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

Damage control surgery: it's evolution over the last 20 years

In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become the primary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods. Its core concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of following this paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focused resuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. These simple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular and visceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have been developed over the past two decades, from permissive hypotension and damage control resuscitation to advanced ventilators and hemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be reduced. The combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potent blend. As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable one.

Negative-pressure wound therapy for critically ill adults with open abdominal wounds: a systematic review

BACKGROUND

Open abdominal management with negative-pressure wound therapy (NPWT) is increasingly used for critically ill trauma and surgery patients. We sought to determine the comparative efficacy and safety of NPWT versus alternate temporary abdominal closure (TAC) techniques in critically ill adults with open abdominal wounds.

METHODS

We conducted a systematic review of published and unpublished comparative studies. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, the Cochrane Database, the Center for Reviews and Dissemination, clinical trials registries, and bibliographies of included articles. Two authors independently abstracted data on study design, methodological quality, patient characteristics, and outcomes.

RESULTS

Among 2,715 citations identified, 2 randomized controlled trials and 9 cohort studies (3 prospective/6 retrospective) met inclusion criteria. Methodological quality of included prospective studies was moderate. One randomized controlled trial observed an improved fascial closure rate (relative risk [RR], 2.4; 95% confidence interval [CI], 1.0-5.3) and length of hospital stay after addition of retention sutured sequential fascial closure to the Kinetic Concepts Inc. (KCI) vacuum-assisted closure (VAC). Another reported a trend toward enhanced fascial closure using the KCI VAC versus Barker's vacuum pack (RR, 2.6; 95% CI, 0.95-7.1). A prospective cohort study observed improved mortality (RR, 0.48; 95% CI, 0.25-0.92) and fascial closure (RR, 1.5; 95% CI, 1.1-2.0) for patients who received the ABThera versus Barker's vacuum pack. Another noted a reduced arterial lactate, intra-abdominal pressure, and hospital stay for those fitted with the KCI VAC versus Bogotá bag. Most included retrospective studies exhibited low methodological quality and reported no mortality or fascial closure benefit for NPWT.

CONCLUSION

Limited prospective comparative data suggests that NPWT versus alternate TAC techniques may be linked with improved outcomes. However, the clinical heterogeneity and quality of available studies preclude definitive conclusions regarding the preferential use of NPWT over alternate TAC techniques.

LEVEL OF EVIDENCE

Systematic review, level III.

Total management of the open abdomen

The management of complex abdominal problems with the 'open abdomen' (OA) technique has become a routine procedure in surgery. The number of cases treated with an OA has increased dramatically because of the popularisation of damage control for life-threatening conditions, recognition and treatment of intra-abdominal hypertension and abdominal compartment syndrome and new evidence regarding the management of severe intra-abdominal sepsis. Although OA has saved numerous lives and has addressed many problems related to the primary pathology, this technique is also associated with serious complications. New knowledge about the pathophysiology of the OA and the development of new technologies for temporary abdominal wall closure (e.g. ABThera™ Open Abdomen Negative Pressure Therapy; KCI USA Inc., San Antonio, TX) has helped improve the management and outcomes of these patients. This review will merge expert physician opinion with scientific evidence regarding the total management of the OA.

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.

Surgical strategies for management of the open abdomen

Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.

The open abdomen: definitions, management principles, and nutrition support considerations

The use of the "open abdomen" as a technique in the management of the complex surgical patient stems from the concept of damage control. Damage control principles underscore the importance of an abbreviated laparotomy focused on control of hemorrhage and gastrointestinal contamination in patients presenting with significant physiologic compromise. Definitive repair of injuries is postponed and the abdomen is temporarily "closed" using one of a number of different techniques. The ultimate goal is formal abdominal fascial closure within 48-72 hours of the initial laparotomy. Frequently, daily trips to the operating room are required for incremental closure of the abdominal fascia. However, in some cases, fascial closure is not possible secondary to ongoing visceral edema and loss of the peritoneal domain. In these cases, the patient is left with an "open abdomen" until skin grafting over the exposed peritoneal organs can be performed. Patients with an open abdomen have peritoneal contents exposed to the atmosphere and require a complex dressing to maintain fascial domain and provide protection to exposed organs. These patients are typically critically ill and managed in the intensive care unit early in the disease process. The open abdomen has become an important tool for the management of physiologically unstable patients requiring emergent abdominal surgical procedures. These patients present unique challenges to the critical care and nutrition support teams. Careful attention to fluid and electrolyte management, meticulous wound care, prevention of enteroatmospheric fistula, and individualized nutrition support therapy are essential to successful recovery in this patient population.

Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia

Purpose

Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall.

Methods

Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3–4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized.

Results

The abdominal wall gap in the 19 patients ranged in size from 240 cm² to more than 900 cm². An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60–100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed.

Conclusion

The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]

BACKGROUND

Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany.

MATERIAL AND METHODS

A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively.

RESULTS

The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years.

CONCLUSIONS

Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Negative pressure therapy: a viable option for general surgical management of the open abdomen

BACKGROUND

Management of the open abdomen (OA) is challenging for surgeons and requires experienced medical teamwork. The need for improvements in temporary abdominal closure methods has led to the development of a negative-pressure therapy (NPT; ABThera OA NPT, KCI USA, Inc, San Antonio, TX).

METHOD

The authors present a 19-patient case series documenting their use of NPT for OA management in nontraumatic surgery. All received NPT until the fascia was considered ready for closure.

RESULTS

Of 19 patients, 17 (89.5%) achieved fascial closure with a Kaplan-Meier (KM) median time to closure of 6 days. Mean hospital and intensive care unit stays were 32.1 and 26.6 days, respectively. During their hospitalization, 5 patients (26.3%) died, with a KM median time to mortality of 53 days.

CONCLUSION

These findings demonstrate effective use of NPT for managing the OA in critically ill patients, and this has led the authors to use it in their general surgery practice.

Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing

Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.

Prevention of infections associated with combat-related thoracic and abdominal cavity injuries

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Early Diagnosis and Evidence-Based Care of Surgical Sepsis

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.

Understanding Intra-Abdominal Hypertension

Received November 10, 2009. Received Revised June 17, 2010. Submitted June 21, 2010. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are highly morbid conditions that are common and underrecognized in the intensive care unit. Intra-abdominal hypertension affects the critically ill patient population and is not solely limited to the trauma and surgical subgroups. The recognition of IAH and ACS as distinct clinical states has become more apparent. Extensive bench and clinical research has shed significant light into the definition, incidence, etiology, physiology, clinical manifestations, and treatment strategies. Although further research into this morbid condition is needed, improvement in recognition is a critical first step. This review aims to scrutinize the basic science and clinical literature available on this condition in a surgically focused, organ-system-based approach.

Foley catheter enterostomy for postoperative bowel perforation: an effective source control

BACKGROUND

Control of bowel effluents is imperative in cases of postoperative bowel perforation, and this is best achieved by stoma formation. When stoma formation is impossible, the surgeon is often left with less optimal choices. We have used a Foley catheter enterostomy to provide source control in difficult cases of bowel perforation, and the details are reviewed in this report.

METHODS

Three patients underwent reoperation for postoperative bowel perforation. Two patients had leaking ileocolic anastomoses, and one patient had a leak from a serosal tear. In all cases a Foley catheter enterostomy was constructed at the point of the leak. The balloon was filled with 3 ml of saline, and the affected bowel segment was fixed to the inside of the abdominal wall by a purse-string suture supplied with a few additional stitches. Moreover, gentle traction was applied to the balloon by external suture fixation of the catheter.

RESULTS

Immediate control of bowel effluents from the leak was achieved in all cases. Early enteral feeding was possible in two of the three patients, and the catheter was removed after 17-28 days. Drainage of bowel contents from the catheter wounds stopped within 2 days.

CONCLUSIONS

This report demonstrates an effective and safe technique for sealing a postoperative bowel perforation with a Foley catheter enterostomy. It is useful in cases where a stoma cannot be brought out. The technique provides immediate source control and enables early enteral feeding. The utility of the procedure may be limited when the defect is large, when the surrounding bowel wall lacks integrity, and when it is not possible to mobilize the affected bowel segment toward the inside of the abdominal wall without tension.

