Skin only or silo closure in the critically ill patient with an open abdomen

Fechamento de laparostomia com descolamento cutâneo-adiposo: uma técnica simples e eficaz para um problema complexo

OBJETIVO: Descrever uma técnica de fechamento de laparostomia através de descolamento cutâneo-adiposo e os resultados obtidos. MÉTODOS: Entre janeiro de 2003 a outubro de 2008 quarenta pacientes laparostomizados com silo plástico (bolsa de Bogotá) foram fechados usando-se a técnica descrita neste trabalho. Dados foram coletados dos prontuários e da busca ativa após alta hospitalar. RESULTADOS: A maioria dos pacientes eram homens (95%), com trauma por arma de fogo (70%). As médias de ISS e APACHE II foram de 28,78 e 20, respectivamente. Hérnia ventral ocorreu em 81,5% dos pacientes, num intervalo médio de seguimento de 9,2 meses. Aproximadamente 1/3 dos pacientes apresentavam hérnias pequenas e não desejavam corrigi-las quando questionados. Somente dois pacientes estavam insatisfeitos com o procedimento em relação a atividades cotidianas e aspectos estéticos. Não houve óbitos ou fístulas intestinais em decorrência do fechamento. CONCLUSÃO: Embora não represente uma técnica de fechamento mioaponeurótico, o descolamento cutâneo-adiposo é simples, seguro e de baixo custo. É uma boa opção terapêutica para os pacientes laparostomizados, principalmente quando o fechamento da aponeurose não for possível nos primeiros 7 a 10 dias.

Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial

BACKGROUND

Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We hypothesized that a modification of the vacuum-assisted closure (VAC) technique that provides constant fascial tension and prevents abdominis rectis retraction would facilitate primary fascial closure and reduce morbidity.

METHODS

In all, 53 patients with severe abdominal sepsis were allocated randomly into 2 groups, and 30 patients were analyzed. In the VAC group, we included patients managed only with the VAC device, whereas the retentions sutured sequential fascial closure (RSSFC) group included patients to whom RSSFC was performed.

RESULTS

The abdomen was left open for 12 days (P = .0001) with 4.4 ± 1.35 changes per patient for the VAC group (P = .001) and 8 days with 2.87 ± 0.74 dressing changes per patient for the RSSFC group, respectively. Abdominal closure was possible in only 6 patients in the VAC group, whereas for the RSSFC group, abdominal closure was achieved in 14 patients (P = .005). Planned hernia was exclusively decided in patients in the VAC group (P = .001). The hospital stay was 17.53 ± 4.59 days for the VAC group and 11.93 ± 2.05 days for the RSSFC group (P = .0001). The median initial intra-abdominal pressure (IAP) was 12 mm Hg for the VAC group and 16 mm Hg for the RSSFC group (P < .0001).

CONCLUSION

We demonstrated the superiority of RSSFC compared with the single use of the VAC device. In our opinion, sequential fascial closure can immediately begin when abdominal sepsis is controlled.

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.

Modern management of complex open abdominal wounds of war: a 5-year experience

BACKGROUND

Optimal management of the open abdomen remains controversial.

STUDY DESIGN

Retrospective review of patients injured during Operations Enduring Freedom and Iraqi Freedom returning to Walter Reed Army Medical Center (WRAMC) from January 2003 to October 2007 for treatment of open abdomen.

RESULTS

Three hundred fifty-four patients were evacuated to WRAMC after laparotomy, including 86 patients (24%) with open abdomen. Three transferred patients were excluded. Eighty-three patients, mean age 26 years (range 18 to 54 years), sustaining injury from secondary blast (n = 47), gunshot (n = 29), and blunt trauma (n = 7) were studied. Surgical management included early definitive abdominal closure (EDAC, n = 56; 67%), primary fascial closure (n = 15; 18%), planned ventral hernia (PVH, n = 9; 11%) and vacuum-assisted closure with AlloDerm (n = 3; 4%). EDAC closure involves serial closure with Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh (62%) or AlloDerm (31%). There was no substantial difference in injury mechanism, age, length of evacuation to WRAMC, or Injury Severity Score (average 30) according to closure type. Complications included removal of infected prosthetic mesh in 4 EDAC closure patients (5%). Overall morbidity was lowest (60%) in primary repair patients (p = 0.01). Rates of deep venous thrombosis, pulmonary embolism, abdominal wall hematoma, and infection did not differ between groups. Fistula rate was increased with PVH (20%). Two patients with PVH died. PVH and EDAC mesh complications have been minimized in the last 2 years of the study.

