Vacuum-Assisted Wound Closure Achieves Early Fascial Closure of Open Abdomens after Severe Trauma

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Influence of VAC Therapy on Perfusion and Edema of Gracilis Flaps: Prospective Case-control Study

The gracilis muscle flap is a popular choice in reconstructive surgery to repair soft tissue defects or for functional restoration. Little is known on the influence of postoperative application of VAC (vacuum-assisted closure; Kinetic Concepts Inc., San Antonio, Tex.) therapy on perfusion and postoperative flap edema of free gracilis muscle flaps.

Methods

In total, 26 patients with soft tissue defects of lower extremity underwent gracilis muscle flap reconstruction. The study group (VAC, n = 13) was supplied with postoperative negative pressure therapy as a dressing; the control group (NVAC, n = 13) was supplied with conventional fat gauze dressing. Postoperative measurements of micro- and macroperfusion were performed intraoperatively, on postoperative day (POD) 3 and POD 5. Flap edema measurement was performed intraoperatively, on POD 5 and 2 weeks after operation.

Results

The VAC group showed significantly better macroflow during intraoperative VAC treatment, as well on POD 3 and POD 5. Venous outflow was also better with lower hemoglobin levels. Microflow was better in the NVAC group with higher measured oxygen levels. All gracilis muscle flaps of the VAC group showed significantly less flap edema compared with the control group.

Conclusions

VAC application on free gracilis muscle flaps leads to significantly less postoperative flap edema, improved arterial macroflow, and improved venous outflow. VAC therapy can be used without any danger for patient's safety, as flap survival is not endangered, and presents an easy to handle and pleasant dressing regimen for nursing staff and patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level IV.

Intra-Abdominal Pressure Monitoring During Negative Pressure Wound Therapy in the Open Abdomen

INTRODUCTION

Negative pressure wound therapy (NPWT) is commonly used in open abdomen management, where there may be a simultaneous need for prevention of abdominal hypertension, tamponade of hemorrhage, and continuous fascial tension. The regional pressure dynamics of vacuum dressings are poorly understood.

METHODS

Three duroc swine underwent mid-line laparotomy and application of vacuum open abdomen dressing, with and without sponge packing. Twenty-five catheters were placed throughout the abdomen to capture and record pressures in each quadrant as the vacuum system was ranged between (-75 mmHg to -200 mmHg pressure). Vital signs and ventilator pressures were measured and recorded concomitantly.

RESULTS

No variations in ventilatory pressures or vital signs were observed with any setting. NPWT changed pressure in seven of seventy-five catheters (9%), five of which were related to abdominal packing. When data were grouped into abdominal wall, perihepatic, perisplenic, and deep abdominal regions, there was no significant change in abdominal pressure when packing was absent. With packing, only the abdominal wall region showed a pressure change, reaching a maximum of 20% of the set vacuum pressure.

CONCLUSIONS

NPWT does only little to change the intraabdominal pressure, except in superficial locations in packed abdomens and does not appear to cause hemodynamic changes in a porcine open abdomen model. While NPWT may play an important role in fluid scavenging and fascial tensioning, there are likely to be few benefits or drawbacks specifically related to negative abdominal pressure in the deep abdomen.

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.

Open Abdomen and Fluid Instillation in the Septic Abdomen: Results from the IROA Study

Background

Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen.

Materials and methods

A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed.

Results

A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively.

Conclusion

We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Effect of abdominal negative-pressure wound therapy on the measurement of intra-abdominal pressure

BACKGROUND

In critically ill surgical patients undergoing abdominal negative-pressure wound therapy (NPWT), it remains uncertain whether or not intra-abdominal pressure (IAP) measurements should be obtained when NPWT is activated. We aimed to determine agreement between IAP measured with and without NPWT.

