Temporary closure of the abdominal wall (laparostomy)

The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favorable in the treatment of numerous surgical conditions, e.g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed, and a laparostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Regarding the technique and material used for the temporary closure, no prospective randomized data exists, but mesh materials are commonly used. They provide drainage of infectious material, permit visual control of the underlying viscera, facilitate access to the abdominal wall, preserve the fascial margin, enable healing by secondary intention, and allow mobilization of the patient. In the case of decreasing intra-abdominal pressure, meshes can be trimmed to centralize the rectus muscle and to facilitate definitive closure. Non-absorbable meshes have been frequently reported to cause enteric fistulae and persistent infection necessitating mesh explantation. While these infectious complications appear to occur less frequently with the use of absorbable materials, these meshes will finally lead to an incisional hernia, requiring repair with non-absorbable mesh after a period of 6–12 months. Nevertheless, in the complex situation requiring a temporary abdominal wall closure, use of absorbable mesh material is common and represents the state of the art. Electronic Publication     

Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature

Background. The underlying risk associated with visceral mesh erosion is the close opposition of adjacent intestines to the prosthetic graft. This highly morbid condition has been described with most types and techniques of abdominal wall mesh repair. Patient. We report the case of a 52-year-old man who presented with an entero-colocutaneous fistula 10 years after prosthetic mesh repair of an incisional hernia. The fistula was excised and the abdominal wall defect repaired with a tissue-impervious composite. Conclusions. The use of a tissue-impervious barrier avoids development of enteric fistula when a prosthesis is placed directly over the viscera. Electronic Publication     

Intra abdominal hypertension and the abdominal compartment syndrome

The patho-physiological significance of raised intra-abdominal pressure, known as Intra Abdominal Hypertension, with subsequent organ dysfunction and failure, known as Abdominal Compartment Syndrome, has recently been demonstrated to occur relatively frequently in mixed populations of critically ill patients. Clinical diagnosis is unreliable, so routine measurement of intra abdominal pressure should be undertaken, particularly in specific groups of patients known to be at high risk. Whilst definitive therapy requires surgical abdominal decompression, less invasive therapies have been investigated and, if initiated early, may help to minimise progression of the condition. Clearly defined indications for surgical intervention remain elusive however and require prospective investigation. This review summarises the patho-physiology of the syndrome, its diagnosis and surveillance, and current management strategies, both medical and surgical.     

Laparostomy closure in stage 4S neuroblastoma

Laparostomy in children is a rare procedure, and there is little in the literature as to the best method for closure in children with an open abdomen. We describe 2 cases with stage 4S neuroblastoma that required emergency decompressive laparostomy. Both cases highlight advantages and disadvantages with known techniques for achieving skin and fascia closure. We believe this to be the first report of a combination of extracellular matrix mesh and vacuum therapy for successful fascial and skin closure in stage 4S neuroblastoma.     

Intra‐abdominal vacuum‐assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by ‘open’ or ‘close’ abdomen management. We recently introduced the use of intra‐abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.     

Open Abdomen after Severe Acute Pancreatitis

Abstract The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2–3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9–12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.     

The use of the Flexi-Seal? Faecal Management System in laparostomy wounds involving enterocutaneous fistula

We present an innovative application of the Flexi-Seal^® Faecal Management System (FMS) for the diversion of upper and lower gastrointestinal secretions from enterocutaneous fistulae associated with complex wounds. Fistula is a common complication after the formation of a laparostomy, secondary to cases of severe intra-abdominal sepsis, acute mesenteric ischaemia, necrotising infection of the abdominal wall, or intra-abdominal hypertension. A significant mortality rate is associated with such fistula. With the successful continent diversion of gastrointestinal secretions by the Flexi-Seal^® FMS, abdominal wounds can be successfully skin-grafted, and wound healing expedited.     

Comparative study of the microvascular blood flow in the intestinal wall during conventional negative pressure wound therapy and negative pressure wound therapy using paraffin gauze over the intestines in laparostomy

Higher closure rates of the open abdomen have been reported with negative pressure wound therapy (NPWT) than with other kinds of wound management. We have recently shown that NPWT decreases the blood flow in the intestinal wall, and that the blood flow could be restored by inserting a protective disc over the intestines. The aim of the present study was to investigate whether layers of Jelonet? (Smith & Nephew) dressing (paraffin tulle gras dressing made from open weave gauze) over the intestines could protect the intestines from hypoperfusion. Midline incisions were made in ten pigs and were subjected to treatment with NPWT with and without four layers of Jelonet over the intestines. The microvascular blood flow was measured in the intestinal wall before and after the application of topical negative pressures of ?50, ?70 and ?120 mmHg, using laser Doppler velocimetry. Baseline blood flow was defined as 100% in all settings. The blood flow was significantly reduced, to 61 ± 7% (P < 0·001), after the application of ?50 mmHg using conventional NPWT, and to 62 ± 7% (P < 0·001) after the application of ?50 mmHg with Jelonet dressings between the dressing and the intestines. The blood flow was significantly reduced, to 38 ± 5% (P < 0·001), after the application of ?70 mmHg, and to 42 ± 6% (P < 0·001) after the application of ?70 mmHg with Jelonet dressings. The blood flow was significantly reduced, to 34 ± 9% (P < 0·001), after the application of ?120 mmHg, and to 38 ± 6% (P < 0·001) after the application of ?120 mmHg with Jelonet dressings. The use of four layers of Jelonet over the intestines during NPWT did not prevent a decrease in microvascular blood flow in the intestinal wall.     

Omental patch reinforced with polypropylene mesh and split-thickness skin grafting: A new procedure to close the “open abdomen”

IntroductionThe “open abdomen” expression widely used to define a full-thickness defect of the abdominal wall intentionally made in some situations like abdominal compartment syndrome, has been replaced by a newest one called “laparostomy”. The definitive closure of an open abdomen with a giant full abdominal thickness defect remains a problem.Case reportWe present a 67-year old male with a descompressive laparostomy treated with a greater omentum flap sutured hermetically with interrupted stitches at the edges of the muscle wall, reinforced with large mesh of polypropylene (PP) placed on-lay and sutured to the fascia by two concentric running sutures of polypropylene. A vacuum-assisted closure device was placed on the second postoperative day and it was kept during three weeks. By then the PP mesh was completely integrated so skin grafts were applied to the surface of the granulation tissue. An incisional hernia was easily repaired at three years of follow-up. Eight months after the last surgery the patient is satisfied with the result achieved.DiscussionThe great omentum has immunological and angiogenic properties that allow a rapid integration of the polypropylene mesh, even in septic environments, facilitating the engraftment of split-thickness skin graft.The reactive fibrosis caused by the PP mesh replaces the fat tissue but the inner surface is preserved, thereby avoiding subsequent adhesion and facilitates surgical access to the abdominal cavity if necessary in the future.ConclusionThe structure achieved is a strong structure, capable of visceral isolation that can be useful to close some OA.