CONCLUSIONS

Primary closure of fascia is ideal but not always possible. Early definitive closure has avoided PVH. Mesh-related complications have decreased with time.

Closing the open abdomen: improved success with Wittmann Patch staged abdominal closure

BACKGROUND

Although the "open abdomen" has likely contributed to improved outcomes in trauma patients, the challenge of subsequent fascial closure has emerged. Since mid 2004, we have incorporated Wittmann Patch staged abdominal closure into our management of the open abdomen. The purpose of this study was to evaluate the impact of this device on our incidence of fascial closure versus planned ventral hernia.

METHODS

Patients managed by open abdomen from 2001 through 2006 were identified from the trauma registry. Fascial closure immediately after definitive repair of injuries was defined as "early fascial closure." Continuation of the open abdomen beyond the definitive repair of injuries with subsequent fascial closure was defined as "delayed fascial closure." Since April 2004, the Wittmann Patch was uniformly employed in open abdomen management. Patients managed before the use of this device ("pre-Patch") were compared with those managed in the "Patch" era.

RESULTS

Fifty-six open abdomens were managed in the pre-Patch era and 103 were managed in the Patch era. In the pre-Patch era, 33 (59%) underwent early fascial closure, compared with 67 (65%) in the Patch era (p NS). For the remaining patients, the incidence of delayed fascial closure was significantly higher in those managed with the Wittmann Patch compared with those managed in the pre-Patch era (78% vs. 30%, p < 0.001). Planned ventral hernia was performed in 8 (8%) patients in the Patch era versus 16 (29%) patients in the pre-Patch era (p < 0.001). Abdominal complications were similar between groups (11% vs. 9%, p NS).

CONCLUSIONS

Incorporating the Wittmann Patch into a clinical pathway for management of the open abdomen has contributed to an increased incidence of delayed fascial closure. Abdominal complications were similar in both groups, suggesting that the device is not only efficacious, but also relatively safe.

Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac

BACKGROUND

The ability of biologic mesh to remodel into native fascia and prevent hernia recurrence in complicated repairs is appealing. However, few long-term data exist evaluating these products in the setting of bridging fascial defects. These collagen-based mesh products are costly, and long-term evaluation of hernia recurrence rates are necessary to justify their expense.

METHODS

This was a retrospective review of patients undergoing repair of complex abdominal defects with acellular dermal matrix (ADM) at our institution was performed.

RESULTS

Between January 2004 and December 2005, 11 patients underwent complex ventral hernia repairs with bridging ADM. Indications for repair included resection of enterocutaneous fistula, infected mesh, and/or ventral hernia repair. A mean of 175 cm(2) (range 8 to 456) of ADM were used. Mean follow-up was 24 months (range 18 to 37). One patient died on postoperative day 20. Eight of the 10 (80%) remaining patients had recurrences, and 7 underwent further surgery for repair. One patient reported laxity but refused repair. The total cost of ADM alone for these 11 patients was $61,926; the cost for the 8 patients having recurrences was $40,776; and the total mean cost was $5,100/patient.

CONCLUSIONS

Although bridging fascial defects with ADM can be an appealing substitute in extremely complicated cases, our data demonstrate exceedingly high recurrence rates. The long-term outcome of bridging fascial defects with biologic prosthesis does not justify the expense of the product.

In Vitro Comparison of Intra-Abdominal Hypertension Development After Different Temporary Abdominal Closure Techniques

BACKGROUND

To compare volume reserve capacity (VRC) and development of intra-abdominal hypertension after different in vitro temporary abdominal closure (TAC) techniques.

METHODS

A model of the abdomen was designed. The abdominal wall was simulated with polychloroprene, a synthetic rubber compound. A lentil-shaped defect of 150 cm(2) was cut into the anterior aspect of the abdominal wall. TAC of this defect was performed by a zipper system (ZS), a bag silo closure (BSC), or a vacuum assisted closure (VAC) with subatmospheric pressures ranging from 0- to 200 mmHg. The model with intact abdominal wall served as reference. The model was filled with water to baseline level. The intra-abdominal pressure was increased in 2 mmHg steps from baseline level (6 mmHg) to 40 mmHg by adding volume to the system according to a standardized protocol. VRC with corresponding intra-abdominal pressure were analyzed and compared for the different TAC techniques.

RESULTS

VRC was the highest after BSC at all pressure levels studied (P < 0.05). VAC and ZS resulted in significantly lower VRC compared with BSC and reference (P < 0.05). The magnitude of negative pressure on the VAC did not significantly influence the VRC.

