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Abstract
Contrary to the management strategy recommended only 2-3 years ago, temporarily covering the open abdomen with an absorbable mesh or a plastic sheath without preserving the peritoneal space is no longer considered in the patient's best interest. The use of the vacuum pack, in conjunction with vacuum-assisted wound management and new biological prostheses now offer patients with an open abdomen a better and simpler alternative to the giant "planned ventral hernia". With very few exceptions in the most critically ill patients, the survivors of damage control surgery or infected pancreatic necrosis should not be sent home with a huge defect only to undergo a complex reconstruction a year later. Simpler and better alternatives exist. The new concepts and technologies presented in this review, when widely adopted, will rapidly translate into safer and better management of the patient with an open abdomen.
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Affiliation(s)
- B G Scott
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, And Ben Taub General Hospital, Houston, Texas, USA
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Ren J, Yuan Y, Zhao Y, Gu G, Wang G, Chen J, Fan C, Wang X, Li J. Open Abdomen Treatment for Septic Patients with Gastrointestinal Fistula: From Fistula Control to Definitive Closure. Am Surg 2014. [DOI: 10.1177/000313481408000414] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of open abdomen in the management of gastrointestinal fistula complicated with severe intra-abdominal infection is uncommon. This study was designed to evaluate outcomes of our staged approach for the infected open abdomen. Patients who had gastrointestinal fistula and underwent open abdomen treatment were retrospectively reviewed. Various materials such as polypropylene mesh and a modified sandwich package were used to achieve temporary abdominal closure followed by skin grafting when the granulation bed matured. A delayed definitive operation was performed for final abdominal closure without implant of prosthetic mesh. Between 1999 and 2009, 56 (68.3%) of 82 patients survived through this treatment. Among them, 42 patients achieved final abdominal closure. Spontaneous fistula closure occurred in 16 patients with secondary fistula recorded in six patients. Besides, wound complications occurred in 13 patients with two cases for pulmonary infection. Within a 12-month follow-up period after definitive closure, no additional fistula was recorded excluding planned ventral hernia repair. Open abdomen treatment was effective for gastrointestinal fistula complicated by severe intra-abdominal infection. A delayed and deliberate operative strategy aiming at fistula excision and fascial closure, with simultaneous abdominal wall reconstruction, was required for the infected open abdomen.
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Affiliation(s)
- Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- Department of Gastrointestinal-Pancreatic Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yujie Yuan
- Department of Gastrointestinal-Pancreatic Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yunzhao Zhao
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Guosheng Gu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Chen
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chaogang Fan
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xinbo Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit 2013; 19:524-33. [PMID: 23823991 PMCID: PMC3706408 DOI: 10.12659/msm.883966] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022] Open
Abstract
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.
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Schoenmaeckers EJ, Woittiez AJ, Raymakers JF, Rakic S. Continuous Ambulatory Peritoneal Dialysis After Intra-Abdominally Placed Synthetic Mesh for Ventral Hernia Repair. J Laparoendosc Adv Surg Tech A 2011; 21:741-3. [DOI: 10.1089/lap.2011.0160] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - S. Rakic
- Department of Surgery, ZGT Hospital, Almelo, The Netherlands
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Losanoff JE, Salwen WA, Basson MD. Temporary Abdominal Coverage Using One or More “Fish” Visceral Retainers. Am Surg 2011. [DOI: 10.1177/000313481107700135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Julian E. Losanoff
- John D. Dingell VA Medical Center Detroit, Michigan and Wayne State University Detroit, Michigan
| | - Walter A. Salwen
- John D. Dingell VA Medical Center Detroit, Michigan and Wayne State University Detroit, Michigan
| | - Marc D. Basson
- John D. Dingell VA Medical Center Detroit, Michigan and Michigan State University Lansing, Michigan
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Zuriarrain A, Shay A, Demarest G. The sentinel placement of an open abdomen negative pressure unit. Int J Surg Case Rep 2010; 2:4-5. [PMID: 22096673 DOI: 10.1016/j.ijscr.2010.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022] Open
Abstract
The open abdomen is a common condition after a trauma necessitating celiotomy with the inability to close the fascia either due to damage control surgery or abdominal compartment syndrome. Traditionally the open abdomen has been approached with the use of the open abdomen temporary abdominal closure (Barker Vacuum Pack Dressing). More recently there has been the addition of the ABThera™ open abdomen negative pressure unit introduced by KCI. Our case report is based on the first patient to have placement of the ABThera™ device.
