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

Vacuum assisted closure with mesh mediated fascial traction of open abdominal wounds and acute fascial dehiscence, a single institution experience

BACKGROUNDS

Laparostomy is a common means of managing surgical catastrophes, but often results in large ventral hernias which prove difficult to repair. It is also associated with high rates of enteric fistula formation. Dynamic methods of managing the open abdomen have been shown to result in higher rates of fascial closure and fewer complications. Recent publications have suggested the addition of chemical components relaxation with botulinum toxin has an added advantage over prior methods.

METHODS

We report on a series of emergent cases managed by the combination of Botulinum toxin A (BTA) mediated chemical relaxation with a modified method of mesh-mediated fascial traction (MMFT) and negative pressure wound therapy (NPWT).

RESULTS

Thirteen cases (nine laparostomies and four fascial dehiscence) were successfully closed in a median of 12 days, using a median of 4 'tightenings', with no clinical herniation detected at follow up so far (median 183 days, IQR 123-292). There were no procedure-related complications, but one death from the underling pathology.

CONCLUSIONS

We report further cases of vacuum assisted mesh-mediated fascial traction (VA-MMFT) utilizing BTA in successfully managing laparostomy and abdominal wound dehiscence and continues the known high rate of successful fascial closure seen when applied in treating the open abdomen.

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.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

BACKGROUND

Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties.

METHODS

Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals.

RESULTS

Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively.

CONCLUSIONS

Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017

OBJECTIVES

Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality.

METHODS

We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017.

RESULTS

Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%).

CONCLUSIONS

The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair

PURPOSE

Biologic meshes are being increasingly used for abdominal hernia repair in high-risk patients or patients with a previous history of wound infection, due to their infection-resistant properties. Several studies have been carried out to assess whether biologic mesh is superior to synthetic mesh, as well as to establish guidelines for their use. Unfortunately, most of these studies were not rigorously designed and were vulnerable to different types of bias. The systematic reviews that have been published so far on this topic contain the same biases and limitations of the primary articles that are analyzed. The lack of a literature review on the bias on the use of biological mesh prompted us to conduct the literature search, assessment and plan this article.

METHODS

We performed a literature search in PubMed, Embase and Cochrane databases of systematic reviews on biologic mesh for ventral hernia repair. The literature review was conducted using the Population, Intervention, Comparisons, Outcomes and Design approach. We identified 40 studies that matched the stringent criteria we had set. We then created a 13-point instrument to assess for bias and applied it on the primary studies that we intended to analyze.

RESULTS

Most primary studies are case series or case reports of patients undergoing abdominal hernia repair with biologic mesh, without any comparison group, and the inclusion of cases was only specified to be consecutive in 6 out of 40 cases. In terms of assessing outcomes, in none of the 40 articles were the outcome assessors blinded to the intervention or exposure status of participants.

CONCLUSION

The instrument that we created could allow to assess the risk of bias in different kind of studies. Our assessment of the studies based on the criteria that we had set up in the instrument clearly identified that further research needs to be done due to the lack of unbiased studies regarding the use of biologic meshes for abdominal hernia repair.

Analysis for Patient Survival after Open Abdomen for Torso Trauma and the Impact of Achieving Primary Fascial Closure: A Single-Center Experience

Open abdomen indicates the abdominal fascia is unclosed to abbreviate surgery and to reduce physiological stress. However, complications and difficulties in patient care are often encountered after operation. During May 2008 to March 2013, we performed a prospective protocol-directed observation study regarding open abdomen use in trauma patients. Bogota bag is the temporary abdomen closure initially but negative pressure dressing is used later. A goal-directed ICU care is applied and primary fascial closure is the primary endpoint. There were 242 patients received laparotomy after torso trauma and 84 (34.7%) had open abdomen. Twenty patients soon died within one day and were excluded. Among the included 64 patients, there were 49 (76.6%) males and the mean Injury Severity Score was 31.7. Uncontrolled bleeding was the major indication for open abdomen (64.1%) and the average duration of open abdomen was about 4.2 ± 2.2 days. After treatment, 53(82.8%) had primary fascia closure, which is significant for patient survival (odds ratio 21.6; 95% confidence interval: 3.27–142, p = 0.0014). Factors related to failed primary fascia closure are profound shock during operation, high Sequential Organ Failure Assessment Score in ICU and inadequate urine amount at first 48 hours admission.

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.

A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications

BACKGROUND

The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications.