Damage control in trauma and abdominal sepsis

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

Use of topical negative pressure in assisted abdominal closure does not lead to high incidence of enteric fistulae

AIM

Reports suggested an increase in enterocutaneous fistulae with topical negative pressure (TNP) use in the open abdomen. The purpose of this study was to establish if our experience raises similar concerns.

METHOD

This is a 5-year prospective analysis, from January 2004 to December 2008, of 42 patients who developed deep wound dehiscence or their abdomen was left open at laparotomy requiring 'TNP' to assist in their management. The decision to use TNP was taken if it was felt unwise or not feasible to close the abdomen.

RESULTS

There were 22 men; the median age was 68 (range 21-88) years. Twenty of 42 patients had peritonitis, 5/42 had oedematous bowel, 5/42 ischaemic gut, one had a large abdominal wall defect following debridement due to methicillin-resistant staphyloccus (MRSA) infection, 11/42 developed deep wound dehiscence. In 30/42, VAC abdominal dressing system and TNP were applied. In 12/42, VAC GranuFoam and TNP were used, of these five patients required a mesh to control the oedematous bowel. Four of 42 patients died. A total of 34 patients had anastomotic lines, 2/42 developed enteric fistulae, and both survived.

CONCLUSION

This study does not support the reports suggesting a higher fistulae rate with TNP. In our opinion, its use in the open abdomen is safe.

Intraoperative Blood Loss Predicts Hemorrhage-Related Reoperation after Orthotopic Liver Transplantation

Postoperative hemorrhage after orthotopic liver transplantation (OLT) may require early reoperative intervention. Previous studies have shown intraoperative transfusion requirement as a main determinant of reoperative intervention after OLT. The goal of this study was to develop an intraoperative hemorrhage model predicting need for reoperation after OLT. A single institution, retrospective review of adult primary OLT patients from January 2002 to 2008 was conducted. Multivariate logistical regression analysis was performed to identify predictors of reoperation due to postoperative hemorrhage. Secondary analysis was conducted on patients in the reoperation group managed with temporary open abdomen techniques. Four hundred and ten primary transplantations were performed with 59 patients (14.4%) requiring reoperation. The adjusted odds of reoperation when intraoperative blood loss (IBL) increases from 1.5 L to 10.0 L is 2.48 [95% confidence interval: (1.18, 5.31)]. IBL of 10.0 L predicts a 19.4 per cent probability of reoperation. Patients managed with open abdomen (n = 8) exhibited a significant IBL difference (16.0 L vs 6.0 L, P < 0.001) when compared with the closed abdomen cohort. Our results indicate that intraoperative blood loss is the primary predictor of reoperation after OLT and provide a hemorrhage threshold to guide postoperative management of complicated OLT patients.

Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure

OBJECTIVES

This study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery.

DESIGN

Prospective clinical study.

MATERIAL AND METHODS

From October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC.

RESULTS

All wounds could be closed following a median interval of 10.5 (range: 6-19) days after laparostomy. A median of four (range: 2-7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2-36) months.

CONCLUSION

VAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.

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.

Síntese de grandes feridas da parede corpórea com tira elástica de borracha

RACIONAL: As grandes feridas da parede corpórea, decorrentes de traumas extensos, retirada de tumores ou laparostomias prolongadas constituem um desafio cirúrgico de difícil solução. OBJETIVO: Mostrar a eficácia da aproximação das bordas de grandes feridas, utilizando tira elástica de borracha. MÉTODO: Uma ou duas tiras elásticas de borracha (gominha circular) foram suturadas sob tensão moderada às bordas opostas de 21 grandes feridas, em diversas localizações corpóreas. Essas tiras eram substituídas, quando rompiam, ou refixadas, quando perdiam a tensão, até obter-se a aproximação completa das bordas das feridas. RESULTADO: Em todos os casos houve o fechamento completo das feridas, sem outro procedimento ou artifício auxiliar.Não ocorreu complicação maior decorrente desse tratamento. CONCLUSÃO: A síntese de grandes feridas corpóreas com tiras de borracha mantidas sob tensão moderada é uma alternativa simples, eficaz e de custo baixo, que pode ser utilizada em muitas circunstâncias cirúrgicas.

