Component separation technique for abdominal wall reconstruction in burn patients with decompressive laparotomies. ACTA ACUST UNITED AC. 2009;67:1435-1438. [PMID: 20009699 DOI: 10.1097/ta.0b013e3181b5f346]

International consensus conference on open abdomen in trauma

BACKGROUND

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.

METHODS

The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.

RESULTS

OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).

CONCLUSION

OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Component separation in abdominal trauma

Component separation is established for complex hernia repairs. This case presents early component separation and release of the anterior and posterior sheath to facilitate closure of the abdominal wall following emergency laparotomy, reinforcing the repair with a biological mesh. On Day 11 following an emergency laparotomy for penetrating trauma, this patient underwent component separation and release of the anterior and posterior sheath. An intra-abdominal biological mesh was secured, and the fascia and skin closed successfully. Primary abdominal closure can be achieved in patients with penetrating abdominal trauma with the use of component separation and insertion of intra-abdominal biological mesh, where standard closure is not possible.

“Acute postoperative open abdominal wall”: Nosological concept and treatment implications

The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.

Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients

Abdominal wall defects continue to be a challenging problem for reconstructive surgeons. The aim of our study was to report a 3-year experience using a simple Two-step Technique (TST) to treat abdominal wall defects. Between January 2008 and December 2010, 20 patients with abdominal wall defects were treated by TST. Patients had a mean age of 37·5 ± 14·9 years (range: 22-85 years); 5 were women and 15 were men. The size of the defects was prospectively analysed. Early and late complications were recorded. Hospital stay, post-procedure downtime and patient overall satisfaction were systematically assessed. A secondary defect resulting from self-manipulation and an infection were responsible for a complication rate of 10%. Both underwent successful surgical revision which led to full resolution. The average hospital stay was 11·2 ± 4·9 weeks for the series. Long-term complications were scar hyperpigmentation in 11 cases, scar hypertrophy in 5 cases and scar widening in 3 cases. Mean patient satisfaction was 8·3 ± 0·5 [visual analogue scale (VAS) 0-10]. Average downtime post surgery was 4·1 ± 1·2 weeks. The mean follow-up was 24·6 ± 6·7 months. Reconstruction of abdominal wall defect with the TST is a reliable and reproducible technique. This technique provides excellent outcomes, and we anticipate that it will become widespread in the near future.

Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen

BACKGROUND

The furosemide drip (FD), in addition to improving volume overload respiratory failure, has been used to decrease fluid in attempts to decrease intra-abdominal and abdominal wall volumes to facilitate fascial closure. The purpose of this study is to evaluate the FD and the associated rate of primary fascial closure following trauma damage control laparotomy (DCL).

MATERIALS AND METHODS

From January 2004 to September 2008, a retrospective review from a single institution Trauma Registry of the American College of Surgeons dataset was performed. All DCLs greater than 24 h who had a length of stay for 3 or more days were identified. The study group (FD+) and control group (FD-) were compared. Demographic data including age, sex, probability of survival, red blood cell transfusions, initial lactate, and mortality were collected. Primary outcomes included primary fascial closure and primary fascial closure within 7 days. Secondary outcomes included total ventilator days and LOS.

RESULTS

A total of 139 patients met inclusion criteria: 25 FD+ and 114 FD-. The 25 FD+ patients received the drug at a median 4 days post DCL. Demographic differences between the groups were not significantly different, except that initial lactate was higher for FD- (1.7 vs 4.0; P=0.03). No differences were noted between groups regarding successful primary fascial closure (FD+ 68.4% vs FD- 64.0%; P=0.669), or closure within 7 days (FD+13.2% vs FD- 28.0%; P=0.066) of original DCL. FD+ patients suffered more open abdomen days (4 [2-7] vs 2 [1-4]; P=0.001). FD+ did not demonstrate an association with primary fascial closure [Odds ratio (OR) 1.5, 95% confidence interval (CI) 0.260-8.307; P=0.663]. FD+ patients had more ventilator days and longer Intensive Care Unit (ICU)/hospital LOS (P<0.01).

CONCLUSION

FD use may remove excess volume; however, forced diuresis with an FD is not associated with an increased rate of primary closure after DCL. Further studies are warranted to identify ICU strategies to facilitate fascial closure in DCL.

Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing

Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.

Enterocutaneous fistulas in the setting of trauma and critical illness

One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.

Outcome of components separation for contaminated complex abdominal wall defects

BACKGROUND

Contaminated large abdominal wall defects can pose a formidable challenge to the surgeon. This study compared the outcome of components separation (CS) for complex ventral defects with or without contamination.

METHODS

A retrospective review was conducted of all patients who underwent CS over an 8-year period. Pre-operative factors such as the presence/absence of contamination were analyzed for their effect on length of hospitalization, readmission rate, post-operative complications, re-intervention rate, and long-term recurrence.

RESULTS

A total of 34 patients was analyzed. There were 18 males (53%) with a mean age of 57 years. Mean body mass index was 31 kg/m(2). Seventeen patients (50%) had prior repair (mean 2.1 repairs per patient, median 2). Mean size of abdominal defect was 255 cm(2). Out of the 34 patients, 13 had infected or contaminated defects, including 5 patients with infected mesh. Length of stay was longer in the contaminated group (11.1 vs 3.1 days, P < 0.01). A higher complication rate was noted in the setting of contamination (77 vs 38%, P = 0.03). During a mean follow-up of 47 months, no difference was noted in the re-intervention rate (38 vs 29%, P = 0.70) or long-term recurrence rate of the defect (8 vs 5%, P = 1.0) (contaminated vs non-contaminated group, respectively).

CONCLUSIONS

CS is a good option for closure of large contaminated complex abdominal wall defects. Despite an increased risk of postoperative complications and longer hospitalization length, long-term outcomes are favorable.