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Drumond DAF. Fechamento de laparostomia com descolamento cutâneo-adiposo: uma técnica simples e eficaz para um problema complexo. Rev Col Bras Cir 2010; 37:175-83. [DOI: 10.1590/s0100-69912010000300004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 05/06/2009] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Descrever uma técnica de fechamento de laparostomia através de descolamento cutâneo-adiposo e os resultados obtidos. MÉTODOS: Entre janeiro de 2003 a outubro de 2008 quarenta pacientes laparostomizados com silo plástico (bolsa de Bogotá) foram fechados usando-se a técnica descrita neste trabalho. Dados foram coletados dos prontuários e da busca ativa após alta hospitalar. RESULTADOS: A maioria dos pacientes eram homens (95%), com trauma por arma de fogo (70%). As médias de ISS e APACHE II foram de 28,78 e 20, respectivamente. Hérnia ventral ocorreu em 81,5% dos pacientes, num intervalo médio de seguimento de 9,2 meses. Aproximadamente 1/3 dos pacientes apresentavam hérnias pequenas e não desejavam corrigi-las quando questionados. Somente dois pacientes estavam insatisfeitos com o procedimento em relação a atividades cotidianas e aspectos estéticos. Não houve óbitos ou fístulas intestinais em decorrência do fechamento. CONCLUSÃO: Embora não represente uma técnica de fechamento mioaponeurótico, o descolamento cutâneo-adiposo é simples, seguro e de baixo custo. É uma boa opção terapêutica para os pacientes laparostomizados, principalmente quando o fechamento da aponeurose não for possível nos primeiros 7 a 10 dias.
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A ten-year review of enterocutaneous fistulas after laparotomy for trauma. ACTA ACUST UNITED AC 2009; 67:924-8. [PMID: 19901649 DOI: 10.1097/ta.0b013e3181ad5463] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the era of open abdomen management, the complication of enterocutaneous fistula (ECF) seems to be increasing in frequency. In nontrauma patients, reported mortality rates are 7% to 20%, and spontaneous closure rates are approximately 25%. This study is the largest series of ECFs reported exclusively caused by trauma and examines the characteristics unique to this population. METHODS Trauma patients with an ECF at a single regional trauma center over a 10-year period were reviewed. Parameters studied included fistula output, site, nutritional status, operative history, and fistula resolution (spontaneous vs. operative). RESULTS Approximately 2,224 patients received a trauma laparotomy and survived longer than 4 days. Of these, 43 patients (1.9%) had ECF. The rate of ECF in men was 2.22% and 0.74% in women. Patients with open abdomen had a higher ECF incidence (8% vs. 0.5%) and lower rate of spontaneous closure (37% vs. 45%). Spontaneous closure occurred in 31% with high-output fistulas, 13% with medium output, and 55% with low output. The mortality rate of ECF was 14% after an average stay of 59 days in the intensive care unit. CONCLUSION With damage-control laparotomies, the traumatic ECF rate is increasing and is a different entity than nontraumatic ECF. Although the two populations have similar mortality rates, the trauma cohort demonstrates higher spontaneous closure rates and a curiously higher rate of development in men. Fistula output was not predictive of spontaneous closure.