METHODS

A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated.

RESULTS

A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014).

CONCLUSION

This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

Injectable in situ cross-linking chitosan-hyaluronic acid based hydrogels for abdominal tissue regeneration

Abdominal wall defect caused by open abdomen (OA) or abdominal trauma is a serious issue since it induces several clinical problems. Although a variety of prosthetic materials are commonly employed, complications occur including host soft tissue response, fistula formation and chronic patient discomfort. Recently, abundant natural polymers have been used for injectable hydrogel synthesis in tissue regeneration. In this study, we produced the chitosan - hyaluronic acid (CS/HA) hydrogel and investigated its effects on abdominal tissue regeneration. The physical and biological properties of the hydrogel were demonstrated to be suitable for application in abdominal wounds. In a rat model simulating open abdomen and large abdominal wall defect, rapid cellular response, sufficient ECM deposition and marked neovascularization were found after the application of the hydrogel, compared to the control group and fibrin gel group. Further, the possible mechanism of these findings was studied. Cytokines involved in angiogenesis and cellular response were increased and the skew toward M2 macrophages credited with the functions of anti-inflammation and tissue repair was showed in CS/HA hydrogel group. These findings suggested that CS/HA hydrogel could prevent the complications and was promising for abdominal tissue regeneration.

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 and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis

INTRODUCTION

Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies.

METHODS

Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.

RESULTS

26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay.

CONCLUSION

Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.

In vitro pressure manifolding distribution evaluation of ABThera(™) Active Abdominal Therapy System, V.A.C.(®) Abdominal Dressing System, and Barker's vacuum packing technique conducted under dynamic conditions

OBJECTIVES

Temporary abdominal closure methods allow for management of open abdomens where immediate primary closure is not possible and/or where repeat abdominal entries are necessary. We assessed pressure mapping and fluid extraction efficiency of three open abdomen dressing systems: ABThera(™) Active Abdominal Therapy System, V.A.C.(®) Abdominal Dressing System, and Barker's vacuum packing technique.

METHODS

An in vitro test model was designed to simulate physical conditions present in an open abdomen. The model consisted of a rigid rest platform with elevated central region and a flexible outer layer with centrally located incision. Constant -125 mmHg negative pressure was applied according to the type of system, under simulated dynamic conditions, using albumin-based solution with a viscosity of 14 cP. Data were collected by pressure sensors located circumferentially into three concentric zones: Zone 1 (closest to negative pressure source), Zone 2 (immediately outside of manifolding material edge), and Zone 3 (area most distal from negative pressure source). Each value was the result of approximately 100 pressure readings/zone/experiment with a total of three experiments for each system.

RESULTS

Pressure distribution of ABThera Therapy was significantly (p < 0.05) superior to Barker's vacuum packing technique in all three evaluated zones. Similarly, V.A.C. Abdominal Dressing System pressure distribution was significantly (p < 0.05) improved compared to Barker's vacuum packing technique in all zones. There were no pressure distribution differences in Zone 1 between ABThera Therapy and V.A.C. Abdominal Dressing System; however, in Zones 2 and 3, ABThera Therapy was significantly (p < 0.05) superior to V.A.C. Abdominal Dressing System.

CONCLUSIONS

These data suggest that all approaches to negative pressure therapy for open abdomen treatment are not equal. Additional research should be conducted to elucidate clinical implications of data demonstrated here.

Ratio-driven resuscitation predicts early fascial closure in the combat wounded

BACKGROUND

Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy.

METHODS

Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure.

RESULTS

The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure.

CONCLUSION

Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Biologic versus nonbiologic mesh in ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

The current standard of treatment for most ventral hernias is a mesh-based repair. Little is known about the safety and efficacy of biologic versus nonbiologic grafts. A meta-analysis was performed to examine two primary outcomes: recurrence and wound complication rates.

METHODS

Electronic databases and reference lists of relevant articles were systematically searched for all clinical trials and cohort studies published between January 1990 and January 2012. A total of eight retrospective studies, with 1,229 patients, were included in the final analysis.

RESULTS

Biologic grafts had significantly fewer infectious wound complications (p < 0.00001). However, the recurrence rates of biologic and nonbiologic mesh were not different. In subgroup analysis, there was no difference in recurrence rates and wound complications between human-derived and porcine-derived biologic grafts.