Vacuum-assisted closure of laparostomy wounds: a critical review of the literature

Vacuum-assisted closure (VAC) reduces the burden for carers of laparostomy wounds but evidence from randomised trials is lacking. This review analyses the evidence for the VAC abdominal wound management system (KCI, San Antonio, TX) in the open abdomen. Three prospective studies provide level III evidence that VAC allows delayed primary fascial closure in the majority of these wounds up to 21 days after occurrence, but not where duration of VAC was less than 9 days or if vacuum pack techniques were used in place of VAC. Fistulae occurred in a minority of wounds complicated by multi-organ failure or sepsis and could not be attributed to VAC itself. Two retrospective analyses suggested VAC may reduce re-operation rate and length of stay in complex wounds. Whilst randomised controlled trials remain the gold standard of evidence for effectiveness of health care interventions, contemporaneous level III evidence supports the hypothesis that VAC increases the rate of primary fascial closure. Whilst enterocutaneous fistula formation is reported in the most complex of these wounds, there is no more evidence that these are consequential to as opposed to coincident with VAC use.

Damage control surgery and open abdominal management: recent advances and our approach

The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen.

Recurrent Abdominal Compartment Syndrome: An Inciting Factor of the Second Hit Phenomenon

Intra-abdominal hypertension (IAH) after damage control laparotomy (DCL) is not unusual and because of this, patients are treated with open-abdomen techniques to prevent abdominal compartment syndrome (ACS). The occurrence of recurrent ACS (R-ACS) after abdominal wall closure under tension in patients managed with DCL can be a trigger factor for second hit syndrome. Outcomes in this subset have not been previously described. In this 1-year retrospective study of severely injured patients in a Level I trauma center managed with DCL and sequential abdominal wall closure, 26 patients were identified. After attempted abdominal wall closure, 13 (50%) patients had R-ACS and 13 (50%) non-R-ACS. R-ACS patients had a statistically significant higher incidence of multisystem organ failure, acute respiratory distress syndrome, and sepsis as well as requiring longer ventilator support and longer hospital length of stay. We concluded that failure to recognize and treat IAH with development of R-ACS after tension abdominal wall closure in patients with DCL will trigger the second hit syndrome with increased risk of morbidity. Institution of a management algorithm with intra-abdominal pressure/abdominal perfusion pressure surveillance at the time of abdominal wall closure can potentially ameliorate complications.

Opção técnica para a síntese de grandes feridas da parede corpórea

As grandes feridas da parede corpórea, decorrentes de traumas extensos, retirada de tumores ou laparostomias prolongadas constituem um desafio cirúrgico de difícil solução. Neste trabalho o autor tem por finalidade mostrar que aproximação das bordas de grandes feridas, utilizando tira elástica de borracha mantidas sob tensão moderada é uma alternativa simples, eficaz e de custo mínimo, que pode ser utilizada em muitas circunstâncias cirúrgicas.

TNP-assisted fascial closure in a patient with acute abdomen and abdominal compartment syndrome

Topical negative pressure was applied to prevent abdominal compartment syndrome in a patient following surgery for an acute abdomen. It delayed fascial closure, protected the underlying bowel and facilitated abdominal re-entry.

Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: low primary closure rate

BACKGROUND

Abdominal Vacuum-Assisted Closure (V.A.C.) systems for treatment of open abdomens have been predominantly used for trauma patients with a high primary fascial closure rate. Use of the V.A.C. technique in abdominal sepsis is less well established.

METHODS

All patients with abdominal sepsis and treatment with the abdominal V.A.C. system between 2004 and 2007 were prospectively assessed. End points were fascial closure, V.A.C.-related morbidity, and quality of life score (SF-36) at follow-up.

