Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema

Improved subcutaneous edema segmentation on abdominal CT using a generated adipose tissue density prior

PURPOSE

Edema, or swelling, is a common symptom of kidney, heart, and liver disease. Volumetric edema measurement is potentially clinically useful. Edema can occur in various tissues. This work focuses on segmentation and volume measurement of one common site, subcutaneous adipose tissue.

METHODS

The density distributions of edema and subcutaneous adipose tissue are represented as a two-class Gaussian mixture model (GMM). In previous work, edema regions were segmented by selecting voxels with density values within the edema density distribution. This work improves upon the prior work by generating an adipose tissue mask without edema through a conditional generative adversarial network. The density distribution of the generated mask was imported into a Chan-Vese level set framework. Edema and subcutaneous adipose tissue are separated by iteratively updating their respective density distributions.

RESULTS

Validation results on 25 patients with edema showed that the segmentation accuracy significantly improved. Compared to GMM, the average Dice Similarity Coefficient increased from 56.0 to 61.7% ([Formula: see text]) and the relative volume difference decreased from 36.5 to 30.2% ([Formula: see text]).

CONCLUSION

The generated adipose tissue density prior improved edema segmentation accuracy. Accurate edema volume measurement may prove clinically useful.

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.

Direct Peritoneal Resuscitation in Trauma Patients Results in Similar Rates of Intra-Abdominal Complications

Background: Trauma patients undergoing damage control surgery (DCS) have a propensity for complicated abdominal closures and intra-abdominal complications. Studies show that management of open abdomens with direct peritoneal resuscitation (DPR) reduces intra-abdominal complications and accelerates abdominal closure. This novel study compares intra-abdominal complication rates and the effect of DPR initiation in patients who received DPR and those who did not. Patients and Methods: A retrospective chart review was performed on 120 patients who underwent DCS. Fifty patients were identified as DCS with DPR, and matched to 70 controls by gender, race, age, body mass index (BMI), past medical history, mechanism of trauma, and injury severity score. Results: The two groups of patients, those without DPR (-DPR) and those with DPR (+DPR), were similar in their characteristics. The +DPR group was more likely to have a mesh closure than the -DPR (14% and 3%; p = 0.022). The +DPR group took longer to have a final closure (3.5 ± 2.6 days vs. 2.5 ± 1.8; p = 0.020). Infection complications and mechanical failure of the closure technique were similar among the two groups. Timing of DPR initiation had no effect on closure type but did statistically increase the number of days to closure (initiation at first operation 2.8 ± 1.8 days vs. initiation at subsequent operations 6.0 ± 3.3 days; p ≤ 0.001). Conclusions: The use of DPR did not result in different outcomes in trauma patients. Therefore, traditional resuscitative measures for DCS may not be inferior to DCS with DPR. When choosing to use DPR, initiating it at the first operation could reduce the number of days to closure.

Managing the Open Abdomen in Damage Control Surgery: Should Skin-Only Closure be Abandoned?

During damage control laparotomy, surgery is abbreviated to allow for the correction of physiologic disturbances, with a plan to return to the operating theatre for definitive surgical repair. Re-entry into the abdomen is facilitated by temporary abdominal closure (TAC). Skin-only closure is one of the many techniques described for TAC Numerous sources advise against the use of this technique because of the risk of complications. This case report describes the use of skin-only closure during a damage control laparotomy. We reviewed the literature surrounding the various options for TAC to elucidate the potential role of skin-only closure after damage control laparotomy.

Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis?

AIM

To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis.

METHODS

We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition.

RESULTS

The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days).

CONCLUSION

NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.

Closing Contaminated Fascial Defects With Synthetic Mesh and a Vacuum-Assisted Closure Device

BACKGROUND

The use of synthetic mesh is considered too high risk, and therefore, not an option when closing a contaminated abdominal fascial defect. This study evaluated the clinical outcomes when using synthetic mesh combined with vacuum-assisted closure (VAC) dressing to close these facial defects.

MATERIALS AND METHODS

From 2010 to 2016, a retrospective review was performed, including 34 patients in a single rural trauma center who underwent a damage control laparotomy in the presence of a contaminated or infected field. Definitive abdominal closure with a bridging polypropylene mesh along with the application of a VAC dressing was done in all cases. Data collection included baseline demographics, operative indication, postoperative complications, mortality and length of follow up.