METHODS

In this analytic cross-sectional study, critically ill surgical adults (≥18 y) requiring abdominal NPWT for temporary abdominal closure after a damage control laparotomy were selected. Patients with urinary tract injuries or with pelvic packing were excluded. Paired IAP measures were performed in the same patient, with and without NPWT; two different operators performed the measures unaware of the other's result. Bland-Altman methods assessed the agreement between the two measures. Subgroup analyses (trauma and nontrauma) were performed.

RESULTS

There were 198 IAP measures (99 pairs) in 38 patients. Mean IAP with and without NPWT were 8.33 (standard deviation 4.01) and 8.65 (standard deviation 4.04), respectively. Mean IAP difference was -0.323 (95% confidence interval -0.748 to 0.101), and reference range for difference was -4.579 to 3.932 (P = 0.864). From 112 IAP measures (56 pairs) in 21 trauma patients, mean IAP difference was -0.268 (95% confidence interval -0.867 to 0.331), and reference range for the difference was -4.740 to 4.204 (P = 0.427).

CONCLUSIONS

There was no statistically significant disagreement in IAP measures. IAP could be measured with or without NPWT. In critically ill surgical patients with abdominal NPWT for temporary abdominal closure, monitoring and management of IAP either with or without NPWT is recommended.

Management Approaches for Enterocutaneous Fistulas

There are very few clinical studies that highlight a definitive and comprehensive guideline for the management of enterocutaneous fistulas. Most accepted guidelines are found in textbooks and are taken from expert advice and case reports. The goal of this review is to highlight advancements relevant to the management of enterocutaneous fistulas from the recent two to three years. Although strong evidence-based guidelines are lacking, the consensus is that a multidisciplinary team working with a clear treatment plan targeting multiple aspects of management can maximize patient outcomes.

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.

VAC-instillation therapy in abdominal mesh exposure: a novel indication

BACKGROUND

Defects of the abdominal wall pose a problem for general surgeons that negatively affects patient prognosis. In cases of abdominal wall wound dehiscence and exposed abdominal mesh, conservative treatment has not been proven effective to date. We aimed to study patient outcomes in cases of abdominal wall wound dehiscence with mesh exposure treated with vacuum-assisted closure system with intermittent instillation (VAC-instillation) as a temporary cover to achieve wound closure.

METHODS

A retrospective cohort study was performed to evaluate and compare the outcomes of 45 patients with postoperative abdominal wall wound dehiscence and exposed mesh: 34 were treated with conventional dressings and 11 with the VAC-instillation device. Clinical records were reviewed, and patient demographics, indication for abdominal surgery, and existing risk factors were noted. Patient outcome was evaluated in terms of number of reoperations, length of hospital stay, and total time of treatment.

RESULTS

Demographic features did not differ significantly between the two groups. Patients treated with conventional dressings required a significantly higher number of surgeries to achieve wound closure. We did not find statistical differences between the two groups regarding length of hospital stay, but the VAC-instillation group showed a significantly shorter total time of treatment. The incidence of complications was lower in the VAC-instillation group, though hernia recurrence rate was slightly higher in these patients.

CONCLUSIONS

VAC-instillation is a valid option for the conservative treatment of critical patients with abdominal wall wound dehiscence and exposed infected mesh that allows recovery with fewer surgeries and complications and avoids the need of mesh removal.

Small Bowel Fistulas and the Open Abdomen

Over the last 15 years, the contemporary strategies to treat the open abdomen have reduced the lethal complications. Systematic intensive care and modern wound management in conjunction with a plastic barrier to protect the viscera and topical negative pressure on the soft tissues have reduced the development of small bowel fistulas. The literature selected for this review shows that the surgical handling of the exposed bowel, the choice of the material for temporary coverage and early progressive closure of the defect are crucial for the prevention of fistulas. At present, surgeons worldwide have adopted these principles leading to an increase of primary or delayed closure rates. When a small fistula occurs, biological dressings like human acellular dermal matrix and fibrin glue may help to seal the orifice and to treat the patient conservatively. In case of a large fistula, vacuum-assisted wound management is recommended as well. Through a separate hole in the vacuum sponge matching to the fistula, the enteric contents are sucked off while the wound bed heals and is prepared for split thickness skin graft. Surgical resection of established fistula unresponsive to conservative measures should only be performed on patients well-nourished and free of infection with a delay of at least six months. for patients with an open abdomen, surgical expertise and a well-structured management plan offer the best chances to overcome this potentially devastating condition — with or without fistula.