CONCLUSIONS

Use of biologic mesh for ventral hernia repair results in less infectious wound complications but similar recurrence rates compared to nonbiologic mesh. This supports the application of biologic mesh for ventral hernia repair in high-risk patients or patients with a previous history of wound infection only when the significant additional cost of these materials can be justified and synthetic mesh is considered inappropriate.

A Case of Pediatric Abdominal Wall Reconstruction: Components Separation within the Austere War Environment

Summary:

Reconstructive surgeons supporting military operations are required to definitively treat severe pediatric abdominal injuries in austere environments. The safety and efficacy of using a components separation technique to treat large ventral hernias in pediatric patients in this setting remains understudied. Components separation technique was required to achieve definitive closure in a 12-month-old pediatric patient in Kandahar, Afghanistan. Her course was complicated by an anastomotic leak after small bowel resection. Her abdominal was successfully reopened, the leak repaired, and closed primarily without incident on postinjury day 9. Abdominal trauma with a large ventral hernia requiring components separation is extremely rare. A pediatric patient treated with components separation demonstrated minimal complications, avoidance of abdominal compartment syndrome, and no mortality.

Managing the open abdomen in a district general hospital

INTRODUCTION

The need to manage an open abdomen is becoming more common in general surgical practice and a variety of methods of temporary abdominal closure (TAC) are available. The evidence for the efficacy of the various forms of TAC as well as the subsequent definitive fascial closure (DFC) rates and complications comes mainly from large trauma series in the US, which represent a different patient population to those in the UK in whom TAC is usually required.

METHODS

All cases of open abdomen management in our hospital over a five-year period were reviewed to ascertain the methods of TAC used, our success in achieving DFC and the applicability of managing such cases in a district hospital environment.

RESULTS

Nineteen patients underwent TAC, with two deaths (10.5%) and an overall DFC rate at hospital discharge of 12/17 (70.6%). The median lengths of critical care and hospital stays were 19.5 and 38.0 days respectively. Thirteen out of seventeen survivors had at least one significant complication.

CONCLUSIONS

The management of the open abdomen can be achieved safely in a district general hospital setting with acceptable outcomes for the non-trauma patients commonly seen in UK practice but it is a resource intensive and expensive undertaking.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury

PURPOSE

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

METHODS

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

RESULTS

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

CONCLUSIONS

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.

Planned re-laparotomy and the need for optimization of physiology and immunology

Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.

Abdominal damage control surgery and reconstruction: world society of emergency surgery position paper

Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts

BACKGROUND

Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field.

METHODS

A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011.

RESULTS

The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae.

CONCLUSIONS

With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

Open abdomen management: a review of its history and a proposed management algorithm

In this review we look into the historical development of open abdomen management. Its indication has spread in 70 years from intra-abdominal sepsis to damage control surgery and abdominal compartment syndrome. Different temporary abdominal closure techniques are essential to benefit the potential advantages of open abdomen management. Here, we discuss the different techniques and provide a new treatment strategy, based on available evidence, to facilitate more consistent decision making and further research on this complicated surgical topic.

Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study

BACKGROUND

We conducted a prospective observational multi-institutional study to examine the natural history of the open abdomen (OA) after trauma and identify risk factors for failure to achieve definitive primary fascial closure (DPC) after OA use in trauma.

METHODS

Adults requiring OA for trauma were enrolled during a 2-year period. Demographics, presentation, and management variables were used to compare primary fascial closure and non-primary fascial closure patients, with logistic regression used to identify independent risk factors for failure to achieve primary fascial closure.

RESULTS

A total of 572 patients from 14 American College of Surgeons-verified Level I trauma centers were enrolled. The majority were male (79%), mean (SD) age 39 (17) years. Injury Severity Score (ISS) was 15 or greater in 85% of patients and 84% had an abdominal Abbreviated Injury Scale (AIS) score of 3 or greater. Overall mortality was 23%. Initial primary fascial closure with unaltered native fascia was achieved in 379 patients (66%). Patients surviving at least 48 hours were grouped into those achieving DPC and those who did not achieve DPC after OA use. After logistic regression, independent risk factors for failure to achieve DPC included the number of reexplorations required (adjusted odds ratio [AOR], 1.3; 95% confidence interval (CI), 1.2-1.6; p < 0.001) the development of intra-abdominal abscess/sepsis (AOR, 2.4; 95% CI, 1.2-4.8; p = 0.011) bloodstream infection (AOR, 2.6; 95% CI, 1.2-5.7; p = 0.017), acute renal failure (AOR, 2.3; 95% CI, 1.2-5.7; p = 0.007), enteric fistula (AOR, 6.4; 95% CI, 1.2-32.8; p = 0.010) and ISS of greater than 15 (AOR, 2.5; 95% CI, 1.1-5.9; p = 0.037).

