Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen

BACKGROUND: Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS: The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS: During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS: Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.     

Novel technique of temporary abdominal closure with continuous medial fascial traction dynamic for patients with open abdomen

Open abdomen has been an effective treatment for abdominal catastrophes in trauma and general surgery, is one of the greatest advances in recent decades and has become a common procedure in both trauma and general surgery. Temporary abdominal closure techniques in managing open abdomen help to achieve many benefits without incurring many complications. We present a series of patients in which a temporary abdominal closure technique was used that generates continuous medial fascial traction dynamic in patients with open abdomen for different causes.     

One hundred percent fascial approximation with sequential abdominal closure of the open abdomen

BACKGROUND: Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure. METHODS: After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect. RESULTS: Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was 7.5 +/- 1.0 days (range 4-16) and average number of laparotomies to closure was 4.6 +/- 0.5 (range 3-8). All patients attained primary fascial closure. CONCLUSION: We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen.     

Early aggressive closure of the open abdomen

BACKGROUND: The aim of this series is to describe a new and aggressive approach to definitive closure of the open abdomen. METHODS: A retrospective review of 37 patients who underwent definitive abdominal closure using a combination of vacuum pack, vacuum-assisted wound management and human acellular dermal matrix (HADM). RESULTS: All patients' open abdomens were maintained with vacuum assisted wound management in attempts for primary closure. Once it was determined that the abdomen would not close primarily; it was closed with HADM and skin advancement. The mean duration of the open abdomen was 21.7 days (range 6-45), with an average of 127.78 cm of HADM, the largest number being 800 cm, with decreasing use of product later in the series. No major complications were seen with the repair. Superficial wound infection occurred with two patients that were easily treated with wet to dry dressing changes. No intraabdominal complications such as fistula or graft loss were seen. All patients left the hospital with an intact abdominal wall and skin. All 37 patients survived to discharge and were seen in follow-up within one month. No early hernia formation was seen at the one month follow up with the longest at three years. No abdominal wall complications were seen in subsequent follow up patients. CONCLUSIONS: Early aggressive closure of the open abdomen is possible with a combination of vacuum pack, vacuum-assisted wound management and HADM. Short term results are promising and warrant further study.     

Managing the open abdomen: negative pressure closure versus mesh-mediated fascial traction closure: a randomized trial

Purpose

To compare the effectiveness of abdominal wall closure using the vacuum-assisted closure (NPC) as described by Barker et al. with an institutional protocol using a double polyvinyl bag in the first surgery, which is changed in subsequent surgeries to a polyvinyl bag placed over the bowel loops and a prolene mesh attached to the abdominal fascia (MMFC).

Methods

Randomized controlled trial. Patients with open abdomen (OA) due to a traumatic or a medical cause were included in the study. Variables studied included demographics, indication for surgery, number of interventions, hospital length of stay (HLOS), ICU length of stay, abdominal wound care costs, complication rates, and method and time to definitive fascial closure.

Results

From June 2011 to April 2013, 75 patients were enrolled in the study. Patients who died within 48 h were excluded; therefore, 53 patients in total were assessed. NPC achieved fascial closure in 75 % of patients, and MMFC achieved closure in 71.9 % of patients. The closure rates in patients with OA secondary to medical causes (80 % by NPC vs. 71.4 % by MMFC) or traumatic causes (70 % by NPC vs. 73.7 % by MMFC) were similar in both treatment groups. There were no differences between the groups with respect to cause of OA, complications, length of hospital stay, or the length of stay in the intensive care unit.

Conclusion

MMFC is a method comparable to NPC for the temporary management of OA that results in similar closure and complication rates.

     

Analysis of medical risk factors and outcomes in patients undergoing open versus endovascular abdominal aortic aneurysm repair

OBJECTIVE: The emergence of endovascular repair (ER) for infrarenal abdominal aortic aneurysm (AAA) has provided surgeons with a new technique that should ideally improve patient outcomes. To more accurately characterize the advantages of ER versus traditional/open AAA repair (TOR), we compared the preoperative medical risk factors (PMRFs) and perioperative outcomes (PO) of those patients undergoing elective treatment of infrarenal AAA with ER and TOR over a recent 18-month period at our center. METHODS: Through our institutional vascular surgery patient registry, all patients undergoing aortic aneurysm repair of any type between December 1999 and June 2001 were identified. Only those patients undergoing elective infrarenal AAA repair were analyzed. Hospital records were examined for all patients, and PMRF and PO were assessed via Society for Vascular Surgery/International Society for Cardiovascular Surgery reporting guidelines. Student t, chi(2), Fisher exact, or Wilcoxon rank sum tests were applied where appropriate to determine differences among PMRF and PO according to method of aneurysm repair. RESULTS: During the 18-month study period, a total of 199 aortic aneurysms were repaired at our institution. Ninety-nine elective infrarenal AAA repairs made up the study cohort (ER, n = 33; TOR, n = 66). When examined by method of aneurysm repair, no differences existed in demographics or AAA size. Patients undergoing ER had a significantly greater degree of preoperative pulmonary comorbidity than patients undergoing TOR (P <.001). However, no differences existed in terms of American Society of Anesthesiologists classification or cardiac (P =.52), cerebrovascular (P =.44), diabetic (P =.51), hypertensive (P =.90), hyperlipidemia (P =.91) or renal (P =.23) comorbidities between the two groups. Perioperative morbidity and mortality rates were also not significantly different by method of repair. ER was associated with shorter operative time, intensive care unit stay, and overall hospital length of stay (P <.0001). However, subsequent operative procedures related to the AAA repair were performed more frequently after ER (TOR = 1.5% versus ER = 15.2%; P = 0.015). CONCLUSION: These results suggest that ER offers improvements in hospital convalescent and operating room times but no beneficial impact on overall morbidity and mortality rates when similar PMRFs exist, especially when used at medical centers where low morbidity and mortality rates are already established for TOR. Other centers performing ER should undertake such an analysis to assess its impact on their patients.     