RESULTS

Median age of the patients was 67 y (IQR 40-87 y), with 22 (65%) being male at the time of operation. The median duration of clinical follow-up was 15.15 mo. The observed complications included three fistulas, two hernias, nine draining sinus tracts, and three mesh explanations with an overall complication rate of 41.1%. Although the absolute observed fistula rate was 8.8% (3 cases), the adjusted mesh-related fistulas formation rate after chart review was 0.0%. No mortalities were attributed directly to mesh-related complication.

CONCLUSIONS

This study found no mesh-related fistulas when using a synthetic mesh along with a VAC dressing for abdominal closure in a contaminated field. These results may provide a platform for further study regarding the safety of this technique.

Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis

Background

Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication.

Methods

A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization.

Results

Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure.

Conclusions

Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.

Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review

BACKGROUND

Abdominal compartment syndrome (ACS) in severely injured patients is associated with high morbidity and mortality. Many efforts have been made to improve outcome of patients with ACS. A treatment algorithm for ACS patients was introduced on January 1, 2005 by the World Society of the Abdominal Compartment Syndrome. The aim of this study was to determine the prevalence and mortality rate of ACS among severely injured patients before and after January 1, 2005 using a systematic literature review.

METHOD

Databases of Embase, Medline (OvidSP), Web of Science, CINAHL, CENTRAL, PubMed publisher, and Google Scholar were searched for terms related to severely injured patients and ACS. Original studies reporting ACS in trauma patients were considered eligible. Data on study design, population, definitions, prevalence, and mortality rates were extracted. Pooled prevalence and mortality of ACS among severely injured patients were calculated for both time periods using inversed variance weighting assuming a random effects model. Tests for heterogeneity were applied.

RESULTS

A total of 80 publications were included. Prevalence of studies that finished enrolling patients before January 1, 2005 ranged from 0.5% to 36.4% and 0.0% to 28.0% in studies after that date. For severely injured patients admitted to the ICU, this range was 0.5% to 1.3% before 2005 and 0% in one publication in the second time period. For patients with visceral injuries, ACS prevalence ranged 1.0% to 20.0%; one study in the second time period reported 11.1%. The prevalence among severely injured patients who underwent trauma laparotomy ranged from 0.9% to 36.4% in the first time period. Two studies after January 1, 2005 reported ACS prevalence of 2.3% and 13.2%, respectively. The mortality rate in both time periods ranged between 0.0% and 100.0%.

CONCLUSION

The overall prevalence of ACS ranged from 0.0% to 36.4%. Future studies are needed to measure the effect of improved trauma care and effectiveness of the World Society of the Abdominal Compartment Syndrome Consensus Statements.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

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.

The Compartment Syndrome of the Abdominal Cavity: A State of the Art Review

Abdominal compartment syndrome gains increasing recognition. It impairs physiology and requires treatment. It occurs more commonly with acute rather than chronic abdominal hypertension. Functional impairments involve the cardiovascular system, respiratory system, hepatic, renal, and gastrointestinal function, and intracranial pressure. Abdominal hypertension decreases venous return, increases systemic vascular resistance and intrathoracic pressure, and therefore reduces cardiac output. It also adversely affects cardiovascular monitoring. In the presence of increased abdominal pressure, atelectasis and pneumonia are likely to develop and impaired ventilation may lead to respiratory failure. Also, blood flow to the liver and kidney may be reduced, resulting in functional impairment of both organs. The adverse effects on gastrointestinal function result from impairing lymphatic, venous, and arterial flow. Anastomotic healing may become a problem under these circumstances. Decreased venous return through the inferior vena cava in obese patients may lead to venous stasis ulcers and hemorrhage. The correlation of increased intracranial pressure and intra-abdominal pressure may be a problem for trauma patients with simultaneous injuries to the head and the abdomen. There are three severity grades of increased intra-abdominal pressure: Acute sustained elevation of intra-abdominal pressure above 10–20 mmHg is called mild abdominal hypertension. Physiologic effects are generally well compensated and usually clinically nonsignificant. Nonoperative therapy may be required. Moderate hypertension is defined as sustained elevation of 21–35 mmHg. Therapy is generally necessary. Surgical abdominal-decompression may be critical. Severe hypertension or abdominal compartment syndrome is defined as sustained elevation above 35 mmHg. Operative decompression is always indicated. The gap between the abdominal wound edges must be temporarily covered to prevent fascia retraction and formation of a huge hernia. All detrimental effects of elevated intra-abdominal pressure and the methods and benefits of its decompression have been well studied, both in the laboratory and in clinical practice. Diagnostic suspicion may be confirmed with objective measurements of intra-abdominal pressure to select patients who may benefit from decompression. Operative decompression is achieved by abdominal fasciotomy and covering the fascial gap with mesh made of Marlex®, Gore-Tex®, silastic, or by a Velcro-like closure mesh (artificial bur). All meshes help to effectively decompress the abdomen. The artificial bur offers further advantages by permitting successive reapproximation of the fascia until final fascial closure, and avoiding the fistula and hernia formation seen with the other meshes.