CONCLUSION

Our study identifies independent risk factors associated with failure to achieve primary fascial closure during initial hospitalization after OA use for trauma. Additional study is required to validate appropriate algorithms that optimize the opportunity to achieve primary fascial closure and outcomes in this population.

LEVEL OF EVIDENCE

Prognostic study, level III.

An experience in the management of the open abdomen in severely injured burn patients

Few descriptions of temporary abdominal closure for planned relaparotomy have been reported in burned patients. The purpose of this study is to describe our experience and outcomes in the management of burned patients with an open abdomen. The authors performed a retrospective review of all admissions to our burn center from March 2003 to June 2008, identifying patients treated by laparotomy with temporary abdominal closure. The authors collected data on patient demographics, indication for laparotomy, methods of temporary and definitive abdominal closure, and outcomes. Of 2,104 patients admitted, 38 underwent a laparotomy with temporary abdominal closure. Their median TBSA was 55%, and the incidence of inhalation injury was 58%. Abdominal compartment syndrome was the most common indication for laparotomy (82%) followed by abdominal trauma (16%). The in-hospital mortality associated with an open abdomen was 68%. Temporary abdominal closure was performed most commonly using negative pressure wound therapy (90%). Fascial closure was performed in 21 patients but was associated with a 38% rate of failure requiring reexploration. Of 12 survivors, fascial closure was achieved in seven patients and five were managed with a planned ventral hernia. Burned patients who necessitate an open abdomen management strategy have a high morbidity and mortality. Fascial closure was associated with a high rate of failure but was successful in a select group of patients. Definitive abdominal closure with a planned ventral hernia was associated with no increased mortality and remains an option when "tension-free" fascial closure cannot be achieved.

Biologic grafts for ventral hernia repair: a systematic review

BACKGROUND

Biologic grafts hold promise of a durable repair for ventral hernias with the potential for fewer complications than synthetic mesh. This systematic review was performed to evaluate the effectiveness and safety of biologic grafts for ventral hernia repair.

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched for studies on biologic grafts for the repair of ventral hernias. Outcomes are presented as weighted pooled proportions.

RESULTS

Twenty-five retrospective studies were included. Recurrence depended on wound class, with an overall rate of 13.8% (95% confidence interval [CI], 7.6-21.3). The recurrence rate in contaminated/dirty repairs was 23.1% (95% CI, 11.3-37.6). Abdominal wall laxity occurred in 10.5% (95% CI, 3.7-20.3) of patients. The surgical morbidity rate was 46.3% (95% CI, 33.3-59.6). Infection occurred in 15.9% (95% CI, 9.8-23.2) of patients but only led to graft removal in 4.9% of cases.

CONCLUSIONS

No randomized trials are available to properly evaluate biologic grafts for ventral hernia repair. The current evidence suggests that biologic grafts perform similarly to other surgical options. Biologic grafts are associated with a high salvage rate when faced with infection.

Controversies in the care of the enterocutaneous fistula

Enterocutaneous fistula and its variations are some of the most difficult problems encountered in the practice of general surgery. Reliable evidence that can be used to direct the care of patients afflicted with this malady is limited. There are controversies in several areas of care. This article addresses some of the gray areas of care for the patient with enterocutaneous fistula. There is particular attention directed toward the phenomenon of enteroatmospheric fistula, as well as prevention and abdominal wall reconstruction, which is often required in these individuals.

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 evolution of damage control surgery

The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.

Advanced technologies in trauma critical care management

Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.

The effect of different temporary abdominal closure materials on the growth of granulation tissue after the open abdomen

BACKGROUND

Temporary abdominal closure (TAC) is often performed after an open abdomen to prevent postoperative complications. Reducing the time of TAC and performing a skin grafting as early as possible would improve the outcome of open abdomen. This study was designed to evaluate the effects of different TAC materials and topically applied exogenous growth factors on the growth of granulation tissue covered on the wound areas after the open abdomen.