CONCLUSIONS

In the present in vitro model, BSC demonstrated the highest VRC of all evaluated TAC techniques. Different levels of subatmospheric pressures applied to the VAC did not affect VRC. The results for ZS and VAC indicate that these TAC techniques may increase the risk for recurrent intra-abdominal hypertension and should therefore not be used in high-risk patients during the initial phase after abdominal decompression.

Cobertura temporária da cavidade abdominal com curativo a vácuo

OBJETIVO: Descrever técnica de curativo para cobertura temporária da cavidade abdominal que utiliza sistema de vácuo. MÉTODO: A técnica foi aplicada em 12 pacientes. Inicialmente coloca-se sobre a laparostomia a bolsa plástica fenestrada, em seguida a primeira camada de compressas. Sobre esta, coloca-se o tubo de látex. Este é recoberto por outra camada de compressas as quais são fixadas sobre o curativo com o campo cirúrgico auto-aderente. O tubo de látex é conectado ao sistema de vácuo com pressão de -10 a -50 mmHg. Trocam-se os curativos a cada 12 horas. Material utilizado bolsa plástica de solução salina, compressas cirúrgicas, tubo de látex, campo cirúrgico auto-aderente de 50cm x 30cm e vácuo do sistema de gases hospitalares. RESULTADOS:A peritonite grave foi a indicação mais freqüente para laparostomia, seguida da síndrome de compartimento abdominal. Fechamento definitivo da cavidade abdominal foi possível em oito pacientes (67%) em média após 11 dias (9 a 21 dias) da laparostomia. Não houve complicações associadas ao método. O custo diário aproximado do curativo foi de R$ 50,00. CONCLUSÃO: O curativo a vácuo proporcionou boa contenção das vísceras abdominais, controlou o extravasamento de secreções e o edema. Permitiu o fechamento definitivo da cavidade abdominal na maioria dos casos e foi de baixo custo.

Uso da peritoneostomia na sepse abdominal

Dentre as modalidades terapêuticas da sepse abdominal, a peritoneostomia tem papel decisivo permitindo explorações e lavagens da cavidade de forma facilitada. Observamos pacientes com diagnóstico clínico de sepse abdominal internados no Serviço de Coloproctologia do Hospital Universitário da Universidade Federal de Sergipe, e que foram submetidos a peritoneostomia de janeiro de 2004 a janeiro de 2006. Foram avaliados quanto ao diagnóstico primário e secundário, tipo de peritonite secundária, antibioticoterapia, esquema de lavagens, tempo de peritoneostomia, complicações e desfecho. Estudamos 12 pacientes, com idade de 15 a 57, média de 39,3 anos. Diagnóstico primário: abdome agudo inflamatório em 6(50%), abdome agudo obstrutivo em 2(16,7%), abdome agudo perfurativo em 2(16,7%), fístula enterocutânea em 1(8,3%) e abscesso intra-cavitário em 1(8,3%). Diagnóstico secundário: perfuração de cólon em 4(33,3%), abscessos intra-cavitários em 3(25%), deiscências de anastomoses em 3(25%), 1(8,3%) com tumor perfurado de sigmóide e 1(8,3%) com necrose de cólon abaixado. Peritonite fecal em 10(83,3%) e purulenta em 2(16,7%). A antibioticoterapia teve duração média de 19 dias. Lavagens de demanda em 6(50%), programadas em 4(33,3%) e regime misto em 2(16,7%). O tempo médio de peritoneostomia foi de 10,9 dias (1-36). Como complicações: evisceração em 2(16,7%) e fistulização em 1(8,3%). Quatro pacientes evoluíram com óbito.

Bioavailability of Oral Fluconazole in Critically Ill Abdominal Trauma Patients With and Without Abdominal Wall Closure: a Randomized Crossover Clinical Trial

BACKGROUND

Patients with non-apposed fascial edges, known as laparostomy patients, have traditionally been given intravenous medications, because enteral absorption of medications was thought to be unpredictable. We hypothesized that critically ill patients with "open abdomens" would have bioavailability similar to that of matched patients with closed fascial edges.

METHODS

Fluconazole, a commonly prescribed anti-fungal with good bioavailability was used as a marker of absorption. Postoperative abdominal trauma patients were enrolled in a case-control (laparostomy versus closed abdomen) crossover design study to receive either an oral or parenteral fluconazole (400 mg loading dose followed by 200 mg QD) for one week. After a washout period, the alternate route of administration was used for the second week. Blood levels were collected at the end of each week of therapy. Rectal swab stool specimens were cultured for fungi on days 0, 7, and 15.

