Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems

Management of Acute Wounds-Expert Panel Consensus Statement

Significance: The Wound Healing Foundation recognized the need for consensus-based unbiased recommendations for the treatment of wounds. As a first step, a consensus on the treatment of chronic wounds was developed and published in 2022. The current publication on acute wounds represents the second step in this process. Acute wounds may result from any number of conditions, including burns, military and combat operations, and trauma to specific areas of the body. The management of acute wounds requires timely and evidence-driven intervention to achieve optimal clinical outcomes. This consensus statement provides the clinician with the necessary foundational approaches to the causes, diagnosis, and therapeutic management of acute wounds. Presented in a structured format, this is a useful guide for clinicians and learners in all patient care settings. Recent Advances: Recent advances in the management of acute wounds have centered on stabilization and treatment in the military and combat environment. Specifically, advancements in hemostasis, resuscitation, and the mitigation of infection risk through timely initiation of antibiotics and avoidance of high-pressure irrigation in contaminated soft tissue injury. Critical Issues: Critical issues include infection control, pain management, and the unique considerations for the management of acute wounds in pediatric patients. Future Directions: Future directions include new approaches to preventing the progression and conversion of burns through the use of specific gel formulations. Additionally, the use of three-dimensional bioprinting and photo-modulation for reconstruction is a promising area for continued discovery.

Damage Control Laparotomy and Management of the Open Abdomen

Management of the open abdomen has been used for decades by general surgeons. Techniques have evolved over those decades to improve control of infection, fluid loss, and improve the ability to close the abdomen to avoid hernia formation. The authors explore the history, indications, and techniques of open abdomen management in multiple settings. The most important considerations in open abdomen management include the reason for leaving the abdomen open, prevention and mitigation of ongoing organ dysfunction, and eventual plans for abdominal closure.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

Damage control surgery in emergency general surgery: What you need to know

ABSTRACT

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

The temporary abdominal closure techniques used for trauma patients: a systematic review and meta-analysis

Purpose

The choice of temporary abdominal closure (TAC) method affects the prognosis of trauma patients. Previous studies on TAC are challenging to extrapolate due to data heterogeneity. We aimed to conduct a systematic review and comparison of various TAC techniques.

Methods

We accessed web-based databases for studies on the clinical outcomes of TAC techniques. Recognized techniques, including negative-pressure wound therapy with or without continuous fascial traction, skin tension, meshes, Bogota bags, and Wittman patches, were classified via a method of closure such as skin-only closure vs. patch closure vs. vacuum closure; and via dynamics of treatment like static therapy (ST) vs. dynamic therapy (DT). Study endpoints included in-hospital mortality, definitive fascial closure (DFC) rate, and incidence of intraabdominal complications.

Results

Among 1,065 identified studies, 37 papers comprising 2,582 trauma patients met the inclusion criteria. The vacuum closure group showed the lowest mortality (13%; 95% confidence interval [CI], 6%-19%) and a moderate DFC rate (74%; 95% CI, 67%-82%). The skin-only closure group showed the highest mortality (35%; 95% CI, 7%-63%) and the highest DFC rate (96%; 95% CI, 93%-99%). In the second group analysis, DT showed better outcomes than ST for all endpoints.

Conclusion

Vacuum closure was favorable in terms of in-hospital mortality, ventral hernia, and peritoneal abscess. Skin-only closure might be an alternative TAC method in carefully selected groups. DT may provide the best results; however, further studies are needed.

Crush injury with significant soft tissue loss managed utilising biological and dynamic tissue systems: a case study

Major traumatic crush injuries are difficult to manage, with high morbidity, requiring prolonged, complex treatment with many procedures. Free-flap reconstruction is often used yet full functionality still may not be regained. In this case study of a traumatic crush injury of the anterior distal tibia, ankle and foot of a 48-year-old male patient, we opted for an alternative management strategy using a combination of a dynamic tissue system (DTS) and biological xenografts (porcine urinary bladder matrix and a multi-tissue platform). The DTS was kept in place in an outpatient setting for four weeks postoperatively and removed after that time. At the 3-month follow-up, the wound was significantly smaller at about 15% of the original size. The wound healed completely before 6-month follow-up. Our patient's traumatic crush injury was successfully healed using an alternative management strategy, DTS and biologic xenografts.

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization.

METHODS

A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated.

RESULTS

Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity.

CONCLUSION

We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level IV.

Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen

Purpose

One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction.

Methods

Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT).

Results

The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia.

Conclusion

Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.