METHODS

Healthy Sprague-Dawley rats were randomly assigned to four groups of six animals each. Twenty-four hours after induction of peritonitis and intra-abdominal hypertension by intraperitoneal injection of nitrogen, relaparotomies were done. The abdomen was then closed with polyethylene sheet or polypropylene mesh plus growth factor (or not). On the seventh day after TAC surgery, TAC materials were removed, and granulation tissue on the wound surface was assessed microscopically. Microvascular densities, thickness of granulation tissue, and fibroblast counts were also measured.

RESULTS

Microvascular densities, thickness of granulation tissue, and fibroblast counts were the highest for polypropylene mesh closure plus recombinant bovine basic fibroblast growth factor (rbFGF) followed by polypropylene mesh plus recombinant human growth hormone (rhGH) and polypropylene mesh alone, with polyethylene sheet alone being the least.

CONCLUSIONS

Polypropylene mesh could promote the growth of granulation tissue after the open abdomen. Topical application of rhGH or rbFGF further hastens the process, with the effect of rbFGF being the greatest.

Current options in the management of complex abdominal wall defects

The management of complex abdominal wall defects is challenging and often requires an individualized strategy with additional measures to minimize morbidity and recurrence. We retrospectively reviewed all patients who underwent reconstruction of complex abdominal wall defects at Emory Hospital by the senior author over a 7-year period. Abdominal hernia defects were categorized into primary, secondary, and tertiary hernias; infection; composite tumor defects; and dehiscence. Charts were queried for comorbidities, surgical technique, and outcome measures such as complications and recurrence. A total of 165 patients included in the series, with an average age of 52 years, and an average body mass index of 38 kg/m. Mesh was used in 81.8% of cases, 77% of those (mesh) being acellular dermal matrices (ADM). Component separation was performed in 75 patients (45.4%). The overall complication rate was 23.6% (39/165) including infection, delayed healing, skin necrosis, and fistulae, and was higher in patients with 2 or more comorbidities and those who required synthetic mesh reconstruction. The hernia recurrence or bulge was observed in 20.6% (34/165), and 29.4% of these patients required an additional, equally complex procedure. Hernia recurrence was significantly associated with a history of previous recurrent hernia, and hypertension (P < 0.04 and P = 0.001, respectively). Recurrence was higher in patients with 2 or more comorbidities (26% vs. 14%, P = 0.022). The recurrence rate was similar for synthetic and ADM reconstructions; however, the complication rates were higher when synthetic mesh was used. Attention to surgical technique, optimization of comorbidities, and the increased use of biologic meshes will minimize the need for operative intervention of complications following reconstruction of complex abdominal wall defects. Components separation and ADM have been very useful additions to the surgical management in these high-risk patients.

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.

Comparison of abdominal damage control surgery in combat versus civilian trauma

BACKGROUND

The majority of individuals who perform damage control surgery in the military arena are trained in civilian venues. Therefore, it is important to compare and contrast damage control performed in civilian and military settings. In contrast to civilian trauma, which is primarily caused by blunt injury and addressed at one or two surgical facilities, combat casualties primarily sustain explosion-related injuries and undergo treatment at multiple levels of care across continents. We aimed to compare patients undergoing abdominal damage control surgery across these two very different settings.

METHODS

Parallel retrospective reviews were conducted over 2 years (2005-2006) in a combat setting and at a US Level I trauma center. Patients were examined during the first 7 days after injury.

RESULTS

The civilian population (CP) was older (40 vs. 23; p < 0.01) with a higher injury severity score (35 vs. 27; p < 0.02). The CP experienced greater blunt injury than the military population (MP) (83 vs. 4%; p < 0.01). Explosion-related injury was only present in the MP (64%). At baseline, the CP presented with lower systolic blood pressure (108 vs. 126) and larger base deficit (9.8 vs. 6.5; p < 0.05). The MP underwent more surgeries (3.5 vs. 2.9; p = 0.02) with similar rates of fascial closure (48.7% vs. 70.0%; p = 0.11). Complication rates were similar between the CP and the MP (43% vs. 58%, respectively; p = 0.14).

CONCLUSIONS

Military and civilian trauma patients who undergo damage control surgery experience similar fascial closure rates despite differing demographics and widely disparate mechanisms of injury. The MP undergoes a greater number of procedures than the CP, but complication rates do not differ between the groups.

Development of a novel method of progressive temporary abdominal closure

BACKGROUND

This paper describes our experience with a novel method of temporary abdominal closure that permits frequent reassessment of the abdominal contents and progressive reapproximation of the fascial edges without compromising definitive fascial closure outcomes.