RESULTS

Sixteen patients were studied. The mean injury severity score was 23 (range 9-41). The bioavailability of enteral fluconazole was 51% +/- 30% in the open abdomen and 63% +/- 19% (p = 0.347) in the closed abdomen patients. There was great variation in the bioavailability between the individual patients, with a range of 30%-100% in both groups. Three patients developed rectal colonization with Candida krusei.

CONCLUSION

The bioavailability of enterally dosed fluconazole was highly variable in both the open and closed abdomen patients. Intravenous administration of pharmaceuticals may provide more reliable serum levels in the first 2 weeks after trauma-related laparotomy.

The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis

BACKGROUND

Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections.

MATERIALS AND METHODS

Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day.

RESULTS

The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group.

CONCLUSION

Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.

Use of the "Bogota bag" for temporary abdominal closure in patients with secondary peritonitis

Various methods may be used for temporary closure of the abdomen. Use of the "Bogota bag" (BB) technique for abdominal closure has been reported primarily in the management of injuries. This review describes our experience using the BB technique in cases of secondary peritonitis. Abdomenal closure using BB was reviewed retrospectively in 152 patients with secondary peritonitis. Of the 152 cases of BB use reviewed, 79 patients had complications of previous abdominal operations, 57 had secondary peritonitis, 14 had complications of abdominal trauma, and 2 were cases of mesenteric events. The BB remained in situ from 1 to 19 days. Changes occurred between 1 and 11 times per patient (mean, 2.8). In nine patients, early diagnosis of leaking of small bowel content under the bag was noted, and 36 patients (24%) died from sepsis. In 12 patients, the resolution of abdominal sepsis permitted secondary closure 10 days later. In 16 patients, mesh repair was performed after 4 weeks. Musculocutaneal flap repair was used in one case, and 13 patients had skin grafts. Eleven patients eventually underwent ventral hernia repair. Early temporary closure of the abdominal wall using BB in patients with abdominal sepsis and planned re-explorations is simple, safe, inexpensive, and effective. This temporary abdominal cover provides good exposure of abdominal content between re-explorations and may prevent fistula formation. The development and subsequent repair of large hernias constitute one of the difficult postoperative problems requiring future solution.

Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions

BACKGROUND

Few good surgical options exist for the repair of complex anterior abdominal wall defects, particularly those in which bacterial contamination is present. The use of prosthetic mesh increases complication rates when the mesh is placed directly over viscera or when the surgical site is contaminated from a pre-existing infection or enteric spillage. The use of an acellular dermal matrix (ADM), which becomes vascularized and remodeled into autologous tissue after implantation, may represent a low-morbidity alternative to prosthetic mesh products in these complex settings. This study examined our experience with ADM in the reconstruction of contaminated abdominal wall defects.

METHODS

Patients undergoing abdominal wall reconstructions in the face of contamination with ADM between May 2002 and December 2005 underwent retrospective chart review. Demographics, indications for ADM placement, plane of implantation, complications, and follow-up data were evaluated.

RESULTS

Sixty-seven patients were identified. The indications for ADM placement included incarcerated hernias, infected mesh, fistulae, early/delayed abdominal wall reconstruction after intra-abdominal catastrophe or trauma, dehiscence/evisceration, and spillage of enteric contents. The ADM was positioned either above the fascia or beneath the fascia or was sutured directly to the fascial edges. Sixteen patients developed a wound infection; the majority of these were superficial and required only local wound care, 5 required some further surgical intervention, and 2 required removal of the ADM. Twelve patients developed recurrent hernias. The mean follow-up time for the study population was 10.6 months.

CONCLUSIONS

ADM can be used safely and effectively as an alternative to traditional mesh products for abdominal wall reconstructions, even in the setting of contaminated fields.

[Abdominal vacuum device with open abdomen]

BACKGROUND

For the treatment of peritonitis or abdominal compartment syndrome, an open abdomen can be required. Because of the high complication rate associated with this method, different technical modifications were developed that are now being applied. Abdominal vacuum-assisted closure is increasingly favoured. We analyse our experience with this device in a distinct group of patients from gastrointestinal cancer surgery.

PATIENTS AND METHOD

From June 2003 to December 2005, 36 patients were treated with 151 double-layer abdominal vacuum devices. Indications for applying this device were peritonitis (n = 22), abdominal compartment syndrome (n = 11), and necrotising fasciitis (n = 3). Thirty-four patients gave anamneses of malignoma.