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.

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication

Background

Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances.

Method

A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR.

Results

From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well.

Conclusions

In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review

Open abdomen (OA) has been an effective treatment for abdominal catastrophes in traumatic and general surgery. However, management of patients with OA remains a formidable task for surgeons. The central goal of OA is closure of fascial defect as early as is clinically feasible without precipitating abdominal compartment syndrome. Historically, techniques such as packing, mesh, and vacuum-assisted closure have been developed to assist temporary abdominal closure, and techniques such as components separation, mesh-mediated traction, bridging fascial defect with permanent synthetic mesh, or biologic mesh have also been attempted to achieve early primary fascial closure, either alone or in combined use. The objective of this review is to present the challenges of these techniques for OA with a goal of early primary fascial closure, when the patient's physiological condition allows.

Delayed primary closure in open abdomen with stoma using dynamic closure system

BACKGROUND

The situation of abdominal sepsis secondary to colonic perforation sometimes forces treat the patient with multiple interventions in the open abdomen (OA) context. Correct management of OA is important to restore the patient's clinical situation and to avoid further complications of the abdominal wall. Delayed primary closure of the abdomen using a dynamic and progressive traction is a relatively new technique for treating the OA.

CASE PRESENTATION

We report the case of a 50 year old woman with history of malnutrition and chronic obstructive pulmonary disease, affects for an OA after several surgical interventions. Two previous interventions (right colectomy, ileostomy and laparotomy with Bogotá bag) for disseminated peritonitis and abdominal compartment syndrome were performed. Six days after the Bogota bag the of the dynamic closure system ABRA(®) system was placed to delayed primary closure of the abdomen with excellent result results of the contingency of the abdominal wall.

DISCUSSION

The most common technique in the current management of OA is the placement of vacuum-assisted closure or the use of a mesh. These systems generally require several operations to restore the integrity of the abdominal wall. However, the dynamic closure of the abdominal wall makes it possible to restore it into the same process.

CONCLUSIONS

ABRA system allows delayed primary closure of the abdominal wall in an OA by sepsis secondary to colonic perforation. The stoma was not a problem with this technique. The final closure of the abdomen was at 16 days after the ABRA placement. The abdominal wall has not alterations in the follow up after 3 years.

The Value of Vacuum-Assisted Closure in Septic Patients Treated with Laparostomy

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration ( P < 0.001), number of dressing changes ( P < 0.001), re-exploration rate ( P < 0.002), successful abdominal closure rate ( P < 0.0001), and development of enteroatmospheric fistulas ( P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

Surgical strategies for management of the open abdomen

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

Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery

BACKGROUND

Damage control surgery is a staged approach to the trauma patient in extremis that improves survival, but leads to open abdominal wounds that are difficult to manage. We evaluated whether directed peritoneal resuscitation (DPR) when used as a resuscitation strategy in severely injured trauma patients with hemorrhagic shock requiring damage control surgery would affect the amount of and timing of resuscitation and/or show benefits in time to abdominal closure and reduction of intra-abdominal complications.

STUDY DESIGN

A retrospective case-matched study of patients undergoing damage control surgery for hemorrhagic shock secondary to trauma between January 2005 and December 2008 was performed. Twenty patients undergoing standardized wound closure and adjunctive DPR were identified and matched to 40 controls by Injury Severity Score, age, gender, and mechanism of injury. A single early death was excluded because of inability to control ongoing hemorrhage.