Early Initiation of a Standardized Open Abdomen Treatment With Vacuum Assisted Mesh-Mediated Fascial Traction Achieves Best Results

Background: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Complete fascial closure is an essential treatment objective and can be achieved by the use of different dynamic closure techniques. Both surgical technique and-decision making are essential for optimal patient outcome in terms of fascial closure. The aim of this study was to analyse patients' outcome after the use of mesh-mediated fascial traction (MMFT) associated with negative pressure wound therapy (NPWT) and identify important factors that negatively influenced final fascial closure. Methods: A single center ambispective analysis was performed including all patients treated for an open abdomen in a tertiary referral center from 3/2011 till 2/2020. All patients with a minimum survival >24 h after initiation of treatment were analyzed. The data concerning patient management was collected and entered into the Open Abdomen Route of the European Hernia Society (EHS). Patient basic characteristics considering OA indication, primary fascial closure, as well as important features in surgical technique including time after index procedure to start mesh mediated fascial traction, surgical closure techniques and patients' long-term outcomes were analyzed. Results: Data were obtained from 152 patients who underwent open abdomen therapy (OAT) in a single center study. Indications for OAT as per-protocol analysis were sepsis (33.3%), abdominal compartment syndrome (31.6%), followed by peritonitis (24.2%), abdominal trauma (8.3%) and burst abdomen (2.4%). Overall fascial closure rate was 80% as in the per-protocol analysis. When patients that started OA management with MMFT and NPWT from the initial surgery a significantly better fascial closure rate was achieved compared to patients that started 3 or more days later (p < 0.001). An incisional hernia developed in 35.8% of patients alive with a median follow-up of 49 months (range 6-96 months). Conclusion: Our main findings emphasize the importance of a standardized treatment plan, initiated early on during management of the OA. The use of vacuum assisted closure in combination with MMFT showed high rates of fascial closure. Absence of initial intraperitoneal NPWT as well as delayed start of MMFT were risk factors for non-fascial closure. Initiation of OA with VACM should not be unnecessary delayed.

Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters

Purpose

Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure.

Methods

A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719).

Results

Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC.

Conclusion

The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02336-x) contains supplementary material, which is available to authorized users.

A modified negative pressure wound therapy for the treatment of refractory wounds: A preliminary study

Negative pressure wound therapy (NPWT) is an important therapy for the management of refractory wounds. The aim of this retrospective preliminary study was to introduce a modified NPWT (m-NPWT) and compared the efficacy of it with conventional NPWT (c-NPWT) in the management of refractory wounds.A total of 127 patients with refractory wounds receiving the NPWT from January 2010 to October 2017 in our hospital were retrospectively reviewed. The demographics and clinical data were collected from medical records and compared between m-NPWT group and c-NPWT group.There were 65 patients in c-NPWT group and 62 patients in m-NPWT group. No significant difference was observed between 2 groups in antimicrobial use (P = .51), hospitalization time (P = .24), wound-healing rate (P = .44) or complication rate (P = .59). However, patients in m-NPWT group had shorter wound-healing time (24.82 vs 27.66 days, P < .01), less debridement times (1.23 vs 2.08, P < .01), less total cost (3743.93 vs 6344.33 yuan, P < .01) and higher satisfaction rate (56/62 vs 44/65, P = .02) compared to those in c-NPWT group.The m-NPWT technique was an efficient and safe alternative therapy for refractory wounds.

Dynamic closure techniques for treatment of an open abdomen: an update

BACKGROUND

The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain as it is associated with a high incidence of complications and poor outcomes. The objective is to perform a systematic review on dynamic closure techniques for fascial closure during open abdomen management.

METHODS

An electronic database search was conducted involving 4 different databases (MEDLINE (PubMed), SCOPUS, WEB OF SCIENCE (WOS) and EMBASE). All studies that described dynamic closure techniques in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest.

RESULTS

Thirteen studies were included in the final synthesis. Overall methodological quality was low with a high number of retrospective observational studies and low number of patients. All included studies are observational cohort studies. No studies reported on the use of either Wittmann patch, dynamic retention sutures or ABRA system. Two studies reported on the ABRA system in combination with Negative Pressure Wound Therapy (NPWT), while 9 reported on mesh-mediated fascial traction (MMFT) combined with NPWT. Other types of fascial traction, either by dynamic suture lines or by a self-made silastic tube system, and NPWT were reported in 2 studies. Overall closure rates are 93.2% for the ABRA system + NPWT versus 72.0% for the mesh-mediated fascial traction + NPWT.

CONCLUSION

Careful selection and good management of OA patients will avoid prolonged treatment and facilitate early fascial closure. Future research should focus on comparison of different temporary dynamic closure techniques to evolve toward best treatment options, in terms of both fascial closure rates and long-term incisional hernia rates.