Problems with definitive abdominal closure using "zipper" and after "left open abdomen"

There are many problems associated with definitive closure of "left open abdomen" and abdominal zip. If the assumption can be made that after an operation multiple lavages will be necessary, we recommend a transverse laparotomy because there is much less retraction of the abdominal wall than with longitudinal laparotomy. Definitive closure with split-skin is inadequate as the missing elasticity especially with underlying small intestine loops leads to tearing, besides the mechanical properties of a thiersch as replacement for the abdominal wall is bad. Should the intra-abdominal infection have affected the abdominal wall itself, the implantation of an abdominal zip is useless as it tears away in a short time. Primary laparostoma is then the therapy of choice. The earlier definitive closure is planned, the easier this can be done. Prognosis does not depend on the way of temporary closure but on underlying pathology and on the possibility of resolving problems in adequate time.     

The open abdomen and temporary abdominal closure systems – historical evolution and systematic review

Aim Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication. Method Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end‐points included delayed fascial closure and in‐hospital mortality. The secondary end‐points were intra‐abdominal complications. Results The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%). Conclusion Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.     

腹腔镜胆囊切除术与开腹胆囊切除术免疫功能的比较

胆囊结石病人40例，择期手术分别行腹腔镜胆囊切除术（LC）和开腹胆囊切除术（LC）各20例。测定手术前后血清白细胞介素-6（I－6），C-反应蛋白及外周血T淋巴细胞亚群改变，比较二种不同胆囊切除手术方式的手术创伤程度对机体免疫功能的影响。结果OC组术后12、24及48小时血清IL－6和CRP含量分别高于LC组（P＜0．05）。两组术后24小时CD4、CD4及CD4／CD8百分率有显著差异（P<0.05），72小时CD4、CD8及CD4／CD8比值相近（P＞0.05）。两组平均手术时间和切口长度有显著差异（P<0．05）。结果表明，OC手术创伤大，术后免疫功能改变明显，LC切口小，平均手术时间短是术后血清IL－6和CRP含量低及外周血T淋巴细胞亚群无明显改变的主要原因。     

Management of open abdomen with an absorbable mesh closure

Purpose  

To examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used.     

Delayed primary closure of the septic open abdomen with a dynamic closure system

Background  

The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall.     

Managing the open abdomen with vacuum-assisted closure therapy: retrospective evaluation of 22 patients

BACKGROUND: The authors reviewed their experience in the management of "open abdomen" using the vacuum-assisted closure device (VAC), in order to assess its morbidity particularly in terms of fistula, and the outcome of abdominal wall integrity. METHODS: Between January 2003 and October 2006, 22 patients required management with an "open abdomen" technique (18 patients were managed with the VAC abdominal dressing device with application of a specific sheet and 4 other patients simply required a dressing with the polyurethane sponge). The mean age was 55 years, and M/F sex ratio was 2.67. Indications were abdominal compartment syndrome in 7 patients, initial "abdominal closure" after trauma in one patient, severe abdominal sepsis in 7 patients, and abdominal wound dehiscence where closure was impossible in 7 patients. RESULTS: There were no enteric fistulae. Two infections were seen--a chronic suppuration which resolved with antibiotic therapy and a deep abscess which was drained with radiologic guidance. Of the 18 cases of "open abdomen" managed with the VAC, 15 were alive. Six (40%) underwent a delayed primary closure at a mean interval of 9 days; the others underwent secondary healing by granulation, and 10 eventually underwent split thickness skin grafting at a mean interval of 50 days. With VAC closure of the "open abdomen", the development of ventral hernia is an anticipated outcome; in four cases, patients underwent abdominal wall reconstruction at an interval of one year. CONCLUSION: Laparostomy or "open abdomen" using the VAC dressing system should be considered an established and well-defined technique which provides temporary abdominal coverage with limited morbidity.