RESULTS

There were no differences in age, gender, or mechanism of injury between the groups. Injury Severity Score (35.07 +/- 17.1 versus DPR 34.95 +/- 16.95; p = 0.82) and packed red blood cell administration in 24 hours (23.8 +/- 14.35 U versus DPR 26.9 +/- 14.1 U; p = 0.43) were similar between the groups. Presenting pH was similar between the study group and the DPR group (7.24 +/- 0.13 d versus DPR 7.26 +/- 0.11; p = 0.8). Time to definitive abdominal closure was significantly less in the DPR group compared with controls (DPR: 4.35 +/- 1.6 d versus 7.05 +/- 3.31; p < 0.003). DPR also allowed for a higher rate of primary fascial closure, lower intra-abdominal complication rate, and lower rate of ventral hernia formation at 6 months. Adjunctive DPR afforded a definitive wound closure advantage compared with Wittmann patch closure techniques (DPR 4.35 +/- 1.6 versus Wittmann patch 6.375 +/- 1.3; p = 0.004).

CONCLUSIONS

The addition of adjunctive DPR to the damage control strategy shortens the interval to definitive fascial closure without affecting overall resuscitation volumes. As a result, this mitigates intra-abdominal complications associated with open abdomen and damage control surgery and affords better patient outcomes.

[Damage control concept in liver trauma. Package strategies and secondary measures]

Liver injuries may occur alone as well as within the broader context of polytrauma. Immediate surgical intervention is indicated in hemodynamically instable patients with detection of free intra-abdominal fluid as demonstrated by imaging studies. For these patients, a damage control concept has been devised in order to decrease early mortality after trauma. With this strategy complex reconstructive interventions are avoided during the initial phase. Stabilization of the patient by treatment of the lethal triad consisting of hypothermia, coagulopathy and metabolic acidosis is at the core of this therapeutic concept. Should there be a need for reconstructions or other major surgical interventions these will be performed with delay after stabilization of the patient. Packing for the temporary treatment of liver injuries is part of the damage control concept.

Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen

Background

This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This “open abdomen” must then be temporarily closed. However, the FC rate varies between techniques.

Methods

The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) “open abdomen,” “fascial closure,” “vacuum,” “reapproximation,” and “ventral hernia.” Open abdomen was defined as “the inability to close the abdominal fascia after laparotomy.” Two reviewers independently extracted data from original articles by using a predefined checklist.

Results

The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%).

Conclusions

These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Vacuum-assisted closure for defects of the abdominal wall

BACKGROUND

Reconstruction of the abdominal wall poses a problem common to many surgical specialties. Abdominal wall defects may be caused by trauma and/or prior surgery, with dehiscence or infection. Several options to repair the structural integrity of the abdominal wall exist, including primary closure, flaps, mesh, and skin grafts. Complications of these procedures include recurrent infection of the abdominal wall, infection of mesh, dehiscence, flap death, and poor skin graft take. Risk factors predisposing to these complications include tissue edema, preoperative tissue infection, and patient debilitation, with poor wound healing potential. Ideally, reconstruction should be performed on a nonedematous, clean tissue bed with bacterial levels less than 10 bacteria/cm in a well-nourished patient.

METHODS

Vacuum-assisted closure was used in a series of patients in an attempt to prepare the abdominal wall for reconstruction and reduce the risk of complications. Charts were reviewed for 100 patients who underwent abdominal wall reconstruction after vacuum-assisted closure therapy. Their wound cause, reconstruction technique, complications, and number of days on the vacuum-assisted closure device are reported.

RESULTS

The ability of vacuum-assisted closure to reduce edema, increase blood flow, potentially decrease bacterial colonization, and reduce wound size greatly facilitated abdominal wall reconstruction. The vacuum-assisted closure device served as a temporary dressing with which to control dehiscence and to maintain abdominal wall integrity when bowel wall edema prevented abdominal closure.

CONCLUSION

Vacuum-assisted closure therapy frequently shortened time to abdominal wall reconstruction and simplified the method of reconstruction.

