2.77 %) and skin dehiscence in two patients (5.55 %). Haematoma was registered in case of one patient (2.77 %) on the fifth post-operative day. Seroma formation occurred in case of eight patients (22.22 %), which required percutaneous tapping. A fistula formation was observed in one patient (2.77 %) 45 days after the surgery. The intra-abdominal pressure remained moderately elevated during the early post-operative period (9.65–5.76 mmHg on post-operative days 1 and 5). Reoperation was performed in one case due to haematoma. No fatality occurred.

Conclusions

The 1-year recurrence rate in case of the abdominal wall reconstruction using double-layer autologous dermal flap is favourable. Being compliant with the surgical technique developed, the procedure is safe to perform. The number of surgical site infections and fistula formations is low. Based on the questionnaires evaluated, all patients would choose this method instead of the previous reconstruction(s). The method is cost-effective. Based on the results, this procedure is feasible for the treatment of recurrent and/or infected abdominal wall, incisional ventral hernias in obese “high risk” patients.

     

Use of controlled fascial tension and an adhesion preventing barrier to achieve delayed primary fascial closure in patients managed with an open abdomen

Open management of the abdomen has become an accepted technique for both the treatment and the prevention of abdominal compartment syndrome. It has also gained popularity as a treatment option in situations requiring multiple laparotomies such as uncontrolled intra-abdominal infections and severe abdominal injury necessitating damage control surgery. A significant number of patients managed with the open abdomen technique are unable to undergo complete abdominal wall closure and consequently develop large, complex anterior abdominal wall hernias. We report the use of a controlled fascial tensioning device, the Wittmann Patch (Starsurgical, Inc, Burlington, WI), in combination with an adhesion preventing barrier to allow for unhindered sequential medial advancement of the fascia toward the midline. The use of these 2 devices together may lead to a higher incidence of fascia-to-fascia abdominal wall closure than the use of fascial tension alone.     

Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction—A Novel Technique for Late Closure of the Open Abdomen

Background Open abdomen (OA) treatment often results in difficulties in closing the abdomen. Highest closure rates are seen with the vacuum-assisted wound closure (VAWC) technique. However, we have experienced occasional failures with this technique in cases with severe visceral swelling needing longer treatment periods with open abdomen. Feasibility and short-term outcome of a novel combination of techniques for managing the open abdomen are presented. Methods The VAWC technique was combined with medial traction of the fasciae through a temporary mesh in seven consecutive patients. The VAWC-system was changed and the mesh tightened every 2–3 days. Results Median (range) age in the 7 men was 65 (17–78) years. The diagnoses were ruptured abdominal aortic aneurysm (AAA) (3), operation for juxtarenal AAA (1), iatrogenic aortic lesion (1), trauma (1) and abdominal abscesses (1). Four patients were decompressed due to abdominal compartment syndrome (ACS) or intra-abdominal hypertension, and 3 could not be closed after laparotomy. Intra-abdominal pressure prior to OA treatment was 24 (17–36) mmHg. Maximal separation of the fasciae was 16 (7 –30) cm. Delayed primary closure was achieved in all patients after 32 (12–52) days with OA. No recurrent ACS was seen. No technique-specific complication was observed. Two small incisional hernias, one intra-abdominal abscess and one wound infection occurred in three patients. Conclusions Delayed primary closure in cases with severe visceral swelling and long periods of OA seems feasible with this technique.