Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management

Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management

PURPOSE

To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM).

METHODS

Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25).

RESULTS

VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004).

CONCLUSION

VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

Optimal tentative abdominal closure for open abdomen: a multicenter retrospective observational study (OPTITAC study)

BACKGROUND

Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure.

MATERIALS AND METHODS

A multicenter, retrospective, cohort study of adults who survived OA greater than 48 h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100 mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics.

RESULTS

Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100 mmHg) was associated with fewer primary fascia closures than less than 50 mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)].

CONCLUSION

High negative pressure (>100 mmHg) should be avoided in NPWT during tentative abdominal closure for OA.

Double-Breasted Anterior Rectus Sheath Turnover Flap

The management of the open abdomen follows wound management with temporary abdominal closure prior to definitive closure while concurrently managing patient nutrient and fluid losses. This case report describes the successful use of double-breasted anterior rectus sheath turnover (DART) flap for early open abdomen closure to facilitate oncological management. The patient is a 47-year-old female with uterine smooth muscle neoplasm whose laparotomy wound was complicated with abdominal wound dehiscence and intra-abdominal infection. The abdomen could be closed with no fistula formation, iatrogenic bowel perforations, or overlying skin necrosis, and a follow-up showed no hernia occurrence. In conclusion, the DART flap provides a simple and autologous option for early tension-free midline closure of the open abdomen with acceptable intra- and postoperative complications.

Abdominal Wall Incisional Hernia Repair with the Anterior Component Separation Technique and Reinforcement with an Anterior Rectus Abdominis Sheath Flap

Mesh repair is currently the mainstay of treatment for abdominal wall incisional hernias and is considered the standard of care. However, if radiotherapy is used, the possibility of complications such as exposure or infection of the prosthesis after the surgery as a complication of the radiotherapy is a concern. The patient was a 51-year-old woman who underwent laparotomy by a mid-abdominal incision for ovarian tumors. Approximately 2 years later, the patient presented with a hypertrophic scar of the wound and mild pain in the scar. The hypertrophic scar was improved gradually by corticosteroid injection. However, she had a bulge on the left side of the umbilicus just below the hypertrophic scar. Computed tomography showed a 65 × 69 mm2 hernial orifice on the left side of the umbilical abdominal wall, and an abdominal wall incisional hernia was diagnosed. The patient underwent closure by the ACS technique and reinforcement by unilateral inversion of the anterior rectus abdominis sheath for the abdominal wall incisional hernia. No recurrence of the hypertrophic scar or abdominal wall incisional hernia was observed during the follow-up period. In the present case, the hernial orifice was closed by a modified ACS technique that was combined with the anterior rectus abdominis sheath turnover flap. This technique is likely a less invasive and relatively simple method resulting in a tighter repair of the abdominal hernia than the ACS method alone, without prostheses.

Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap

Background

Reconstructing abdominal wall defects has been a difficult task for surgeons. The abdominal wall defects range from defects of only soft tissue to full thickness defects including all the three layers of the abdomen. Only soft tissue defects are commonly caused by peritonitis and laparotomies, and full thickness defects can occur from en bloc resection of tumours as well as trauma. Treatment options available include component separation, partition technique, flap coverage, and more recently acellular dermal matrix.

Methods

This retrospective study done between 2016 and 2020 where 20 patients were operated for abdominal wall defect using Pedicled ALT flap in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Hospital, Jaipur, Rajasthan, India.

Results

The study consisted of total 20 patients, 14 males and 6 females. Eight patients were post electric burn, 5 patients had suffered trauma, 4 patients underwent resection of abdominal wall tumour and 3 patients were post laparotomy for peritonitis. Mean age of patients was 48 years (range from 36 to 62 years). Mean fascia defect size was 14.2 cm (range 12.2 to 16.4 cm). Mean operative time was 170 minutes (range from 140 minutes to 220 minutes). Postoperative hospital stay ranged from 8 days to 24 days (mean- 12 days).

Conclusion

Pedicled ALT flap has expanded the armamentarium of plastic surgeons for reconstruction of abdominal wall defects.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Is open abdominal management useful in nontrauma emergency surgery for older adults? A single-center retrospective study

PURPOSE

Open abdominal management (OAM) is being adopted increasingly frequently in nontrauma patients. This study assessed the effectiveness of OAM in nontrauma older adults.