Cobertura temporária da cavidade abdominal com curativo a vácuo

OBJETIVO: Descrever técnica de curativo para cobertura temporária da cavidade abdominal que utiliza sistema de vácuo. MÉTODO: A técnica foi aplicada em 12 pacientes. Inicialmente coloca-se sobre a laparostomia a bolsa plástica fenestrada, em seguida a primeira camada de compressas. Sobre esta, coloca-se o tubo de látex. Este é recoberto por outra camada de compressas as quais são fixadas sobre o curativo com o campo cirúrgico auto-aderente. O tubo de látex é conectado ao sistema de vácuo com pressão de -10 a -50 mmHg. Trocam-se os curativos a cada 12 horas. Material utilizado bolsa plástica de solução salina, compressas cirúrgicas, tubo de látex, campo cirúrgico auto-aderente de 50cm x 30cm e vácuo do sistema de gases hospitalares. RESULTADOS:A peritonite grave foi a indicação mais freqüente para laparostomia, seguida da síndrome de compartimento abdominal. Fechamento definitivo da cavidade abdominal foi possível em oito pacientes (67%) em média após 11 dias (9 a 21 dias) da laparostomia. Não houve complicações associadas ao método. O custo diário aproximado do curativo foi de R$ 50,00. CONCLUSÃO: O curativo a vácuo proporcionou boa contenção das vísceras abdominais, controlou o extravasamento de secreções e o edema. Permitiu o fechamento definitivo da cavidade abdominal na maioria dos casos e foi de baixo custo.

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

OBJECTIVE

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

METHOD

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

RESULT

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

CONCLUSION

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

A new technique in closure of burst abdomen: TI, TIE and TIES incisions

BACKGROUND

Burst abdomen is a continuing problem for the general surgeon as the incidence of such complication may reach 3% with a mortality rate exceeding 25%.

METHODS

New technique: A lateral incision is done from inside the abdomen along a line between the costal margin above to the iliac crest below in the area between the mid and anterior axillary line. According to the depth of the incision, the incision may either involve the transversus abdominus and internal oblique muscles (TI incision), or include in addition the external oblique muscle (TIE incision), or it may also involve the Scarpa's fascia (TIES incision). Such incisions would give an extra length on each side towards medial advancement. Eight patients, 5 men and 3 women aged 34-67 years, with burst abdomen after major gastrointestinal and hepatobiliary surgery failed to close primarily were managed using this technique. Long-term follow-up patients was done for development of complications. Electromyogram (EMG) for the rectus muscle and sensory loss for the abdominal wall were also tested. The distance between the 2 cut edges of the different release incisions was measured clinically (TIES incisions) or using ultrasound device (TI and TIE incisions). Scarpa's fascia biopsy was taken from 1 patient of the TIE group for histopathological study 6 years after surgery.

RESULTS

One patient died on the third postoperative day (mortality 12.5%), and 2 patients developed sub-incisional abscesses (25%). No single case of re-burst occurred. Long-term follow-up showed no single case of incisional hernia in the site of the midline surgical incision, but incisional hernia did occur in all the sites of TIES incisions. Incisional hernia did not occur in the TI incision and, more strangely, neither did it occur in any of the TIE incisions. Follow-up of the incisions width showed a significant increase in width of the TIES with time while there was no significant increase in that of the TI or TIE. There was a sensory loss at and below the level of umbilicus in the TIES group. EMG showed evidence of motor affection to the rectus muscle at and below the level of the umbilicus in all groups. Scarpa's fascia biopsy was taken to try to find an explanation for the absence of incisional hernia in TIE incisions and was found to be 3 times as thick and the type I collagen was replaced by collagen type III.

CONCLUSION

The new method described is simple, straightforward and tension free, with a comparable mortality and morbidity. The Scarpa's fascia adaptation and its ability to change have enormous applications in general and reconstructive surgery, but further evaluation of such phenomenon is needed.

Vacuum-assisted closure for the treatment of abdominal wounds

Abdominal wall defects pose a significant surgical challenge. The defect may result from trauma, infections, previous major surgery, or some combination of these etiologies. This article describes the Vacuum-Assisted Closure device (VAC, KCI, San Antonio, Texas) and how it can help in treating these defects.

To close or not to close, that is one of the questions? Perceptions of Trauma Association of Canada surgical members on the management of the open abdomen

BACKGROUND

The optimal abdominal closure in critically ill surgical/trauma patients remains controversial with a wide variety of commonly employed techniques. We sought to evaluate clinical equipoise by surveying Canadian surgeons regarding the use of temporary abdominal closure strategies in damage control and emergency situations.

METHODS

A structured mixed-mode (Website and paper), scenario-based questionnaire was developed by members of the Canadian Trauma Trials Collaborative and directed to surgical members of the Trauma Association of Canada (TAC).