RESULTS

Thirty patients with abdominal sepsis were included in the study. Primary fascial closure was feasible in 10, partial closure in 4, and no closure in 16 patients. Median number of V.A.C. changes was 3 (range, 1-10). Nine patients died. V.A.C.-related morbidity was as follows: two fistulas, three fascial edge necroses, one skin blister, and four prolapses of small bowel between the fascia and foam. Univariate analysis showed no variables influencing primary closure rate or V.A.C.-related morbidity. Mortality was significantly influenced by age (P < 0.001), respiratory failure (P = 0.01), and pneumonia (P = 0.03). At follow-up, V.A.C. patients scored lower in the physical health scores and similar in the mental health scores compared with the normal population.

CONCLUSIONS

Treatment of the open abdomen in patients with abdominal sepsis with the abdominal V.A.C. system is safe with good long-term quality of life. Primary closure rate in these patients is substantially lower than in trauma patients. Stepwise closure of the fascia during V.A.C. changes should be attempted to avoid additional lateral retraction of fascial edges. V.A.C.-related complications may be avoided with careful surgical technique.

Dynamic retention suture closure: modified Bogotá bag approach

BACKGROUND

Management of patients with abdominal compartment syndrome requires abdominal decompression and the use of the open abdomen technique. Various options exist for the management of the open abdomen including expensive, commercially available devices to aid in the gradual closure of the abdominal wall. A previously described temporary closure technique using dynamic retention sutures was modified and used in eleven trauma injured patients at the Puerto Rico Trauma Center.

METHODS

Retrospective case series of 11 trauma patients, seven blunt and four penetrating, treated at the Puerto Rico Trauma Center with the modified Bogotá bag (MBB) approach from October 2005 to November 2006.

RESULTS

The MBB approach was applied in 11 out of 43 trauma patients (26%) who had undergone a Bogotá bag closure during an initial damage control surgery. Patients' average age was 27.5 (2-65) y old, including 8 males and 3 females, with an injury severity score (ISS) of 23.3 (9-38). The MBB placement allowed serial approximation in the Trauma ICU with subsequent delayed primary abdominal closure. The procedure was used for an average of 7.3 (4-12) d. Abdominal closure was achieved in 10 out of 11 patients (91%).

CONCLUSIONS

The MBB technique has preliminarily proven to be effective, allowing delayed primary closure in 91% of the cases. The MBB approach represents an inexpensive and useful alternative in the management of the open abdomen.

Preventing loss of domain: a management strategy for closure of the "open abdomen" during the initial hospitalization

BACKGROUND

In the management of the abdominal compartment syndrome resulting in an open abdomen, the so-called "planned ventral hernia" is considered an acceptable outcome. We describe a technique of surgical management of the abdominal wound that allows fascial closure in most cases during the initial admission.

METHODS

Consecutive trauma patients with abdominal compartment syndrome managed with an open abdomen over a 3-year period were identified. Medical records and the trauma data registry were reviewed for demographics, injury characteristics, operative treatment, timing and type of wound management, closure of the abdomen, and outcome.

RESULTS

From January 2004 to January 2007, 23 patients underwent management with an open abdomen. The mechanism of injury was blunt in 83% of patients and penetrating in 17%. All 18 survivors underwent primary fascial closure of the abdomen using a vacuum- and tie-assisted technique of wound closure. The mean time to closure was 11 +/- 4.4 days (range, 4-18 days). In all, 9 complications occurred in 7 patients, which included 1 reoperation for abscess after fascial closure. There was no dehiscence and no fistula. The Apache II score was 19.3 +/- 6.9 (range, 7-30), and the injury severity score was 32.3 + 10.6 (range, 9-50).

CONCLUSIONS

A technique of managing the open abdomen that prevents fascial retraction results in a high primary closure rate with an acceptable rate of short-term complications.