METHODS

We retrospectively reviewed all adults who underwent nontrauma emergency laparotomy requiring postoperative intensive care unit (ICU) management between September 2012 and August 2017 at our hospital. Patients ≥ 80 years old, who underwent OAM, were compared with those < 80 years old. The primary outcome was the 90-day mortality. Secondary outcomes were the 30-day mortality, unplanned relaparotomy, and the ICU length of stay (LOS).

RESULTS

The OAM group comprised 58 patients, including 27 who were ≥ 80 years old. The patients ≥ 80 years old in the OAM group had a significantly higher 90-day mortality rate (33% vs. 10%; p = 0.027) than those < 80 years old. There were no significant differences in the 30-day mortality rate, patients' unplanned relaparotomy rate, or ICU LOS between the patients ≥ 80 years old and those < 80 in the OAM group.

CONCLUSIONS

Older adults who underwent OAM had a significantly higher mortality rate than younger patients. However, the OAM strategy for older nontrauma patients may still be useful and reasonable considering the severe condition of these patients.

Covering a large abdominal wall defect using bilateral anterolateral myocutaneous thigh flap: A case report

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A variety of methods for abdominal wall closure have been described.

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Closure of a defect by myocuteous thigh flap is a viable option.

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In this report, bilateral anterolateral myocutaneous thigh flaps has been discussed.

Introduction

Closure of the abdominal wall defect by myocuteous thigh flap is an option. The aim of this paper is to report a case of abdominal wall defect covered by bilateral anterolateral myocutaneous thigh flap.

Case report

A 45-year-old female presented with a large defect in the anterior abdominal wall. It was decided to cover the wound with bilateral anterolateral myocutaneous thigh flap as the defect was so large to be filled with a single flap. Under general anesthesia, a flap was elevated lateral to a line joining mid inguinal point to the lateral epicondyle, the flap was rotated under inguinal skin and sutured to the defect. The procedure was repeated for the contralateral side two weeks later.

Discussion

Lower abdominal wall defects can be reconstructed by the use of the combined technique of sublay technique, intraperitoneal mesh placement, pedicled great omentum flap and rotation skin graft, also tensor fascia lata has been proven to be a safe and versatile flap.

Conclusion

Bilateral anterolateral myocutaneous thigh flap is practical whenever indicated. It is best suited for covering of the lower abdominal defects.

Use of autologous dermal flap as mesh coverage in the treatment of large abdominal-wall defect in patients following massive weight loss: presentation of a novel surgical technique

PURPOSE

Reconstruction of large abdominal-wall defects (AWD) in patients after massive weight loss (MWL) can be challenging. Patients are left with a sizeable amount of excess skin and subcutaneous tissue which can serve as a natural and readily available source of mesh coverage. In this article, we present our experience in the reconstruction of large AWD in patients after MWL, using autogenous dermal flaps combined with a synthetic mesh.

METHOD

All patients with large AWD and MWL, diagnosed between January 2012 and December 2016, were considered to be candidates for the procedure. During the operation, an attempt was made to attain full closure of the defect above the mesh. In those patients for whom such closure was not possible, a dermal flap technique was used. Patients were closely monitored for at least 1 year. Outcome measures included early and late postoperative complications. Data are presented as mean ± standard deviation (SD).

RESULTS

Over the study period, a total of 14 patients underwent a surgery involving combined mesh and dermal flap technique. Early post-operative complications included three patients who suffered from minor wound disruption and were treated with local dressings. One patient had an abdominal-wall hematoma that required an evacuation. Two patients suffered from an epidermal cyst and chronic sinuses that required surgical debridement. None of the patients experienced intra-abdominal complication, respiratory failure, or required ICU treatment. No mesh contamination or hernia recurrence was observed during the follow-up period of 22.25 ± 6.4 months.

CONCLUSION

Autologous dermal flap combined with mesh technique may serve as an effective surgical alternative in patients after MWL with large AWD for whom full muscular coverage of the underlying prosthesis is not possible.

Blurring the boundary between open abdomen treatment and ventral hernia repair

PURPOSE

Therapeutic approaches for septic open abdomen treatment remain a major challenge with many uncertainties. The most convincing method is vacuum-assisted wound closure with mesh-mediated fascia traction with a protective plastic sheet placed on the viscera. As this plastic sheet and the mesh must be removed before final fascial closure, such a technique only allows temporary abdominal closure. This retrospective study analyzes the results of a modification of this technique allowing final abdominal closure using an anti-adhesive permeable polyvinylidene fluoride (PVDF) mesh.