Early Definitive Closure of the Open Abdomen: A Quiet Revolution

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delayed Closure of 61 Open Abdomen Patients Based on an Algorithm

Hemodynamic resuscitation, source control, and delayed abdominal closure are the three fundamental steps for open abdomen (OA) management. When to start delayed abdominal closure and how to determine which delayed closure method should be applied to each OA patient are not clarified in the literature. We evaluated an algorithm that was developed to address these two questions. A retrospective chart review was conducted for OA patients treated for according to the algorithm. When hemodynamic stabilization and source control using negative pressure therapy resulted in regression of sepsis and decreased procalcitonin levels, patients were assigned to either the skin-only or fascial closure groups according to their Björck scores and open abdominal fascial closure (OAFC) scores. The novel OAFC scoring system was created by adding age and malignancy to the sequential organ failure assessment (SOFA) score. For skin-only closure, skin flaps and skin grafts were used; for fascial closure, an abdominal re-approximation anchor system (ABRA) or ABRA plus biologic mesh was applied. From January 2008 through September 2014, 108 OA patients were managed based on the algorithm; 61 were included in this study. Abdominal closure rate was 90.2 % (55/61). Overall hospital mortality rate was 11.4 % (7/61). Small hernias developed in only 12.5 % (4/32) of the fascial closure group. In this retrospective study, the algorithm with the novel OAFC score provided practical and valid guidance to clarify when to start delayed abdominal closure and which delayed closure method to use for each OA patient.

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.

Damage Control and the Open Abdomen: Challenges for the Nonsurgical Intensivist

BACKGROUND

As strategies in acute care surgery focus on damage control to restore physiology, intensivists spanning all disciplines care for an increasing number of patients requiring massive transfusion, temporary abdominal closures, and their sequelae.

OBJECTIVE

To equip the nonsurgical intensivist with evidence-based management principles for patients with an open abdomen after damage control surgery.

DATA SOURCE

Search of PubMed database and manual review of bibliographies from selected articles.

DATA SYNTHESIS AND CONCLUSIONS

Temporary abdominal closure improves outcomes in patients with abdominal compartment syndrome, hemorrhagic shock, and intra-abdominal sepsis but creates new challenges with electrolyte derangement, hypovolemia, malnutrition, enteric fistulas, and loss of abdominal wall domain. Intensive care of such patients mandates attention to resuscitation, sepsis control, and expedient abdominal closure.

Management of the open abdomen using combination therapy with ABRA and ABThera systems

BACKGROUND

The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen.

METHODS

We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia.

RESULTS

Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%).

CONCLUSION

We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjuction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.

Vacuum-assisted close versus conventional treatment for postlaparotomy wound dehiscence

Purpose

The conventional treatment for postlaparotomy wound dehiscence usually involves surgical revision. Recently, vacuum-assisted closure has been successfully used in postlaparotomy wound dehiscence. The aim of the present study was to compare the clinical outcome of 207 patients undergoing vacuum-assisted closure therapy or conventional treatment for postlaparotomy wound dehiscence.

Methods

Two hundred and seven consecutive patients underwent treatment for postlaparotomy wound dehiscence: vacuum-assisted closure therapy (January 2007 through August 2012, n = 25) or conventional treatment (January 2001 through August 2012, n = 182).

Results

The failure rate to first-line treatment with vacuum-assisted closure and conventional treatment were 0% and 14.3%, respectively (P = 0.002). There was no statistically significant difference in the enterocutaneous fistulas and hospital stay after vacuum-assisted closure therapy or conventional treatment respectively.