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Wind J, van Koperen PJ, Slors JFM, Bemelman WA. Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg 2008; 197:24-9. [PMID: 18639232 DOI: 10.1016/j.amjsurg.2007.11.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 11/05/2007] [Accepted: 11/05/2007] [Indexed: 10/21/2022]
Abstract
BACKGROUND Closure of an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects is a challenging problem. In the present study, the results of the components separation technique are described. METHODS All patients with an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects (ie, laparostomy of ventral hernia) who underwent a single-stage repair using the components separation technique in the period from January 2000 to July 2007 were reviewed retrospectively. RESULTS A total of 32 patients were included. The median operating time was 204 minutes (range 87-573). In 18 patients, additionally to the components separation, an absorbable mesh was used. Postoperatively, in 16 patients 22 complications were reported. There were 9 patients with local wound problems. The median postoperative hospital stay was 12 days (range 5-74). Seven patients developed a ventral hernia. Four of them were small asymptomatic recurrences. Four out of the 15 patients with an enterocutaneous fistula developed a recurrent fistula. The median follow-up was 20 months (range 3-54). CONCLUSION Closure of enterocutaneous fistula and/or stomas and simultaneous repair of large abdominal wall defects is feasible using the components separation technique but morbidity is considerable. Early recurrence of abdominal hernia and fistula is acceptable.
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Affiliation(s)
- Jan Wind
- Department of Surgery, Academic Medical Center, Postbox 22660, 1100 DD Amsterdam, the Netherlands
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Arigon JP, Chapuis O, Sarrazin E, Pons F, Bouix A, Jancovici R. Prise en charge des abdomens ouverts par la thérapie vacuum-assisted closure (VAC®) : évaluation rétrospective de 22 malades. ACTA ACUST UNITED AC 2008; 145:252-61. [DOI: 10.1016/s0021-7697(08)73755-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gäddnäs F, Saarnio J, Ala-Kokko T, Laurila J, Koivukangas V. Continuous retention suture for the management of open abdomen: a high rate of delayed fascial closure. Scand J Surg 2008; 96:301-7. [PMID: 18265858 DOI: 10.1177/145749690709600408] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Open abdomen is most often a consequence of damage control surgery, abdominal decompression or intra-abdominal infections. Ventral hernia after unsuccessful closure of open abdomen causes marked disability to the patient. Several methods for delayed fascial closure have been developed. Patients treated with continuous retention suture were evaluated to find out how often fascial closure was achieved, and what complications were related to the technique. METHOD A retrospective analysis of 16 open abdomen patients treated with continuous retention suture. RESULTS The most common cause of open abdomen was abdominal infection. Complete fascial closure was achieved in nine of the eleven surviving patients. Closure failed in one patient. Partial closure was also achieved in one patient. The median time between leaving the abdomen open and starting the process of closure was twelve days. The longest period of open abdomen before successful fascial closure was 29 days. Five patients died before the process of closure was complete. CONCLUSION Delayed fascial closure can be accomplished by using the retention suture method described here.
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Affiliation(s)
- F Gäddnäs
- Department of Surgery, Division of Intensive Care, Oulu University Hospital, Oulu, Finland
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12
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Losanoff JE, Millis JM. Temporary abdominal coverage for adult liver transplantation. Liver Transpl 2007; 13:1349-50; author reply 1351-2. [PMID: 17763392 DOI: 10.1002/lt.21216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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13
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Torres Neto JDR, Barreto AP, Prudente ACL, Santos AMD, Santiago RR. Uso da peritoneostomia na sepse abdominal. ACTA ACUST UNITED AC 2007. [DOI: 10.1590/s0101-98802007000300005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Dentre as modalidades terapêuticas da sepse abdominal, a peritoneostomia tem papel decisivo permitindo explorações e lavagens da cavidade de forma facilitada. Observamos pacientes com diagnóstico clínico de sepse abdominal internados no Serviço de Coloproctologia do Hospital Universitário da Universidade Federal de Sergipe, e que foram submetidos a peritoneostomia de janeiro de 2004 a janeiro de 2006. Foram avaliados quanto ao diagnóstico primário e secundário, tipo de peritonite secundária, antibioticoterapia, esquema de lavagens, tempo de peritoneostomia, complicações e desfecho. Estudamos 12 pacientes, com idade de 15 a 57, média de 39,3 anos. Diagnóstico primário: abdome agudo inflamatório em 6(50%), abdome agudo obstrutivo em 2(16,7%), abdome agudo perfurativo em 2(16,7%), fístula enterocutânea em 1(8,3%) e abscesso intra-cavitário em 1(8,3%). Diagnóstico secundário: perfuração de cólon em 4(33,3%), abscessos intra-cavitários em 3(25%), deiscências de anastomoses em 3(25%), 1(8,3%) com tumor perfurado de sigmóide e 1(8,3%) com necrose de cólon abaixado. Peritonite fecal em 10(83,3%) e purulenta em 2(16,7%). A antibioticoterapia teve duração média de 19 dias. Lavagens de demanda em 6(50%), programadas em 4(33,3%) e regime misto em 2(16,7%). O tempo médio de peritoneostomia foi de 10,9 dias (1-36). Como complicações: evisceração em 2(16,7%) e fistulização em 1(8,3%). Quatro pacientes evoluíram com óbito.