METHODS

The outcome of all consecutive patients with septic open abdomen treatment at one academic surgical department from January 2013 to June 2015 was retrospectively analyzed.

RESULTS

Retrospectively, 57 severely ill consecutive patients with septic open abdomen treatment with a 30-day mortality of 26% and a 2-year mortality of 51% were included in the study. In 26 patients, no mesh was implanted; in 31 patients, mesh implantation was done at median third-look laparotomy, median 5 days postoperative. Re-laparotomies after mesh implantation (median n = 2) revealed anastomotic leakage in 16% but no new bowel fistula. In 40% of those patients who had mesh implantation, fascia closure was not achieved and the mesh was left in place in a bridging position avoiding planned ventral hernia.

CONCLUSION

The application of an anti-adhesive PVDF mesh for fascia traction in vacuum-assisted wound closure of septic open abdomen is novel, versatile, and seems to be safe. It offers the highly relevant possibility for provisional and final abdominal closure.

The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen

Background

In a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities.

Methods

Between 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ).

Results

The turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1-42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3-15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities.

Conclusions

Based on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

Systematic Review of Laparostomy/Open Abdomen to Prevent Acute Compartimental Syndrome (ACS)

Laparostomy is defined as a surgical technique in which the peritoneal cavity is opened and left open, called "open abdomen" (OA). An open abdomen presents numerous challenges for the clinician. Specific pathologies like severe intraabdominal sepsis, trauma requiring damage control, abdominal compartment syndrome, staged abdominal repair and other complex abdominal pathologies can be managed with laparostomy. Laparostomy allows abdominal re-exploration, clearing and control of abdominal fluid of the fascia, avoiding intra-abdominal hypertension (IAH), abdominal wall closure.

Prevention of Incisional Hernias after Open Abdomen Treatment

Management of a patient with an open abdomen is difficult, and the primary closure of the fascial edges is essential to obtain the best patient outcome, regardless of the initial etiology of the open abdomen. The use of temporary abdominal closure devices is nowadays the gold standard to have the highest closure rates with mesh-mediated fascial traction as the proposed standard of care. However, the incidence of incisional hernias, although much more controlled than when leaving an abdomen open, is high and reaches up to 65%. As shown for other high-risk patient subgroups, such as obese patients, patients with an abdominal aneurysm, and patients with former -ostomy sites, the prevention of incisional hernias might be key to further optimize patient outcomes after open abdomen treatment. In this overview, current available modalities to decrease the incidence of incisional hernia are discussed. Most of these preventive options have been shown effective in giant ventral hernia repair and might work effectively in this patient cohort with open abdomen as well.

Elastic TPU Mesh as Abdominal Wall Inlay Significantly Reduces Defect Size in a Minipig Model

Background: The open abdomen with mesh implantation, followed by early reoperation with fascial closure, is a modern surgical approach in difficult clinical situations such as severe abdominal sepsis. As early fascial closure is not possible in many cases, mesh-mediated fascial traction is helpful for conditioning of a minimized ventral hernia after open abdomen. The aim of this study was to evaluate the clinical utilization of an innovative elastic thermoplastic polyurethane mesh (TPU) as an abdominal wall inlay in a minipig model. Methods: Ten minipigs were divided in two groups, either receiving an elastic TPU mesh or a nonelastic polyvinylidene fluoride (PVDF) mesh in inlay position of the abdominal wall. After 8 weeks, mesh expansion and abdominal wall defect size were measured. Finally, pigs were euthanized and abdominal walls were explanted for histological and immunohistochemical assessment. Results: Eight weeks after abdominal wall replacement, transversal diameter of the fascial defect in the TPU group was significantly smaller than in the PVDF group (4.5 cm vs. 7.4 cm; p = 0.047). Immunhistochemical analysis showed increased Ki67 positive cells (p = 0.003) and a higher number of apoptotic cells (p = 0.047) after abdominal wall replacement with a TPU mesh. Collagen type I/III ratio was increased in the PVDF group (p = 0.011). Conclusion: Implantation of an elastic TPU mesh as abdominal wall inlay is a promising approach to reduce the size of the ventral hernia after open abdomen by mesh-mediated traction. However, this effect was associated with a slightly increased foreign body reaction in comparison to the nonelastic PVDF.

The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen

BACKGROUND

In a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities.

METHODS

Between 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ).

RESULTS

The turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1-42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3-15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities.