A prospective look at the current state of open abdomens

The present study examines the current management, closure rate, and complications of open abdomens in trauma patients admitted to an Academic Level I trauma center between May 2004 and April 2007. Variables examined include mechanism, injuries, use of antibiotics and paralytics, type of abdominal closure, days to closure, complications, ICU and hospital length of stay, and mortality. Stepwise logistic regression was performed to identify independent predictors of failed abdominal closure. Of 900 laparotomies, 93 (10%) were left open. Eighty-five (91%) patients survived for closure opportunity. Definitive fascial closure was achieved in 72 (85%) at 3.9 +/- 3.7 days (range 1-21 days). Of the remaining 13 patients, seven were closed with biologic material, five by skin grafting, and one had skin-only closure. Entero-atmospheric fistulas occurred in 14 (15%) patients. Two independent risk factors associated with failed abdominal closure were the presence of deep surgical site infection [odds ratio (OR) 17.4; 95% confidence interval (CI) 2.6-115.8, P = 0.003] and intra-abdominal abscess (OR 7.4; 95% CI 1.1-51.0, P = 0.04). In conclusion, open abdomens are commonly necessary after trauma laparotomies. Definitive fascial closure can be achieved in 85 per cent of cases. In conjunction with biologics, closure can be achieved in 93 per cent of cases. Failure to primarily close the abdomen is associated with a significantly higher risk for entero-atmospheric fistula occurrence.

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.

Abdominal compartment syndrome: a concise clinical review

OBJECTIVE

There has been an increased awareness of the presence and clinical importance of abdominal compartment syndrome. It is now appreciated that elevations of abdominal pressure occur in a wide variety of critically ill patients. Full-blown abdominal compartment syndrome is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction resulting from elevated intra-abdominal pressure. This review provides a current, clinically focused approach to the diagnosis and management of abdominal compartment syndrome, with a particular emphasis on intensive care.

METHODS

Source data were obtained from a PubMed search of the medical literature, with an emphasis on the time period after 2000. PubMed "related articles" search strategies were likewise employed frequently. Additional information was derived from the Web site of the World Society of the Abdominal Compartment Syndrome (http://www.wsacs.org).

SUMMARY AND CONCLUSIONS

The detrimental impact of elevated intra-abdominal pressure, progressing to abdominal compartment syndrome, is recognized in both surgical and medical intensive care units. The recent international abdominal compartment syndrome consensus conference has helped to define, characterize, and raise awareness of abdominal compartment syndrome. Because of the frequency of this condition, routine measurement of intra-abdominal pressure should be performed in high-risk patients in the intensive care unit. Evidence-based interventions can be used to minimize the risk of developing elevated intra-abdominal pressure and to aggressively treat intra-abdominal hypertension when identified. Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of intra-abdominal hypertension and abdominal compartment syndrome.

A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development

During the past several years, vacuum-assisted closure (VAC) systems have been increasingly used in the treatment of gastrointestinal cutaneous fistulas, particularly those associated with open abdomen. Recently, I experienced 2 cases in which the original fistula closed after treatment by the VAC system. However, these patients, who had exposed bowel, developed an additional fistula that required surgery. In a recent article from an intestinal-failure unit in the United Kingdom, Rao et al(1) reported on a series of 29 patients treated with VAC, 6 of whom developed new gastrointestinal cutaneous fistulas. Four of these 6 patients died. My own experiences, plus the report of Rao et al,(1) suggest the possibility that the use of the VAC system in patients with exposed bowel and an open abdomen may be associated with subsequent fistula development. Although the numbers are small, it also raises the question that development of a fistula in a patient treated with VAC may result in higher mortality.

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.

Damage control surgery in the abdomen: An approach for the management of severe injured patients

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.

Mesh repair for postoperative wound dehiscence in the presence of infection: is absorbable mesh safer than non-absorbable mesh?

OBJECTIVE

In patients with postoperative wound dehiscence in the presence of infection, extensive visceral oedema often necessitates mechanical containment of bowel. Prosthetic mesh is often used for this purpose. The aim of the present study was to assess the safety of the use of non-absorbable and absorbable meshes for this purpose.

METHOD

All patients that had undergone mesh repair of abdominal wound dehiscence between January 1988 and January 1998 in the presence of intra-abdominal infection were included in a retrospective cohort study. All surviving patients had physical follow-up in February 2001.