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Aydin C, Aytekin FO, Yenisey C, Kabay B, Erdem E, Kocbil G, Tekin K. The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis. Langenbecks Arch Surg 2007; 393:67-73. [PMID: 17530284 DOI: 10.1007/s00423-007-0189-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 03/07/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections. MATERIALS AND METHODS Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day. RESULTS The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group. CONCLUSION Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.
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Affiliation(s)
- Cagatay Aydin
- Pamukkale Universitesi, Tip Fakultesi, Genel Cerrahi A.D, 20070 Kinikli, Denizli, Turkey.
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Sullivan SR, Engrav LH, Anaya DA, Bulger EM, Foy HM. Bilateral anterior abdominal bipedicle flap with permanent prosthesis for the massive abdominal skin-grafted hernia. Am J Surg 2007; 193:651-5. [PMID: 17434376 DOI: 10.1016/j.amjsurg.2006.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 12/11/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fascial closure after damage control or decompression laparotomy is not always possible. The result is a ventral hernia covered with skin grafts. Massive hernias impair bowel, bladder, and respiratory function and are displeasing aesthetically. Most repair methods provide inadequate closure of large full-thickness abdominal wall defects. We describe our method of repair using bilateral anterior abdominal bipedicle flaps over permanent mesh. METHODS We reviewed 6 patients who underwent this repair method. This staged repair first involves flap elevation followed by delay. In the next stage, the hernia skin graft is excised, mesh is placed, and flaps are advanced to midline to cover the mesh. RESULTS The average hernia size was 885 +/- 274 cm2 (28-cm wide x 31-cm vertical), with a range of up to 37-cm wide. An average of 3 surgeries were required for closure, with a mean hospital stay of 22 days. No patients developed hernia recurrence with a mean follow-up period of 23 months. CONCLUSIONS This method provides successful and durable closure of massive skin-grafted hernias.
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Affiliation(s)
- Stephen R Sullivan
- Division of Plastic and Reconstructive Surgery, University of Washington, Harborville Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104-9796, USA
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Abstract
BACKGROUND The open abdomen, or laparostomy, is becoming increasingly used in the management of critically ill surgical patients. METHODS The published work on laparostomy is reviewed, in the light of personal experience, with particular attention to the history and pathophysiology associated with laparostomy. RESULTS AND CONCLUSION The combination of an inert plastic sheet in contact with the viscera, and the application of subatmospheric pressure on the wound, is an effective combination to maximize the prospects of delayed primary wound closure while minimizing the chance of fistula and ventral hernia.
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Affiliation(s)
- Alan de Costa
- Department of Surgery, Cairns Base Hospital, Cairns Private Hospital, Mount Druitt Hospital Sydney, New South Wales, Australia
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Kendrick JE, Leath CA, Melton SM, Straughn JM. Use of a fascial prosthesis for management of abdominal compartment syndrome secondary to obstetric hemorrhage. Obstet Gynecol 2006; 107:493-6. [PMID: 16449161 DOI: 10.1097/01.aog.0000168445.41145.7b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Massive obstetric hemorrhage can be catastrophic, with considerable maternal morbidity and mortality. CASE A 41-year-old term gravida experienced massive postpartum hemorrhage attributed to an amniotic fluid embolism with rapid development of disseminated intravascular coagulation and resultant abdominal compartment syndrome. In this critically ill patient, a fascial prosthesis used for abdominal wall closure was placed to expedite multiple abdominal explorations and packing. Additionally, this device facilitated fascial closure once the abdominal compartment syndrome was resolved. CONCLUSION Abdominal compartment syndrome resulting from overwhelming obstetric hemorrhage may necessitate emergent decompressive laparotomy to alleviate increased intra-abdominal pressure and end-organ dysfunction. The fascial prosthesis allows a staged abdominal wall closure to be performed once the abdominal compartment syndrome is resolved.