CONCLUSIONS

Based on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

International consensus conference on open abdomen in trauma

BACKGROUND

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.

METHODS

The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.

RESULTS

OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).

CONCLUSION

OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Management of the Sequelae of Severe Congenital Abdominal Wall Defects

Background

The survival rate of newborns with severe congenital abdominal wall defects has increased. After successfully addressing life-threatening complications, it is necessary to focus on the cosmetic and functional outcomes of the abdominal wall.

Methods

We performed a chart review of five cases treated in our institution.

Results

Five patients, ranging from seven to 18 years of age, underwent the following surgical approaches: simple approximation of the rectus abdominis fascia, the rectus abdominis sheath turnover flap, the placement of submuscular tissue expanders, mesh repair, or a combination of these techniques depending on the characteristics of each individual case.

Conclusions

Patients with severe congenital abdominal wall defects require individualized surgical treatment to address both the aesthetic and functional issues related to the sequelae of their defects.

Evaluation of polypropylene mesh coated with biological hydrogels for temporary closure of open abdomen

Polypropylene mesh, as a temporary abdominal closure device, may cause mechanical intestine injury and inflammatory response. Chitosan/gelatin hydrogel has excellent biocompatibility, soft and elastic properties. This work is to assess the effects of the chitosan/gelatin hydrogel coated polypropylene mesh on open abdomen wounds. Histological analysis and detection of healing-related factors were conducted to evaluate the inflammation and wound healing process. After 1-day implantation in a murine model of open abdomen, the coated polypropylene mesh, compared with simple polypropylene mesh, demonstrated well protection of the intestine serosa. After 14-day implantation, it reduced the inflammation response by down-regulating the cytokines interleukin-6 and tumor necrosis factor-α, and up-regulating the anti-inflammatory factor interleukin-10. Meanwhile, the composite stimulated granulation tissue growth, and promoted matrix deposition and angiogenesis after 7 and 14 days. In conclusion, the modified temporary abdominal closure composite could significantly protect the intestines from mechanical damage and accelerate wound healing.

Coverage of supraumbilical abdominal wall defects: The tunnelled-pedicled ALT technique

Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22-29 × 10-14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6-68 months of follow-up. The tunneled pedicled ALT flap may provide a reliable alternative method for abdominal wall reconstruction, including supraumbilical defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:119-127, 2017.

Components separation technique is feasible for assisting delayed primary fascial closure of open abdomen

Background and aims:

The goal after open abdomen treatment is to reach primary fascial closure. Modern negative pressure wound therapy systems are sometimes inefficient for this purpose. This retrospective chart analysis describes the use of the ‘components separation’ method in facilitating primary fascial closure after open abdomen.

Material and methods:

A total of 16 consecutive critically ill surgical patients treated with components separation during open abdomen management were analyzed. No patients were excluded.

Results:

Primary fascial closure was achieved in 75% (12/16). Components separation was performed during ongoing open abdomen treatment in 7 patients and at the time of delayed primary fascial closure in 9 patients. Of the former, 3/7 (43%) patients reached primary fascial closure, whereas all 9 patients in the latter group had successful fascial closure without major complications (p = 0.019).

Conclusion:

Components separation is a useful method in contributing to successful primary fascial closure in patients treated for open abdomen. Best results were obtained when components separation was performed simultaneously with primary fascial closure at the end of the open abdomen treatment.

A novel technique for managing open abdomen with the combined use of mesh-mediated traction and the bilateral anterior rectus abdominis sheath turnover flap method: how to do it

Proper management of abdominal compartment syndrome and open abdomen is important for improving the survival of critically ill patients. However, in cases requiring a prolonged period of open abdomen, it is frequently difficult to perform definitive fascial closure due to lateralization of the abdominal musculature. We herein present a novel combined technique for managing open abdomen. A 74-year-old male with diffuse peritonitis was transferred to our department, after which a long period of open abdomen made it difficult to achieve fascial closure. Polypropylene mesh was sutured to the fascial edges to reduce the gap, which was then serially tightened under negative pressure wound therapy. However, since it was not possible to accomplish definitive fascial closure, abdominal closure was performed using the bilateral anterior rectus abdominis sheath turnover flap method after removing the mesh, without any complications. This combined technique may be an effective alternative in patients requiring open abdomen with subsequent difficulty in achieving definitive fascial closure.