Conclusion

Our findings support that vacuum-assisted closure therapy is a safe and reliable option in postlaparotomy wound dehiscence with very low failure rate in surgical revision compared with conventional treatment.

Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen

INTRODUCTION

Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to develop evidence-based recommendations describing the use of NPWT in the open abdomen.

METHODS

A systematic review was carried out to investigate the efficacy of a range of Temporary Abdominal Closure methods including variants of NPWT. Evidence-based recommendations were developed by an International Expert Panel and graded according to the quality of supporting evidence.

RESULTS

Pooled results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits in the open abdomen. This increased to 82% by the addition of a 'dynamic' closure method. Slightly lower rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent and seemed to be related to the underlying medical condition rather than being influenced by the choice of dressing, Treatment goals for open abdomen were defined prior to developing eleven specific evidence-based recommendations suitable for different stages and grades of open abdomen.

DISCUSSION AND CONCLUSION

The most efficient temporary abdominal closure techniques are NPWT kits with or without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a complex treatment pathway for the individual patient.

Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction

BACKGROUND

The open abdomen has become an accepted treatment option of critically ill patients with severe intra-abdominal conditions. Fascial closure is a particular challenge in patients with peritonitis. This study investigates whether fascial closure rates can be increased in peritonitis patients by using an algorithm that combines vacuum-assisted wound closure and mesh-mediated fascial traction. Moreover, fascial closure rates for patients with peritonitis, trauma or abdominal compartment system (ACS) are compared.

METHODS

Data were collected prospectively from all patients who underwent open abdomen management at our institution from 2006 to 2012. All patients were treated under a standardised algorithm that combines vacuum-assisted closure and mesh placement at the fascial level.

RESULTS

During the study period, 53 patients (mean age 53 years) underwent open abdomen management for a mean duration of 15 days. Indications for leaving the abdomen open were peritonitis (51 %), trauma (26 %), and ACS or abdominal wall dehiscence (23 %). The fascial closure rate was 79 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. Mortality was 13 %. No patient developed an enteroatmospheric fistula or abdominal wall dehiscence after closure. The mean duration of treatment was significantly longer in peritonitis patients (20 days) than in patients without peritonitis (10 days) (p = 0.03). There were no significant differences in fascial closure rates between patients with peritonitis (87 %), trauma (85 %), and ACS or abdominal wall dehiscence (100 %) (p = 0.647).

CONCLUSIONS

Regardless of the underlying pathology, high fascial closure rates can be achieved using a combination of vacuum-assisted closure and mesh-mediated fascial traction.

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

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

Fluid volume overload negatively influences delayed primary facial closure in open abdomen management

BACKGROUND AND AIM

The open abdomen (OA) is associated with significant morbidity and mortality, and its management poses a formidable challenge. Inability to achieve primary closure of the abdominal wall is one of the most severe complications of this technique. Factors influencing primary fascial closure, however, are unknown. This study aims to explore the influence of fluid volume overload on the application of vacuum-assisted and mesh-mediated fascial traction (VAWCM) in OA treatment.

METHODS

A review of patients undergoing OA management using VAWCM technique from January 2006 to November 2011 was performed. Patients with aged <18 y OA treatment for fewer than 5 d and abdominal wall hernia before OA treatment were excluded.

RESULTS

Average age was 45 ± 10.1 y and average OA treatment time was 31 ± 6.8 d. The complete fascial closure rate was 60%. The overall mean bodyweight-based fluid overload was 7.2 kg (range: -8.0 to +21.6 kg), representing a mean percent weight gain of 11.5% (range: -9.5% to +27%). Patients with fluid-related weight gain ≥10% had a lower primary facial closure rate than those with <10% (39% versus 77%). And primary facial closure rate seems to further decrease with fluid-related weight gain ≥20%, suggesting a dose-response effect of progressive fluid accumulation.

CONCLUSIONS

The VAWCM method provided a high primary fascial closure rate after long-term treatment of OA. Fluid volume overload negatively influences delayed primary facial closure. Judicious intravenous fluid resuscitation should be advocated in the therapy of critically ill patients.