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Affiliation(s)
- James E Kendrick
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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Miller RS, Morris JA, Diaz JJ, Herring MB, May AK. Complications after 344 damage-control open celiotomies. ACTA ACUST UNITED AC 2006; 59:1365-71; discussion 1371-4. [PMID: 16394910 DOI: 10.1097/01.ta.0000196004.49422.af] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We reviewed our experience with the open abdomen and hypothesized that the known high wound complication rates were related to the timing and method of wound closure. METHODS All trauma admissions from 1995 through 2002 requiring an open abdomen and temporary abdominal coverage were included. The study group was then classified by three wound closure methods used in survivors: 1) primary (primary fascial closure); 2) temporizing (skin only, spit thickness skin graft and/or absorbable mesh), and 3) prosthetic (fascial repair using nonabsorbable prosthetic mesh). RESULTS In all, 344 patients required an open abdomen and temporary abdominal coverage either as part of a planned staged damage-control celiotomy (66%) or the development of the abdominal compartment syndrome (33%). Of these, 276 patients survived to wound closure. Sixty-nine of the 276 (25%) suffered wound complications (wound infection, abscess, and/or fistula). Thirty-four (12%) died after wound closure; seven of the deaths as a direct result of the wound complication. Complications increased significantly after 8 days (p < 0.0001) from the initial operative intervention to fascial closure. Primary fascial closure was achieved in 180 of 276 (65%) patients. Although there was no difference in the mean Injury Severity Score between the three groups, the primary group had significantly fewer mean transfusion requirements, shorter mean time to fascial closure, and a lower complication rate as compared with either the temporizing or prosthetic groups. The primary group thus incurred significantly less mean initial hospitalization charges. CONCLUSION Morbidity associated with wound complications from the open abdomen remains high (25%). Morbidity is associated with the timing and method of wound closure and transfusion volume, but independent on injury severity. Also, delayed primary fascial closure before 8 days is associated with the best outcomes with the least charges.
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Affiliation(s)
- Richard S Miller
- Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
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Losanoff JE, Millis JM. Susceptibility of prosthetic biomaterials to infection. Surg Endosc 2005; 20:174-5. [PMID: 16247570 DOI: 10.1007/s00464-005-0071-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 02/10/2005] [Indexed: 10/25/2022]
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Howdieshell TR, Proctor CD, Sternberg E, Cué JI, Mondy JS, Hawkins ML. Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen. Am J Surg 2004; 188:301-6. [PMID: 15450838 DOI: 10.1016/j.amjsurg.2004.03.007] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2003] [Revised: 03/16/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.
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Affiliation(s)
- Thomas R Howdieshell
- Department of Surgery, Trauma/Surgical Critical Care, University of New Mexico Health Sciences Center, MSC10-5610, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Mayberry JC, Burgess EA, Goldman RK, Pearson TE, Brand D, Mullins RJ. Enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure for trauma: the plain truth. ACTA ACUST UNITED AC 2004; 57:157-62; discussion 163-3. [PMID: 15284567 DOI: 10.1097/01.ta.0000102411.69521.80] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
HYPOTHESIS The severity of abdominal injury is the determining factor for the development of enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure (AMPC) for trauma. METHODS We conducted a retrospective analysis of case series that included 140 consecutive trauma patients with AMPC surviving more than 48 hours from October 1, 1989, to March 31, 2000, at a Level I trauma center. The days until abdominal wall reconstruction was used as a measure of exposure of the viscera to the mesh. The abdominal trauma index (ATI) was used as the measure of injury severity. Statistical analysis included t test comparisons, logistic regression analysis, and life-table analysis for hernia development. RESULTS Enterocutaneous fistula occurred in 10 patients (7.1%). The ATI (mean, 32.5 +/- 23.1) was the only variable independently associated with fistula formation (p = 0.01). The risk of fistula increased by 4% for each 1 unit increase in ATI (95% confidence interval [CI], 1-7%). One hundred seventeen patients (84%) survived to completion of abdominal wall reconstruction over a mean of 18.9 +/- 22.5 days and 3.6 +/- 1.9 operations. The number of days until abdominal wall reconstruction was the only variable independently associated with ventral hernia development (p < 0.001). The likelihood of fascial closure decreased by 26% (95% CI, 16-44%) per day and the risk of ventral hernia increased by 16% (95% CI, 9-23%) per day. The hernia development rate at 4 years (per life table) was 67% for the total, 13% for patients with delayed fascial closure, and 80% for patients requiring other closure techniques. CONCLUSION Although the severity of abdominal injury is the most important factor for fistula formation, the most important factor for ventral hernia development is the duration of AMPC. Daily interventions, such as mesh tightening, may be necessary to limit ventral hernia in these high-risk patients.