RESULTS

The overall response rate was 84% (86 out of 102). In resuscitated hemodynamically stable trauma patients, 42% (29 out of 69) of respondents elected to primarily close an "extremely tight" abdominal cavity while only 23% (16 out of 70) would primarily close the same patient when physiologic exhaustion (Damage control (DC) conditions-hypothermia, acidosis, and coagulopathy) supervened. Although the majority reported preference for temporizing abdominal closures [73% (51 out of 70) non-DC, 75% (52 out of 69) DC] when the fascia was physically impossible to close; the reported primary use of mesh in these situations was quite high [24.6% (17 out of 69) non-DC, 24% (16 out of 69) DC], including a reported 7% (5 out of 69) nonabsorbable mesh usage in a contaminated octogenarian abdomen.

CONCLUSION

Reported opinions suggest an overall appreciation for markers of "Damage Control," although clinical equipoise exists regarding the preferred technique and a frequent early use of mesh. These results highlight the necessity for further research but suggest challenges in defining a common standard for multicenter trials.

Subcutaneous Endoscopic Fasciotomy in a Porcine Model of Abdominal Compartment Syndrome: A Feasibility Study

PURPOSE

Treatment of abdominal compartment syndrome (ACS) involves abdominal decompression via a laparotomy, which can result in significant wound-related morbidity. Our aim was to determine if subcutaneous endoscopic abdominal fasciotomy in a porcine model of ACS is feasible and what effect it may have on intra-abdominal pressure (IAP) and superior mesenteric artery (SMA) blood flow.

MATERIALS AND METHODS

A total of 6 female pigs weighing 50 kg each were used for the study. Each animal underwent placement of an arterial line, pulmonary artery catheter, SMA blood flow probe, IAP catheter, and intra-abdominal saline infusion line. After endoscopic dissection of a subcutaneous pocket overlying the rectus muscles, saline was infused into the abdomen to a pressure of 40 mm Hg. Physiologic parameters were measured before and after bilateral endoscopic anterior rectus fasciotomies were performed, and analyzed with a paired t-test.

RESULTS

Mean subcutaneous dissection time was 42.5 +/- 11.3 minutes, and mean fasciotomy time was 5.5 +/- 2.3 minutes. There were no significant changes in heart rate, cardiac output, pO(2), or pH during the experiment. IAP increased exponentially as fluid was instilled into the abdomen. SMA blood flow decreased reliably and linearly with increasing IAP. Mean baseline IAP was 4.0 +/- 1.7 mm Hg. IAP decreased from 37 mm Hg to 25 mm Hg after fasciotomy (P < 0.001). Mean baseline SMA blood flow was 629 +/-164 mL/min. SMA blood flow improved from 265 mL/min to 389 mL/min after fasciotomy (P< 0.01).

CONCLUSION

Subcutaneous endoscopic abdominal fasciotomy is feasible and appears to lower IAP and raise SMA blood flow in a porcine model of ACS.

Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced

OBJECTIVE

The goal of this report is to examine the success of vacuum-assisted fascial closure (VAFC) under a carefully applied protocol in abdominal closure after open abdomen.

SUMMARY BACKGROUND DATA

With the development of damage control techniques and the understanding of abdominal compartment syndrome, the open abdomen has become commonplace in trauma patients. If the abdomen is not closed in the early postoperative period, the combination of adhesions and fascial retraction frequently make primary fascial closure impossible and creation of a planned ventral hernia is required. We have previously reported our experience with the development of a technique for VAFC that allowed for closure of the fascia in many such patients long after initial operation. During this previous study, during which the technique was being developed, VAFC was successful in 69% of patients in whom it was applied, and 22 patients were successfully closed at > or = 9 days after initial surgery (range, 9 to 49 days). A protocol for the use of VAFC in patients with open abdomen was developed on the basis of these data and has been employed since October 2001. The outcome of this protocol's use is examined.

METHODS

This is a prospective evaluation of all trauma patients admitted to Wake Forest University Baptist Medical Center over a 19-month period who required management with an open abdomen. VAFC employs suction applied to a large polyurethane sponge under an occlusive dressing in the wound and allows for constant medial traction of the abdominal fascia. It is attempted in all patients in whom the rectus muscles and fascia are intact. Studied variables include fascial closure rate, time to closure, incidence of wound dehiscence, and hernia development after closure.