[Vacuum dressing technique to temporary cover of laparostomy]

BACKGROUND

The advances in patient care with trauma or severe intra-abdominal infections, brought important gains in survival with the use of peritoneostomies. But the management of patients brought a difficult problem: the primary closure without tension of the abdominal cavity.

AIM

To present a proposal for temporary coverage of peritoneostomies in patients undergoing damage control laparotomy or decompressive laparotomy for abdominal compartment syndrome.

TECHNIC

Isolation of the small intestine loops from abdominal internal; coverage of the intestinal surface with a polyethylene film multiperforated with sterile scissors or scalpel blade, to prevent direct contact with the foam. It is placed below the edges of the defect between the parietal and visceral peritoneum. Over it, a polyurethane sterile foam is fixed to the edges, leaving the defect tension free to the vacuum be applied. Another coverage with a plastic adhesive polyester impregnated with iodine stuck to skin is done, and, at the end, is added a drainage continuous aspiration system. The dressing is changed between three and five days. It was used successfully in four patients with primary closure of the abdominal cavity after seven to 21 days. Of these, three had open abdomen after laparotomy for trauma (two due to damage control and one for lack of primary closure); the fourth had been previously submitted to decompressive laparotomy for abdominal compartment syndrome.

CONCLUSION

The vacuum dressing proved to be good choice for temporary coverage of peritoneostomies allowing faster closure of the abdominal wound, reducing the number of reoperations and providing protection against bacterial contamination of the intestinal loops.

Primary Closure of the Abdominal Wall After “Open Abdomen” Situation

“Open abdomen” is a strategy used to avoid or treat abdominal compartment syndrome. It has reduced mortality both in trauma and non-trauma abdominal catastrophes but also has created a challenging clinical problem. Traditionally, open abdomen is closed in two phases; primarily with a free skin graft and later with a flap reconstruction. A modern trend is to close the abdomen within the initial hospitalization. This requires multi-professional co-operation. Temporary abdominal closure methods, e.g. negative pressure wound therapy alone or combined with mesh-mediated traction, have been developed to facilitate direct fascial closure. Components separation technique, mesh reinforcement or bridging of the fascial defect with mesh and perforator saving skin undermining can be utilized in the final closure if needed. These techniques can be combined. Choice of the treatment depends on the condition of the patient and size of the fascia and skin defect, and the state of the abdominal contents.

In this paper we review the literature on the closure of an open abdomen and present the policy used in our institution in the open abdomen situations.

Negative pressure wound therapy management of the "open abdomen" following trauma: a prospective study and systematic review

INTRODUCTION

The use of Negative Pressure Wound Therapy (NPWT) for temporary abdominal closure of open abdomen (OA) wounds is widely accepted. Published outcomes vary according to the specific nature and the aetiology that resulted in an OA. The aim of this study was to evaluate the effectiveness of a new NPWT system specifically used OA resulting from abdominal trauma.

METHODS

A prospective study on trauma patients requiring temporary abdominal closure (TAC) with grade 1or 2 OA was carried out. All patients were treated with NPWT (RENASYS AB Smith & Nephew) to achieve TAC. The primary outcome measure was time taken to achieve fascial closure and secondary outcomes were complications and mortality.

RESULTS

A total of 20 patients were included. Thirteen patients (65%) achieved fascial closure following a median treatment period of 3 days. Four patients (20%) died of causes unrelated to NPWT. Complications included fistula formation in one patient (5%) with spontaneous resolution during NPWT), bowel necrosis in a single patient (5%) and three cases of infection (15%). No fistulae were present at the end of NPWT.

CONCLUSION

This new NPWT kit is safe and effective and results in a high rate of fascial closure and low complication rates in the severely injured trauma patient.

Internal vacuum-assisted closure device in the swine model of severe liver injury

OBJECTIVES

The authors present a novel approach to nonresectional therapy in major hepatic trauma utilizing intraabdominal perihepatic vacuum assisted closure (VAC) therapy in the porcine model of Grade V liver injury.