Combined therapy of NPWT and bipedicled flap as an alternative approach for giant abdominal wall defect with significant visceral edema: report of a case

Open abdomen management is commonly used for the critically injured patients to avoid abdominal compartment syndrome. But it usually continues for days to weeks and finally results in abdominal wall defect that is too wide to close at once. This article presents an alternative approach to close the giant abdominal wall defect by using the combination of bipedicled flaps with the components separation technique and V.A.C.® system.

Comparison of Outcomes between Early Fascial Closure and Delayed Abdominal Closure in Patients with Open Abdomen: A Systematic Review and Meta-Analysis

Up to the present, the optimal time to close an open abdomen remains controversial. This study was designed to evaluate whether early fascial abdominal closure had advantages over delayed approach for open abdomen populations. Medline, Embase, and Cochrane Library were searched until April 2013. Search terms included “open abdomen,” “abdominal compartment syndrome,” “laparostomy,” “celiotomy,” “abdominal closure,” “primary,” “delayed,” “permanent,” “fascial closure,” and “definitive closure.” Open abdomen was defined as “fail to close abdominal fascia after a laparotomy.” Mortality, complications, and length of stay were compared between early and delayed fascial closure. In total, 3125 patients were included for final analysis, and 1942 (62%) patients successfully achieved early fascial closure. Vacuum assisted fascial closure had no impact on pooled fascial closure rate. Compared with delayed abdominal closure, early fascial closure significantly reduced mortality (12.3% versus 24.8%, RR, 0.53, P < 0.0001) and complication incidence (RR, 0.68, P < 0.0001). The mean interval from open abdomen to definitive closure ranged from 2.2 to 14.6 days in early fascial closure groups, but from 32.5 to 300 days in delayed closure groups. This study confirmed clinical advantages of early fascial closure over delayed approach in treatment of patients with open abdomen.

Effect of intra-abdominal volume increment on kidneys in minipigs with intra-abdominal hypertension after hemorrhagic shock and resuscitation

BACKGROUND

To investigate the effect of intra-abdominal volume increment (IAVI) on intra-abdominal hypertension (IAH) in the kidneys.

METHODS

Eight minipigs were successfully established as IAH models and were randomly divided into two groups: the IAVI group and the sham-operated group. The intravesicular pressure, inferior vena cava pressure and urine volume were measured before shock, 2 h after IAH, and 22 h after surgery, respectively. The following indices were measured: serum creatinine, urea nitrogen, renal cortical thickness, ratio of abdominal anteroposterior diameter/transverse diameter, renal thickness, diameter of the renal sinus and the wet/dry ratio of renal tissues.

RESULTS

The intravesicular pressure (IVP) of the 8 minipig IAH models was calculated to be 21.16 ± 4.63 mmHg. There was a significant increase in the abdominal anteroposterior diameter/transverse diameter ratio. The minipigs in the IAVI group survived during the observational period, whereas 2 minipigs died at 18 h and 20 h in the sham-operated group. Twenty-two hours after surgery, the animals in the IAVI group displayed increased urinary volume (UV) and decreased Cr and Ur and remarkable decreases of VP and IVCP. After IAH, the renal cortical thickness and the renal thickness increased significantly. The renal wet/dry ratio in the sham-operated group was higher than that in the IAVI group.

CONCLUSION

IAVI helps to control renal dysfunction after IAH, which may be related to lowering the intra-abdominal pressure, thus alleviating renal edema and blood stasis.

“Acute postoperative open abdominal wall”: Nosological concept and treatment implications

The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.

Reconstruction of abdominal wall of a chronically infected postoperative wound with a rectus abdominis myofascial splitting flap

BACKGROUND

If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect.

METHODS

From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction.

RESULTS

Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery.

CONCLUSIONS

Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.

Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches

Damage-control surgery and open-abdomen is an acceptable—and often lifesaving—approach to the treatment of patients with severe trauma, abdominal compartment syndrome, necrotizing soft tissue catastrophes, and other abdominal disasters, when closing the abdomen is not possible, ill advised, or will have serious sequelae. However, common consequences of open-abdomen management include large abdominal wall defects, enterocutaneous fistulas (ECFs), and enteroatmospheric fistulas (EAFs). Furthermore, in such patients, a frozen and hostile abdomen (alone or combined with ECFs) is not uncommon. Adding biologic mesh to our surgical armamentarium has revolutionized hernia surgery.