RESULTS

Overall, the vacuum therapy treatment lasted a median of 13 days (range 3-48). With it, four enteric fistulas (11%) and four abdominal wall bleedings (11%) occurred. In our patient group, no new intra-abdominal abscesses were observed. Four patients died during treatment with the vacuum-assisted device and four afterward because of multiple organ failure in acute sepsis (in-hospital mortality 22%). Twenty-six patients (72%) underwent direct fascial closure after a median treatment duration of 10 days. Six patients (17%) required synthetic mesh for fascial closure. After a median follow-up of 100 days, two patients developed ventral hernias and two others showed ossification of the scar.

CONCLUSION

Compared with other methods of temporary abdominal closure, our experience with the vacuum-assisted device demonstrates its advantages concerning clinical feasibility and the relatively low complication rate. The high rate of direct fascial closure with an acceptable rate of ventral hernias following vacuum-assisted abdominal closure are further benefits of this technique.

[Procedures of temporary wall closure in abdominal trauma and sepsis]

Temporary abdominal closure methods differ mainly between vacuum-assisted and conventional approaches. Each method has its indications. Vacuum-assisted methods seem to be superior especially for trauma indications--in terms of lethality, the possibility of secondary closure during primary hospital stay, and frequency of enterocutaneous fistulas. Skin-only closure might be used as a short-term application (e.g. when damage control closure is needed), and the Bogota bag silo gives space to protruding bowels in pending or manifest abdominal compartment syndrome. Temporary fascial mesh closure enables repetitive laparotomies through the mesh, thus sparing the fascia. For that reason it is to be preferred, especially for its good practicability in clinical situations and on mission abroad.

A new technique in closure of burst abdomen: TI, TIE and TIES incisions

BACKGROUND

Burst abdomen is a continuing problem for the general surgeon as the incidence of such complication may reach 3% with a mortality rate exceeding 25%.

METHODS

New technique: A lateral incision is done from inside the abdomen along a line between the costal margin above to the iliac crest below in the area between the mid and anterior axillary line. According to the depth of the incision, the incision may either involve the transversus abdominus and internal oblique muscles (TI incision), or include in addition the external oblique muscle (TIE incision), or it may also involve the Scarpa's fascia (TIES incision). Such incisions would give an extra length on each side towards medial advancement. Eight patients, 5 men and 3 women aged 34-67 years, with burst abdomen after major gastrointestinal and hepatobiliary surgery failed to close primarily were managed using this technique. Long-term follow-up patients was done for development of complications. Electromyogram (EMG) for the rectus muscle and sensory loss for the abdominal wall were also tested. The distance between the 2 cut edges of the different release incisions was measured clinically (TIES incisions) or using ultrasound device (TI and TIE incisions). Scarpa's fascia biopsy was taken from 1 patient of the TIE group for histopathological study 6 years after surgery.

RESULTS

One patient died on the third postoperative day (mortality 12.5%), and 2 patients developed sub-incisional abscesses (25%). No single case of re-burst occurred. Long-term follow-up showed no single case of incisional hernia in the site of the midline surgical incision, but incisional hernia did occur in all the sites of TIES incisions. Incisional hernia did not occur in the TI incision and, more strangely, neither did it occur in any of the TIE incisions. Follow-up of the incisions width showed a significant increase in width of the TIES with time while there was no significant increase in that of the TI or TIE. There was a sensory loss at and below the level of umbilicus in the TIES group. EMG showed evidence of motor affection to the rectus muscle at and below the level of the umbilicus in all groups. Scarpa's fascia biopsy was taken to try to find an explanation for the absence of incisional hernia in TIE incisions and was found to be 3 times as thick and the type I collagen was replaced by collagen type III.

CONCLUSION

The new method described is simple, straightforward and tension free, with a comparable mortality and morbidity. The Scarpa's fascia adaptation and its ability to change have enormous applications in general and reconstructive surgery, but further evaluation of such phenomenon is needed.

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 definitive abdominal closure using serial closure technique on injured soldiers returning from Afghanistan and Iraq

BACKGROUND

Twenty-nine of 1,284 battle-injured soldiers arriving at Walter Reed Army Medical Center from Operations Enduring Freedom and Iraqi Freedom have abdominal wounds requiring delayed definitive closure with Gore-Tex (WL Gore & Assoc) mesh.

METHODS

Serial abdominal closure (SAC) leading to early definitive abdominal closure (EDAC) was achieved using Gore-Tex mesh. Inpatient records of Operations Enduring Freedom and Iraqi Freedom soldiers with open or reopened abdomens were reviewed from March 2003 to August 2005.