METHODS

A Grade V injury was created in the right lobe of the liver in a healthy pig. A Pringle maneuver was applied (4.5 minutes total clamp time) and a vacuum assisted closure device was placed over the injured lobe and connected to suction. The device consisted of a perforated plastic bag placed over the liver, followed by a 15 cm by 15cm VAC sponge covered with a nonperforated plastic bag. The abdomen was closed temporarily. Blood loss, cardiopulmonary parameters and bladder pressures were measured over a one-hour period. The device was then removed and the animal was euthanized.

RESULTS

Feasibility of device placement was demonstrated by maintenance of adequate vacuum suction pressures and seal. VAC placement presented no major technical challenges. Successful control of ongoing liver hemorrhage was achieved with the VAC. Total blood loss was 625 ml (20ml/kg). This corresponds to class II hemorrhagic shock in humans and compares favorably to previously reported estimated blood losses with similar grade liver injuries in the swine model. No post-injury cardiopulmonary compromise or elevated abdominal compartment pressures were encountered, while hepatic parenchymal perfusion was maintained.

CONCLUSION

These data demonstrate the feasibility and utility of a perihepatic negative pressure device for the treatment of hemorrhage from severe liver injury in the porcine model.

Open abdomen treatment with dynamic sutures and topical negative pressure resulting in a high primary fascia closure rate

BACKGROUND

Open abdomen (OA) treatment with negative-pressure therapy is a novel treatment option for a variety of abdominal conditions. We here present a cohort of 160 consecutive OA patients treated with negative pressure and a modified adaptation technique for dynamic retention sutures.

METHODS

From May 2005 to October 2010, a total of 160 patients--58 women (36 %); median age 66 years (21-88 years); median Mannheim peritonitis index 25 (5-43) underwent emergent laparotomy for diverse abdominal conditions (abdominal sepsis 78 %, ischemia 16 %, other 6 %).

RESULTS

Hospital mortality was 21 % (13 % died during OA treatment); delayed primary fascia closure was 76 % in the intent-to-treat population and 87 % in surviving patients. Six patients required reoperation for abdominal abscess and five patients for anastomotic leakage; enteric fistulas were observed in five (3 %) patients. In a multivariate analysis, factors correlating significantly with high fascia closure rate were limited surgery at the emergency operation and a Björk index of 1 or 2; factors correlating significantly with low fascia closure rate were male sex and generalized peritonitis.

CONCLUSIONS

With the aid of initially placed dynamic retention sutures, OA treatment with negative pressure results in high rates of delayed primary fascia closure. OA therapy with the technical modifications described is thus considered a suitable treatment option in various abdominal emergencies.

Total management of the open abdomen

The management of complex abdominal problems with the 'open abdomen' (OA) technique has become a routine procedure in surgery. The number of cases treated with an OA has increased dramatically because of the popularisation of damage control for life-threatening conditions, recognition and treatment of intra-abdominal hypertension and abdominal compartment syndrome and new evidence regarding the management of severe intra-abdominal sepsis. Although OA has saved numerous lives and has addressed many problems related to the primary pathology, this technique is also associated with serious complications. New knowledge about the pathophysiology of the OA and the development of new technologies for temporary abdominal wall closure (e.g. ABThera™ Open Abdomen Negative Pressure Therapy; KCI USA Inc., San Antonio, TX) has helped improve the management and outcomes of these patients. This review will merge expert physician opinion with scientific evidence regarding the total management of the OA.