RESULTS

From November 1, 2001, through May 31, 2003, 212 laparotomies were performed in injured patients; 53 (25%) of these patients required open abdomen management. Mean injury severity score for the group was 34, with an average abdominal abbreviated injury score of 2.9. Forty-five (78%) survived until abdominal closure. Vacuum dressings were used in all 45 but VAFC was not attempted in 2 patients (1 due to development of enterocutaneous fistula, 1 because a rectus flap was used for another wound). Closure rate in those undergoing VAFC was 88% (38), with mean time to closure being 9.5 days. This is significantly higher than the 69% rate of fascial closure during the time in which the technique was developed (P = 0.03). Twenty-one patients (48%) were closed at > or =9 days (range, 9 to 21 days). Two patients (4.6%) developed wound dehiscence and underwent successful reclosure. One patient (2.3%) developed a ventral hernia on follow-up, which has since been repaired

CONCLUSIONS

The use of VAFC under a carefully defined protocol has resulted in significantly higher fascial closure rates, obviating the need for subsequent hernia repair in most patients. The utility of this technique is not limited to the early postoperative period, but it can be successful as much as 3 to 4 weeks after initial operation.

Management of destructive bowel injury in the open abdomen

BACKGROUND

Little attention has been focused on destructive injuries of the bowel in patients requiring open abdominal management. We therefore reviewed our institutional experience for destructive bowel injury requiring open abdominal management with the vacuum pack technique (vac).

METHODS

The trauma registry at a Level I trauma center was used to identify patients sustaining destructive bowel injury for an 11-year period beginning in May 1990. Patients were assessed for pertinent clinical and demographic information, and individuals requiring open abdominal management were compared with those who did not.

RESULTS

One hundred four patients required bowel resection and constitute the study population. Twenty-nine patients had vacs placed, with 22 (75.9%) of the total eventually obtaining delayed fascial closure. Nineteen (183%) patients had resection and primary repair (PR) of large and/or small bowel in conjunction with a vac, 10 (9.6%) patients had stoma formation in conjunction with a vac, 62 (59.6%) patients had resection and PR of small and/or large bowel in conjunction with primary fascial closure, and 13 (12.5%) patients had stoma formation and primary fascial closure. There were no differences in abdominal abscess or leak rates between groups. There were four deaths, none of which was secondary to failure of an anastomosis.

CONCLUSION

Bowel resection with PR appears to be a safe alternative after destructive bowel injury and results in acceptable morbidity when performed in conjunction with open abdominal management.

Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same

BACKGROUND

Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI).

METHODS

The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988.

RESULTS

Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001).

CONCLUSION

Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

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

BACKGROUND

The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients.

METHODS

The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure > or = 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC.

RESULTS

From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99).

CONCLUSION

VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided.

Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome

BACKGROUND

Intra-abdominal hypertension has been recognized as a source of morbidity and mortality in the traumatized patient following laparotomy. Multiple organ dysfunction attributable to intra-abdominal hypertension has been called the abdominal compartment syndrome. The epidemiology and characteristics of these processes remain poorly defined.

METHODS

Intra-abdominal pressure was measured prospectively in all patients admitted to a trauma intensive care unit over 9 months. Data were gathered on all patients with intra-abdominal hypertension.

RESULTS

Some 706 patients were evaluated. Fifteen (2 per cent) of 706 patients had intra-abdominal hypertension. Six of the 15 patients with intra-abdominal hypertension had abdominal compartment syndrome. Half of the patients with abdominal compartment syndrome died, as did two of the remaining nine patients with intra-abdominal hypertension. Patients with abdominal compartment syndrome had a mean intra-abdominal pressure of 42 mmHg compared with 26 mmHg in patients with intra-abdominal hypertension only (P < 0.05).

CONCLUSION

The incidence of intra-abdominal hypertension and abdominal compartment syndrome was 2 and 1 per cent respectively. Intra-abdominal hypertension did not necessarily lead to abdominal compartment syndrome, and often resolved without clinical sequelae. Abdominal compartment syndrome did not occur in the absence of earlier laparotomy. Abdominal compartment syndrome was associated with a marked increase in intra-abdominal pressure (above 40 mmHg).