RESULTS

Twenty-nine soldiers, average age 27 years (range 20 to 42 years) injured by secondary blast effects (n = 19); penetrating (n = 8); motor vehicle crashes (n = 1); and crushing injury (n = 1) were included in the study. Patients arrived at Walter Reed Army Medical Center 8 days (range 3 to 56 days) after injury with Gore-Tex mesh placed 6 days (range 0 to 26 days) from arrival and 14 days (range 4 to 79 days) from injury. SAC was achieved with towel clamp tightening or excision of midline mesh and drawing fascia closer to the midline for an average of 46 days (range 15 to 160 days) before EDAC. One patient is undergoing SAC and another was transferred to another facility. EDAC was achieved in 24 of the remaining of 27 patients (89%). Four patients required early removal of the Gore-Tex mesh, resulting in three patients with planned ventral hernia. One patient underwent EDAC with primary closure and fascial release. EDAC was completed with polypropylene mesh in 17 patients and 6 patients had original Gore-Tex in place. Patients were discharged from the hospital an average of 18 days after closure (range 1 to 89 days) with total hospital days of 62 (range 17 to 197 days). Average followup of patients from placement of Gore-Tex mesh is 264 days (range 31 to 855 days).

CONCLUSIONS

SAC with Gore-Tex mesh led to EDAC in 89% of patients and proved to be a safe and effective alternative to planned ventral hernia. SAC allowed protection of abdominal contents, effective fluid management, reclamation of abdominal domain, and early rehabilitation with minimal complications and only one hernia reoccurrence.

MAKING A VIRTUE OF NECESSITY: MANAGING THE OPEN ABDOMEN

BACKGROUND

The open abdomen, or laparostomy, is becoming increasingly used in the management of critically ill surgical patients.

METHODS

The published work on laparostomy is reviewed, in the light of personal experience, with particular attention to the history and pathophysiology associated with laparostomy.

RESULTS AND CONCLUSION

The combination of an inert plastic sheet in contact with the viscera, and the application of subatmospheric pressure on the wound, is an effective combination to maximize the prospects of delayed primary wound closure while minimizing the chance of fistula and ventral hernia.

Effect of Temporary Abdominal Closure on Colonic Anastomosis and Postoperative Adhesions in Experimental Secondary Peritonitis

BACKGROUND

The effect of relaparotomies and temporary abdominal closure on colonic anastomoses and postoperative adhesions is under debate.

METHODS

In the experiments reported here, colonic anastomosis was constructed 24 hours after cecal ligation and puncture in rats that were divided into three groups of eight animals each. The abdomen was closed primarily in groups I and II, and a Bogota bag was used for abdominal closure in group III. At 24 hours following anastomosis, relaparotomy was performed only in group II and III rats, and the abdomen was closed directly in group II; after removal of the Bogota bag in group III animals, the abdomen was closed directly. On the fifth day of anastomotic construction, bursting pressures and tissue hydroxyproline content of the anastomoses, along with peritoneal adhesions, were assessed and compared.

RESULTS

Mean anastomotic bursting pressures and hydroxyproline contents did not differ among the groups. Median adhesion scores were significantly higher in group III than the other two groups.

CONCLUSIONS

Relaparotomy and the type of temporary closure have no negative effect on anastomotic healing in rats with peritonitis. Temporary abdominal closure with a Bogota bag caused a significantly high rate of adhesions.

The outcome of open pelvic fractures in the modern era

BACKGROUND

Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex.

METHODS

A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004.

RESULTS

Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%).

CONCLUSIONS

The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.

Longitudinal outcomes of intra-abdominal infection complicated by critical illness

BACKGROUND

Critically ill surgical patients remain at high risk of adverse outcomes as a result of intra-abdominal infections, including prolonged length of stay, organ dysfunction, and death despite advances in critical care and innovations in management of the peritoneal cavity. We evaluated the causes and consequences of intra-abdominal infections among critically ill surgical patients in a single tertiary-care intensive care unit (ICU) over a decade.

METHODS

Prospective study of 465 critically ill surgical patients with hollow viscus perforation and peritonitis or abscess from 1991-2002. Data collected were age, gender, admission APACHE III score, multiple organ dysfunction score, ICU and hospital length of stay, abscess (yes/no), site and type of perforation (colon vs. other), de novo vs. nosocomial origin, and mortality. Statistical analysis was by univariate ANOVA for coordinate data, Fisher exact test for continuous data, and logistic regression analysis.