Management of the tense abdomen or difficult abdominal closure after operation for ruptured abdominal aortic aneurysms

Increased intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) are important clinical problems after repair of ruptured abdominal aortic aneurysms and are reviewed here. IAP >20 mm Hg occurs in approximately 50% of patients treated with open abdominal aortic aneurysm repair after rupture, and approximately 20% develop organ failure or dysfunction, fulfilling the criteria for ACS. Patients selected for endovascular aneurysm repair are often more hemodynamically stable, perhaps related to not handling the viscera or more favorable anatomy, resulting in less bleeding and, consequently, decreased risk of developing ACS. Centers that treat most patients with endovascular aneurysm repair tend to have the same proportion of ACS as after open repair. There are no randomized data on these aspects. Early nonsurgical therapy can prevent development of ACS. Medical therapy includes neuromuscular blockade and the combination of positive end-expiratory pressure, albumin, and furosemide. This proactive strategy can reduce the number of decompressive laparotomies, an important detail because treatment of ACS with open abdomen is a morbid procedure. When treatment with an open abdomen is necessary, it is important to choose a temporary abdominal closure that maintains sterile conditions during often prolonged treatment. In addition, it should prevent lateralization of the bowel wall and adhesions between the intestines and the bowel wall. Enteroatmospheric fistulae must be prevented. Many alternative methods have been suggested, but we prefer the combination of vacuum-assisted wound closure with mesh-mediated traction, which will be described.

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.

The open abdomen: definitions, management principles, and nutrition support considerations

The use of the "open abdomen" as a technique in the management of the complex surgical patient stems from the concept of damage control. Damage control principles underscore the importance of an abbreviated laparotomy focused on control of hemorrhage and gastrointestinal contamination in patients presenting with significant physiologic compromise. Definitive repair of injuries is postponed and the abdomen is temporarily "closed" using one of a number of different techniques. The ultimate goal is formal abdominal fascial closure within 48-72 hours of the initial laparotomy. Frequently, daily trips to the operating room are required for incremental closure of the abdominal fascia. However, in some cases, fascial closure is not possible secondary to ongoing visceral edema and loss of the peritoneal domain. In these cases, the patient is left with an "open abdomen" until skin grafting over the exposed peritoneal organs can be performed. Patients with an open abdomen have peritoneal contents exposed to the atmosphere and require a complex dressing to maintain fascial domain and provide protection to exposed organs. These patients are typically critically ill and managed in the intensive care unit early in the disease process. The open abdomen has become an important tool for the management of physiologically unstable patients requiring emergent abdominal surgical procedures. These patients present unique challenges to the critical care and nutrition support teams. Careful attention to fluid and electrolyte management, meticulous wound care, prevention of enteroatmospheric fistula, and individualized nutrition support therapy are essential to successful recovery in this patient population.

Negative pressure therapy: a viable option for general surgical management of the open abdomen

BACKGROUND

Management of the open abdomen (OA) is challenging for surgeons and requires experienced medical teamwork. The need for improvements in temporary abdominal closure methods has led to the development of a negative-pressure therapy (NPT; ABThera OA NPT, KCI USA, Inc, San Antonio, TX).

METHOD

The authors present a 19-patient case series documenting their use of NPT for OA management in nontraumatic surgery. All received NPT until the fascia was considered ready for closure.

RESULTS

Of 19 patients, 17 (89.5%) achieved fascial closure with a Kaplan-Meier (KM) median time to closure of 6 days. Mean hospital and intensive care unit stays were 32.1 and 26.6 days, respectively. During their hospitalization, 5 patients (26.3%) died, with a KM median time to mortality of 53 days.

CONCLUSION

These findings demonstrate effective use of NPT for managing the OA in critically ill patients, and this has led the authors to use it in their general surgery practice.

Early Diagnosis and Evidence-Based Care of Surgical Sepsis

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.

Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction

BACKGROUND

Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications.

METHODS

This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded.

RESULTS

Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76·6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8·55, 95 per cent confidence interval 1·47 to 49·72; P = 0·017). The in-hospital mortality rate was 29·7 per cent. Age (OR 1·21, 1·02 to 1·43; P = 0·027) and failure of fascial closure (OR 44·50, 1·13 to 1748·52; P = 0·043) were independently associated with in-hospital mortality.

CONCLUSION

The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia.

Management of open abdomen with an absorbable mesh closure

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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