Abdominal compartment syndrome after mesenteric revascularization

Abdominal compartment syndrome (ACS) results from increased pressure within the abdominal cavity leading to multisystem organ dysfunction. The most common cause of ACS is increased intraperitoneal volume from any source, but extrinsic compression can also cause increased intra-abdominal pressure. Although ACS has been well described in patients with trauma, little has been reported on ACS in postoperative patients without traumatic injuries. We report on a patient who had acute ACS 2 days after surgical revascularization for chronic mesenteric ischemia. With appropriate treatment, the patient made a rapid and complete recovery. We present this case of acute ACS in the postoperative patient without trauma to increase awareness and help minimize death caused by this devastating syndrome.

Abdominal compartment syndrome in the intensive care unit

The abdominal compartment syndrome is an increasingly recognized complication of both medical and surgical patients in the ICU setting. This syndrome has been described in a wide variety of clinical scenarios and results from a persistent elevation in intra-abdominal pressure characterized by graded organ system dysfunction. Manifestations of abdominal compartment syndrome include cardiovascular, pulmonary, renal, splanchnic, and neurologic impairment. The diagnosis of abdominal compartment syndrome requires a high level of clinical suspicion combined with an increased intra-abdominal pressure, usually obtained via urinary bladder pressure measurement. Patients at risk for abdominal compartment syndrome warrant close monitoring and we recommend prompt abdominal decompression following documentation of increased intra-abdominal pressure in the setting of physiologic compromise. Abdominal compartment syndrome can significantly contribute to the morbidity and mortality of both medical and surgical patients alike in the ICU. The signs and symptoms of abdominal compartment syndrome should become familiar to all critical care practitioners.

Acute renal failure due to abdominal compartment syndrome: report on four cases and literature review

We report on 4 cases of abdominal compartment syndrome complicated by acute renal failure that were promptly reversed by different abdominal decompression methods. Case 1: A 57-year-old obese woman in the post-operative period after giant incisional hernia correction with an intra-abdominal pressure of 24 mm Hg. She was sedated and curarized, and the intra-abdominal pressure fell to 15 mm Hg. Case 2: A 73-year-old woman with acute inflammatory abdomen was undergoing exploratory laparotomy when a hypertensive pneumoperitoneum was noticed. During the surgery, enhancement of urinary output was observed. Case 3: An 18-year-old man who underwent hepatectomy and developed coagulopathy and hepatic bleeding that required abdominal packing, developed oliguria with a transvesical intra-abdominal pressure of 22 mm Hg. During reoperation, the compresses were removed with a prompt improvement in urinary flow. Case 4: A 46-year-old man with hepatic cirrhosis was admitted after incisional hernia repair with intra-abdominal pressure of 16 mm Hg. After paracentesis, the intra-abdominal pressure fell to 11 mm Hg.

A simple, inexpensive, life-saving way to perform iterative laparotomy in patients with severe intra-abdominal sepsis

Between 1 June 1993 and 31 December 1998, 17 patients underwent temporary abdominal closure with 3L urological irrigation bags, because in most cases, there was massive sepsis leading to the conclusion that primary closure was not advisable. Indicative of the seriousness of these conditions, Apache score averaged 19 (range 10-30). The technique consisted of suturing a double thickness of irrigation bags to each side of the wound, and joining the two bags in the midline with running sutures. Abdominal lavage with large quantities of fluid was performed every other day. This type of closure was used for a mean duration of 15 days. Mean length of hospitalization was 60 days. There were only three deaths (17.6%). No incisional hernia occurred after the iterative laparotomies. Deleting patients with acute pancreatitis would have reduced the death rate to only 7%. A 3L urological irrigation bag costs pound 11.60 (24.40 dollars CAN) while a Marlex mesh costs pound 81.40 (171.00 dollars CAN). We conclude that the usage of 3L urological plastic bags is a simple, safe and efficient method for temporary closure of the abdomen.

Bedside open abdominal surgery. Utility and wound management

Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the ICU should be familiar with the concepts and techniques of open abdomen wound management. ICU bedside abdominal surgery may be indicated if the patient is too unstable for transport to the operating room and the surgeon believes a limited procedure, such as a decompression of IAH, will be life-saving. Smaller procedures are also feasible, such as intra-abdominal packing changes for which the operating room is unnecessary. Development of a successful Surgery Outside the Operating Room program depends on mature cooperation between the surgeons and other professional ICU staff. Logistic details of such a program should be discussed and a scheduling protocol should be prepared before an emergent need for bedside surgery.

Management of liver trauma

BACKGROUND AND METHODS

Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience.

RESULTS

Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak.

CONCLUSION

Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.