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Affiliation(s)
- John C Mayberry
- Department of Surgery, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Kapadia F. The cost implications of surveillance of ICU infections. Indian J Crit Care Med 2004. [DOI: 10.5005/ijccm-8-1-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Sauter ER. Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique (Br J Surg 2003; 90: 718-722). Br J Surg 2003; 90:1021-2. [PMID: 12905561 DOI: 10.1002/bjs.4359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Foy HM, Nathens AB, Maser B, Mathur S, Jurkovich GJ. Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control laparotomy. Am J Surg 2003; 185:498-501. [PMID: 12727574 DOI: 10.1016/s0002-9610(03)00059-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The ability to massively transfuse and resuscitate critically ill surgical patients has resulted in unprecedented survival and a new set of complications including abdominal compartment syndrome (ACS) and the "unclosable" abdomen. Traditional methods of temporary abdominal closure have met with several limitations, not the least of which is a marked delay in achieving definitive fascial closure. Since 1991, we have consistently used reinforced silicone elastomer (Silastic) sheeting as a form of temporary abdominal closure in these settings. We report our results using this technique in a large cohort of critically ill surgical patients. METHODS All patients undergoing silicone elastomer temporary abdominal closure since 1991 were identified and their charts abstracted for principal diagnosis and indication for temporary abdominal closure, fluid requirements, number of operations, and time to fascial closure. Time to definitive closure in the respective groups was analyzed using Kaplan-Meir survival curves and the Wilcoxon rank-sum test. Odds ratios for death were analyzed using logistic regression. RESULTS One hundred thirty-four patients underwent temporary abdominal closure with silicone elastomer over this period and only 62% (83) survived their hospital admission. Trauma and ruptured abdominal aortic aneurysm were the most frequent diagnoses. The most frequent indication was edema precluding abdominal closure. The mean crystalloid and blood requirements in the 24 hours preceding temporary abdominal closure were 21 +/- 16 L and 15 +/- 11 U, respectively. Of survivors, 75% (63 of 83) achieved fascial closure during their index admission. The median time to fascial closure in patients ultimately closed was 5 days. The median time to closure and the proportion of patients ultimately closed varied with the indication for closure with an earlier and greater chance of success in patients who could not tolerate closure (ACS) or could not be closed primarily (edema). Age-adjusted mortality was 5 times (95% confidence interval: 2 to 13) higher in patients developing ACS. CONCLUSIONS Nylon reinforced silicone elastomer is a safe, reliable material for temporary abdominal closure in severely ill patients. Primary fascial closure can be obtained in a timely fashion in the majority of patients. The success of obtaining definitive fascial closure depends on the indication for temporary abdominal closure, with visceral edema and ACS having the highest likeliest of early success.
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Affiliation(s)
- Hugh M Foy
- Department of Surgery, Harborview Medical Center, University of Washington, Box 359796, 325 9th Avenue, Seattle, WA 98104, USA.
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Losanoff JE, Richman BW, Jones JW. Intestinal fistulization in the open treatment of peritonitis. Am J Surg 2003; 185:394; author reply 394-5. [PMID: 12657397 DOI: 10.1016/s0002-9610(02)01428-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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