Intra-abdominal hypertension and abdominal compartment syndrome in association with ruptured abdominal aortic aneurysm in the endovascular era: vigilance remains critical

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.

Outcomes of damage control laparotomy with open abdomen management in the octogenarian population

BACKGROUND

Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic.

METHODS

The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival.

RESULTS

Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months).

CONCLUSION

There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.

Abdominal wall reconstruction in patients with enterocutaneous fistulas

Enterocutaneous fistulas (ECFs) remain a feared complication of surgery, particularly in acute care and trauma patients. Despite advances in medical and surgical therapies, ECFs are associated with significant morbidity and mortality; in addition, significant health care resources are consumed in their treatment. Because of the frequency nowadays of open-abdomen and damage-control surgery, of aggressive treatment for abdominal compartment syndrome, and of necrotizing soft tissue infections of the abdominal wall, ECFs are becoming common; so are enteroatmospheric fistulas (EAFs), which represent a new entity where the lumen of the intestine is directly exposed to the outside environment and has no track through subcutaneous or cutaneous tissue. The surgical management of abdominal wall defects, including ECFs and/or EAFs, is often associated with major hernias and other complexities. Careful planning and advanced surgical techniques are required, often involving the use, alone or in combination, of biologic mesh and composite tissue transfer. The treatment of ECFs in patients with large abdominal wall defects is challenging, but with proper techniques, the results can be excellent. Biologic mesh is the mesh of choice in such patients.

Management of open abdomen with an absorbable mesh closure

PURPOSE

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

METHODS

A retrospective study was performed in OA patients from January 2001 to June 2007. Outcomes were analyzed in terms of enteroatmospheric fistula (EAF) formation and survival.

RESULTS

There were 73 OA patients receiving definitive closures (40 trauma and 33 nontrauma). Twenty-four patients were able to undergo a delayed primary fascial closure (DPFC) after initial vacuum pack closure (DPFC rate 33%). The DPFC rate was significantly lower in patients with an associated infection or contamination (9% vs 44%, P = 0.002). The EAF and mortality rates of the DPFC group were 0% and 13%, respectively. Absorbable mesh closure was used in 41 of 49 patients who failed DPFC (84%). There were 9 patients who had EAF (overall EAF rate 12%), 6 of whom were in the AMC group (EAF rate 15%). The overall and AMC group mortality rates were 29% and 37%, respectively.

CONCLUSION

Absorbable mesh closure carries high EAF and mortality rates. Therefore, DPFC should be considered as the primary closure method. Absorbable mesh closure should be reserved for patients who fail DPFC, especially those with peritonitis or contamination.

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.

Vacuum-Pack Temporary Abdominal Wound Management with Delayed-Closure for the Management of Ruptured Abdominal Aortic Aneurysm and Other Abdominal Vascular Catastrophes: Absence of Graft Infection in Long Term Survivors

Patients who undergo open repair of ruptured abdominal aortic aneurysms (rAAA) may require delayed abdominal wound closure to prevent the adverse consequences of intra-abdominal hypertension and abdominal compartment syndrome. However, surgeons may be reticent to use delayed abdominal closure techniques due to concern that such management may increase the risk of graft infection. We retrospectively reviewed our patient experience with rAAA and other vascular catastrophes in which vacuum-pack abdominal wound management with delayed closure was used between 2000 and 2007. Eighteen of 23 patients treated with delayed closure survived (78%). In five early deaths, graft infection was not clinically suspected. Sixteen of 20 rAAA patients survived, with abdominal wound closure achieved at a mean of 4 days. Mean follow up was 53 months, the longest among comparable series. Graft infection has not been encountered in this group. Our results suggest that the potential risk of graft infection should not outweigh the benefits of vacuum-pack temporary abdominal wound management with delayed closure in critically ill patients at high risk for intra-abdominal hypertension and abdominal compartment syndrome after major abdominal vascular procedures.

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.

Closure of a contained open abdomen using a bipedicled myofascial oblique rectus abdominis flap technique

A contained open abdomen is commonly used during damage control laparotomy and consists of the temporary coverage of the abdomen for protection of the viscera and reduction of intra-abdominal pressure. Definitive closure of a contained open abdomen is technically difficult due to the inability to obtain primary fascial suture. The insertion of a prosthetic mesh can be complicated with enterocutaneous fistula, and other definitive closure techniques need several surgical procedures. We describe a low cost technique that allows definitive closure of large abdominal wall defects avoiding the risk of intestinal fistula.