RESULTS

The incidence of intra-abdominal infection was 5.75%, 73.7% of the patients developed organ dysfunction, and mortality was 22.6%. Females comprised 46.8% of the patients. De novo infection represented 71.8% of cases, whereas nosocomial infection comprised 28.2% of cases. Perforations were of the colon (including the appendix) 49.9% of the time. An abscess formed in 22.3% of patients; the remainder had peritonitis but no abscess. Patients in the cohort with peritonitis were older (p = 0.0157), sicker on admission (p = 0.0411) and developed more organ dysfunction (p = 0.0072), but had the same rate of mortality. Despite steadily increasing acuity since 1991 (r(2) = .71, p < 0.0001), the magnitude of organ dysfunction (r(2) = 0.11) and the mortality rate remained constant (r(2) = .01). By logistic regression, abscess correlated with less severe organ dysfunction (score > or = 5 [odds ratio 0.54, 95% CI 0.33-0.90] and > or =9 points [odds ratio 0.38, 95% CI 0.20-0.74]), and increasing magnitude of organ dysfunction was associated with mortality (each point [odds ratio 1.46, 95% CI 1.32-1.61]).

CONCLUSIONS

Although outcomes are improving, generalized peritonitis still causes high organ dysfunction-related mortality among critically ill surgical patients. Further improvements in resuscitation, surgical technique, and pharmacotherapy of severe intra-abdominal infections are needed.

Intra-abdominal hypertension and the abdominal compartment syndrome

BACKGROUND

Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure is abnormally high in association with organ dysfunction. It tends to have a poor outcome, even when treated promptly by abdominal decompression.

METHODS

A search of the Medline database was performed to identify articles related to intra-abdominal hypertension and ACS.

RESULTS

Currently there is no agreed definition or management of ACS. However, it is suggested that intra-abdominal pressure should be measured in patients at risk, with values above 20 mmHg being considered abnormal in most. Abdominal decompression should be considered in patients with rising pressure and organ dysfunction, indicated by increased airway pressure, reduced cardiac output and oliguria. Organ dysfunction often occurs at an intra-abdominal pressure greater than 35 mmHg and may start to develop between 26 and 35 mmHg. The mean survival rate of patients affected by compartment syndrome is 53 per cent.

CONCLUSION

The optimal time for intervention is not known, but outcome is often poor, even after decompression. Most of the available information relates to victims of trauma rather than general surgical patients.

Damage control surgery and the abdomen

There is a complex interplay between primary injury, particularly major abdominal injury in the multi-system trauma patient, and secondary injury, which relate to patient physiology, decision making and surgical technique. Analysis of outcomes is further confounded by the variety of surgical techniques used. The challenge is to match the correct operation, for a critically injured patient, with the patient's physiology. Excellence in general surgery does not equate with excellence in trauma surgery, and a clear understanding of damage control is essential.

One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata

OBJECTIVE

Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata.

METHODS

Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer.

RESULTS

All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients.

CONCLUSION

The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced

OBJECTIVE

The goal of this report is to examine the success of vacuum-assisted fascial closure (VAFC) under a carefully applied protocol in abdominal closure after open abdomen.

SUMMARY BACKGROUND DATA

With the development of damage control techniques and the understanding of abdominal compartment syndrome, the open abdomen has become commonplace in trauma patients. If the abdomen is not closed in the early postoperative period, the combination of adhesions and fascial retraction frequently make primary fascial closure impossible and creation of a planned ventral hernia is required. We have previously reported our experience with the development of a technique for VAFC that allowed for closure of the fascia in many such patients long after initial operation. During this previous study, during which the technique was being developed, VAFC was successful in 69% of patients in whom it was applied, and 22 patients were successfully closed at > or = 9 days after initial surgery (range, 9 to 49 days). A protocol for the use of VAFC in patients with open abdomen was developed on the basis of these data and has been employed since October 2001. The outcome of this protocol's use is examined.

METHODS

This is a prospective evaluation of all trauma patients admitted to Wake Forest University Baptist Medical Center over a 19-month period who required management with an open abdomen. VAFC employs suction applied to a large polyurethane sponge under an occlusive dressing in the wound and allows for constant medial traction of the abdominal fascia. It is attempted in all patients in whom the rectus muscles and fascia are intact. Studied variables include fascial closure rate, time to closure, incidence of wound dehiscence, and hernia development after closure.