METHODS

We developed a novel method of temporary abdominal closure, which we have named the frequent assessment temporary abdominal closure (FASTAC). The records of patients who underwent planned relaparotomy during 5 years were reviewed. The data collected included patient demographics, indication for operation, number of operations, duration of temporary abdominal closure placement, hospital duration of stay, method of definitive abdominal closure, and subsequent ventral hernia repair.

RESULTS

One hundred and thirty-three patients underwent 308 temporary abdominal closure placements, including 16 patients who had a FASTAC placed for open abdomen management. FASTAC remained in place for a significantly greater time with more frequent reassessment. Fascial closure techniques were not different in FASTAC patients. FASTAC patients had a significantly greater duration of stay, which suggests selective placement in a more complicated patient population. The materials for frequent assessment temporary abdominal closure cost only $38 compared with $350 for a large piece of Silastic.

CONCLUSION

FASTAC is a novel, cost-effective method of temporary abdominal closure that allows for frequent bedside intra-abdominal surveillance, maintains abdominal domain, and does not compromise abdominal closure outcomes in the management of the open abdomen.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control

BACKGROUND

The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the world's literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen.

METHODS

A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence.

RESULTS

There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy.

CONCLUSION

The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Gun shot-101: an 8-year review of gunshot injuries in an Irish teaching hospital from a general surgical perspective

BACKGROUND

Gun-related crime offences have increased in the Republic of Ireland steadily over the past number of years. Regional trauma units are witnessing unprecedented numbers of injuries in the Republic of Ireland with limited prior experience.

AIMS

Eight-year retrospective study analysing demographic data, management and outcome of firearm-related injuries.

RESULTS

Patients who experience gunshot injuries in this region are statistically likely to be young, male and unemployed with a single shotgun injury to an extremity. Post-operative survival rates of 100% for those who undergo an exploratory laparotomy.

CONCLUSION

Ireland has comparable survival outcomes to other international centres with similar patient demographics due to timely and appropriate operative intervention. These results serve to provide a template for further patient management.

Early enteral nutrition can be successfully implemented in trauma patients with an "open abdomen"

BACKGROUND

The presence of an "open abdomen" after a trauma laparotomy can complicate the nutritional management of injured patients.

METHODS

The medical records of patients admitted to an American College of Surgeons-verified level 1 trauma center were evaluated. The timing of nutritional support was noted. The method to obtain abdominal closure was also noted.

RESULTS

Twenty-three patients were included in the study. Enteral nutrition was successfully initiated in 52% of patients before fascial closure. Enteral nutrition was initiated 3.8 days after the initial laparotomy in these patients. All patients successfully achieved fascial and skin closure, obviating the need for delayed hernia repair or skin grafting.

CONCLUSIONS

Enteral nutrition can be successfully initiated in patients with "open abdomens." In our series, early enteral nutrition did not alter our ability to ultimately obtain fascial and skin closure.

Morphological and mechanical characteristics of the reconstructed rat abdominal wall following use of a wet electrospun biodegradable polyurethane elastomer scaffold

Although a variety of materials are currently used for abdominal wall repair, general complications encountered include herniation, infection, and mechanical mismatch with native tissue. An approach wherein a degradable synthetic material is ultimately replaced by tissue mechanically approximating the native state could obviate these complications. We report here on the generation of biodegradable scaffolds for abdominal wall replacement using a wet electrospinning technique in which fibers of a biodegradable elastomer, poly(ester urethane)urea (PEUU), were concurrently deposited with electrosprayed serum-based culture medium. Wet electrospun PEUU (wet ePEUU) was found to exhibit markedly different mechanical behavior and to possess an altered microstructure relative to dry processed ePEUU. In a rat model for abdominal wall replacement, wet ePEUU scaffolds (1x2.5 cm) provided a healing result that developed toward approximating physiologic mechanical behavior at 8 weeks. An extensive cellular infiltrate possessing contractile smooth muscle markers was observed together with extensive extracellular matrix (collagens, elastin) elaboration. Control implants of dry ePEUU and expanded polytetrafluoroethylene did not experience substantial cellular infiltration and did not take on the native mechanical anisotropy of the rat abdominal wall. These results illustrate the markedly different in vivo behavior observed with this newly reported wet electrospinning process, offering a potentially useful refinement of an increasingly common biomaterial processing technique.