RESULT

Eighteen patients were included in the study. Meshes consisted of polyglactin (n = 6), polypropylene (n = 8), polyester (n = 1), or a combination of a polypropylene mesh with a polyglactin mesh on the visceral side (n = 3). All patients developed complications, consisting mainly of mesh infection (77%), intra-abdominal abscess (17%), enterocutaneous fistula (17%), or mesh migration through the bowel (11%). Mesh removal was necessary in eight patients (44%). Within four months postoperatively, six patients (33%) had died because of progressive abdominal sepsis. The incidence of progressive abdominal sepsis was significantly higher in the group with absorbable polyglactin mesh than in the group with nonabsorbable mesh (67 vs. 11%, p = 0.02) After a mean follow-up of 49 months, 63% of the surviving patients had developed incisional hernia. Absorbable meshes did not yield better outcomes than nonabsorbable meshes in terms of complications and mortality rate.

CONCLUSION

Synthetic graft placement in the presence of intra-abdominal infection has a high risk of complications, regardless of whether absorbable (polyglactin) or non-absorbable mesh material (polypropylene or polyester) is used, and should be avoided if possible.

Vacuum Effects over the Closing of Enterocutaneous Fistulae: A Mathematical Modeling Approach

Enterocutaneous fistulae are pathological communications between the intestinal lumen and the abdominal skin. Under surgery the mortality of this pathology is very high, therefore a vacuum applying system has been carried previously on attempting to close these fistulae. The objective of this article is the understanding of how these treatments might work through deterministic mathematical modelling. Four models are here proposed based on several assumptions involving: the conservation of the flow in the fistula, a low enough Reynolds number justifying a laminar flow, the use of Poiseuille law to model the movement of the fistulous liquid, as well as phenomenological equations including the fistula tissue and intermediate chamber compressibility. Interestingly, the four models show fistulae closing behaviour during experimental time (t<60 sec). To compare the models, both, simulations and pressure measurements, carried out on the vacuum connected to the patients, are performed. Time course of pressure are then simulated (from each model) and fitted to the experimental data. The model which best describes actual measurements shows exponential pumping flux kinetics. Applying this model, numerical relationship between the fistula compressibility and closure time is presented. The models here developed would contribute to clarify the treatment mechanism and, eventually, improve the fistulae treatment.

Surgical wound case studies with the versatile 1 wound vacuum system for negative pressure wound therapy

Negative pressure wound therapy consists of a wound dressing, a drainage tube inserted into the dressing, an occlusive transparent film, and a connection to a vacuum source that supplies the negative pressure. A new product called the Versatile 1 Wound Vacuum System (BlueSky Medical, La Costa, Calif) is available for negative pressure wound therapy. This article describes the application, management, and effectiveness of the Versatile 1 in 3 cases where the patients have all undergone surgical debridement.

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.

Vakuumtherapie und Defektdeckung beim Weichteiltrauma

This study presents the results of a meta-analysis based on the literature dealing with the clinical applications of vacuum-assisted closure (VAC) in the areas of chronic wounds, acute posttraumatic wounds, compartment syndromes, or injuries of the upper extremities. The studies were analysed for validity, significance of conclusion with respect to success rate, publications, and economic efficacy. The data show that with VAC a very valuable technique has been added to an integrated therapeutic concept of soft tissue reconstruction. However, clinical data from prospective randomised trials to support some of the positive aspects seen in the daily clinical application of the technique are still missing. These would create a sound basis demonstrating the economic efficacy of the technique.

The use of vacuum-assisted closure of abdominal wounds: a word of caution

OBJECTIVE

Vacuum-assisted closure (VAC) has been used in our centre to aid the closure of abdominal wounds. The aim of this study was to examine the clinical outcome of patients in whom VAC therapy had been used in conjunction with laparostomy.

METHOD

All patients in whom VAC was used in the management of open abdominal wounds from November 2003 to March 2005 were included in this study.

RESULTS

There were 29 patients in the study. Nineteen (65.5%) needed ICU care. Six (20%) patients developed leakage of small bowel contents into the abdominal wound cavity because of intestinal fistulation during the VAC therapy. Four of the six (66%) died, all from multi-organ failure.

CONCLUSION

Our study has demonstrated a high incidence of intestinal leakage following VAC therapy. The reasons for this are multifactorial. We would recommend caution in using it on patients with bowel anastomoses or enterotomy repairs.