RESULTS

From November 1, 2001, through May 31, 2003, 212 laparotomies were performed in injured patients; 53 (25%) of these patients required open abdomen management. Mean injury severity score for the group was 34, with an average abdominal abbreviated injury score of 2.9. Forty-five (78%) survived until abdominal closure. Vacuum dressings were used in all 45 but VAFC was not attempted in 2 patients (1 due to development of enterocutaneous fistula, 1 because a rectus flap was used for another wound). Closure rate in those undergoing VAFC was 88% (38), with mean time to closure being 9.5 days. This is significantly higher than the 69% rate of fascial closure during the time in which the technique was developed (P = 0.03). Twenty-one patients (48%) were closed at > or =9 days (range, 9 to 21 days). Two patients (4.6%) developed wound dehiscence and underwent successful reclosure. One patient (2.3%) developed a ventral hernia on follow-up, which has since been repaired

CONCLUSIONS

The use of VAFC under a carefully defined protocol has resulted in significantly higher fascial closure rates, obviating the need for subsequent hernia repair in most patients. The utility of this technique is not limited to the early postoperative period, but it can be successful as much as 3 to 4 weeks after initial operation.

Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same

BACKGROUND

Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI).

METHODS

The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988.

RESULTS

Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001).

CONCLUSION

Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

The use of a subfascial vicryl mesh buttress to aid in the closure of massive ventral hernias following damage-control laparotomy

Damage control laparotomy for life-threatening abdominal conditions has gained wide acceptance in the management of exsanguinating trauma patients as well as septic patients with acute abdomen. Survivors considered too ill to undergo definitive abdominal wall closure are temporized, often with skin grafting on granulated viscera. These maneuvers compromise the integrity of the anterior abdominal wall and result in a subset of patients with loss of abdominal domain and massive, debilitating ventral hernias. A retrospective review was conducted of 21 such patients (16 men, five women) who underwent elective abdominal wall reconstruction at the Hospital of the University of Pennsylvania between November of 1998 and October of 2000. The purpose of this study was to report the authors' experience with these complex abdominal wall reconstructions. A double-layer, subfascial Vicryl mesh buttress was used in all repairs to aid in reestablishing abdominal wall integrity. The mean hernia size was 813 cm2 (range, 75 to 1836 cm2), and the average interval to definitive repair was 24.4 months (range, 3 weeks to 11 years). Mean follow-up was 13.5 months (range, 1 month to 40 months). Twenty patients (95 percent) had successful ventral hernia repair. Four patients with massive hernias (924 to 1836 cm2) required submuscular Marlex mesh implantation. Two patients (10 percent) developed abdominal compartment syndrome that required surgical decompression. One patient (5 percent) developed an incisional hernia at a prior colostomy site. Four patients (19 percent) had superficial skin dehiscence that healed secondarily with daily wound care. There were no mesh infections. In most cases, successful single-stage repair of large ventral hernias following damage control laparotomy can be achieved using a subfascial Vicryl mesh buttress in combination with other established reconstructive techniques. Massive defects exceeding 900 cm2 typically require permanent mesh implantation to achieve fascial closure and to minimize the risk of postoperative abdominal compartment syndrome and recurrent herniation. This technique represents an improved solution to a complicated problem and optimizes the aesthetic and functional outcome for these debilitated patients.

Special issues in plastic and reconstructive surgery

Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.

Late fascial closure in lieu of ventral hernia: the next step in open abdomen management

BACKGROUND

The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients.

METHODS

The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure > or = 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC.

RESULTS

From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99).

CONCLUSION

VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided.

Multiple trauma in children: critical care overview

Multiple trauma is more than the sum of the injuries. Management not only of the physiologic injury but also of the pathophysiologic responses, along with integration of the child's emotional and developmental needs and the child's family, forms the basis of trauma care. Multiple trauma in children also elicits profound psychological responses from the healthcare providers involved with these children. This overview will address the pathophysiology of multiple trauma in children and the general principles of trauma management by an integrated trauma team. Trauma is a systemic disease. Multiple trauma stimulates the release of multiple inflammatory mediators. A lethal triad of hypothermia, acidosis, and coagulopathy is the direct result of trauma and secondary injury from the systemic response to trauma. Controlling and responding to the secondary pathophysiologic sequelae of trauma is the cornerstone of trauma management in the multiply injured, critically ill child. Damage control surgery is a new, rational approach to the child with multiple trauma. The selection of children for damage control surgery depends on the severity of injury. Major abdominal vascular injuries and multiple visceral injuries are best considered for this approach. The effective management of childhood multiple trauma requires a combined team approach, consideration of the child and family, an organized trauma system, and an effective quality assurance and improvement mechanism.