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

Comparison of Continuous Albumin Infusion, Bolus Albumin, and Crystalloid Fluid Administration in Open-Abdomen Surgical-Trauma Patients

Background: The open abdomen (OA), an intentional lack of fascial closure following abdominal cavity opening, is utilized for various indications among surgical-trauma patients. Among intravenous fluid options, administration of albumin as a continuous infusion may improve outcomes in OA. The purpose of this study is to compare the time to abdomen closure among patients with OA according to type of fluid administration. Methods: We conducted a retrospective cohort study of adults with OA from 2012 through 2018 and stratified by intravenous fluid administration into one of three groups: continuous albumin infusion, intermittent bolus albumin, or crystalloid. The primary outcome was median time to abdomen closure. Secondary outcomes included hemodynamic parameters, length of stay (LOS), and mortality. Time to final abdomen closure was analyzed by Cox proportional hazards regression. Results: Eighty-four patients were included with 28 in each cohort. Compared to crystalloids (44.2 [interquartile range, IQR, 36.3-62.9] hours), median time to abdomen closure was significantly longer in bolus albumin (79.0 [IQR, 44.5-130.8] hours; P = .002) and continuous albumin groups (63.6 [IQR, 42.9-139.6] hours; P = .001) in Cox regression analysis. The incidence of hospital mortality was highest in the bolus albumin cohort (continuous albumin: 21.4% vs bolus albumin: 50.0% vs crystalloid: 25.0%; P = .044). All other secondary outcomes were similar between groups. Conclusions: Among patients with OA, administration of intravenous crystalloid was associated with the shortest time to abdomen closure compared to bolus or continuous albumin. Further evaluation of continuous albumin infusion in patients with OA is needed.

Comparative Analysis of Laparoscopic Versus Open Procedures in Specific General Surgical Interventions

Laparoscopic and open surgeries are two distinct surgical approaches with significantly different procedures and outcomes. Minimally invasive surgery, also known as laparoscopic surgery, utilizes small incisions and specialized instruments like the laparoscope to perform procedures. This contrasts with open surgery, which requires larger incisions to directly access the surgical site. Open surgery was the preferred approach for any invasive procedure until the introduction of new technological advances in the form of laparoscopy. While laparoscopy is still evolving, preliminary results demonstrate promise for various operations. Open surgery provides the healthcare professional with more liberty in the form of increased visualization, but it also increases tissue damage and hospital stays. Laparoscopic and open procedures are both valuable surgical methods with advantages and disadvantages. While open surgery is favored for difficult patients, laparoscopic surgery offers a quicker recovery and fewer scars. The choice between the two approaches depends on the patient's condition, surgical demands, and the surgeon's skills. As these methods develop, they become increasingly important for offering safe and efficient surgical treatments across a range of medical specialties.

Visible negative pressure wound therapy for open abdominal management: A single-center retrospective study

Aim

This study aimed to compare open abdominal management (OAM) between visible negative pressure wound therapy (NPWT) and commercial NPWT to determine whether NPWT can detect intestinal ischemia in its early stages without causing complications or worsening prognosis, and to determine whether the actual visualization results in early detection.

Methods

Patients were divided into two groups: those who underwent OAM with visible NPWT (A: 32 patients) and those who underwent OAM with commercial NPWT (B: 12 patients). We compared background factors, disease severity, vital signs, blood test values, and 28-day outcomes between the two groups. We also checked the records to determine how many visualized cases were detected early and operated on. We then examined the weaknesses of this method.

Results

No differences were observed in the background factors or disease severity between the two groups. The duration of the open abdomen and intensive care unit stay were significantly shorter for group A than for group B. The groups showed no significant differences in lactate levels, 28-day outcomes, complications during OAM, or other factors. After a review of the medical records, ischemic progression was detected early, and surgery could be performed in seven cases in the visible NPWT group. The progression of ischemia was confirmed at the time of the second-look operation in two cases in the ascending colon.

Conclusion

The visualization device allowed us to gain insights into the intra-abdominal cavity and determine the appropriate time for closing the abdomen without worsening the prognosis.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®

INTRODUCTION

Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma.

METHODS

Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene.

RESULTS

The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004).

CONCLUSION

DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

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.

Massive traumatic abdominal wall hernia with significant tissue loss: challenges in management

A 41-year-old woman presented to our trauma centre following a high-speed motor vehicle collision with a seatbelt pattern of injury resulting in extensive rupture of her abdominal wall musculature and associated hollow viscus injuries. The abdominal wall had vertical separation between transected rectus, bilateral transverse abdominis and oblique muscles allowing evisceration of small and large bowel into the flanks without skin rupture. Intraoperatively, extensive liquefaction and tissue loss of the abdominal wall was found with significant retraction of the remaining musculature. Initial operative management focused on repair of concomitant intra-abdominal injuries with definitive repair performed in delayed, preplanned stages including bridging with absorbable mesh and placement of an overlying split-thickness skin graft. The patient was discharged from hospital and underwent extensive rehabilitation. One year later, the abdominal wall was definitively repaired with components separation and biological mesh underlay. This stepwise repair process provided her with a robust and enduring abdominal wall reconstruction.

Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes

BACKGROUND

Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or "abbreviated" laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure.

METHODS

An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords "thoracic," "damage control," and "thoracotomy." Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome.

RESULTS

Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%).

CONCLUSION

DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.

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.

Direct Peritoneal Resuscitation: A Novel Adjunct to Damage Control Laparotomy

Direct peritoneal resuscitation is a validated resuscitation strategy for patients undergoing damage control surgery for hemorrhage, sepsis, or abdominal compartment syndrome with open abdomen and planned reexploration after a period of resuscitation in the intensive care unit. Direct peritoneal resuscitation can decrease visceral edema, normalize body water ratios, accelerate primary abdominal wall closure after damage control surgery, and prevent complications associated with open abdomen. This review article describes the physiological benefits of direct peritoneal resuscitation, how this technique fits within management priorities for the patient in shock, and procedural components in the care of open abdomen surgical patients receiving direct peritoneal resuscitation. Strategies for successful implementation of a novel multidisciplinary intervention in critical care practice are explored.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma

BACKGROUND

Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT.

METHODS

The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed.

RESULTS

A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC.

CONCLUSIONS

MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL.

LEVEL OF EVIDENCE

Level III Prognostic.

Effects of Early Altitude Exposure on the Open Abdomen After Laparotomy in Trauma

INTRODUCTION

While damage control surgery and resuscitation techniques have revolutionized the care of injured service members who sustain severe traumatic hemorrhage, the physiologic and inflammatory consequences of hemostatic resuscitation and staged abdominal surgery in the face of early aeromedical evacuation (AE) have not been investigated. We hypothesized that post-injury AE with an open abdomen would have significant physiologic and inflammatory consequences compared to AE with a closed abdomen.

MATERIALS AND METHODS

Evaluation of resuscitation and staged abdominal closure was performed using a murine model of hemorrhagic shock with laparotomy. Mice underwent controlled hemorrhage to a systolic blood pressure of 25 mmHg and received either no resuscitation, blood product resuscitation, or Hextend resuscitation to a systolic blood pressure of either 50 mmHg (partial resuscitation) or 80 mmHg (complete resuscitation). Laparotomies were either closed prior to AE (closed abdomens) or left open during AE (open abdomens) and subsequently closed. AE was simulated with a 1-hour exposure to a hypobaric hypoxic environment at 8,000 feet altitude. Mice were euthanized at 0, 4, or 24 hours following AE. Serum was collected and analyzed for physiologic variables and inflammatory cytokine levels. Samples of lung and small intestine were collected for tissue cytokine and myeloperoxidase analysis as indicators of intestinal inflammation. Survival curves were also performed.

RESULTS

Unresuscitated mice sustained an 85% mortality rate from hemorrhage and laparotomy, limiting the assessment of the effect of simulated AE in these subgroups. Overall survival was similar among all resuscitated groups regardless of the presence of hypobaric hypoxia, type of resuscitation, or abdominal closure status. Simulated AE had no observed effects on acid/base imbalance or the inflammatory response as compared to ground level controls. All mice experienced both metabolic acidosis and an acute inflammatory response after hemorrhage and injury, represented by an initial increase in serum interleukin (IL)-6 levels. Furthermore, mice with open abdomens had an elevated inflammatory response with increased levels of serum IL-10, serum tumor necrosis factor alpha, intestinal IL-6, intestinal IL-10, and pulmonary myeloperoxidase.

CONCLUSION

These results demonstrate the complex interaction of AE and temporary or definitive abdominal closure after post-injury laparotomy. Contrary to our hypothesis, we found that AE in those animals with open abdomens is relatively safe with no difference in mortality compared to those with closed abdomens. However, given the physiologic and inflammatory changes observed in animals with open abdomens, further evaluation is necessary prior to definitive recommendations regarding the safety or downstream effects of exposure to AE prior to definitive abdominal closure.

Open Abdomen in a Critically Ill Patient

One of the damage control strategies used to avoid or treat abdominal compartment syndrome is “open abdomen (OA),” where the facial edges and the skin is left open, exposing the abdominal viscera. Although it reduces the mortality both in trauma and non-trauma abdominal complications, it does create a significant challenge in an intensive care setting, as it has physiological consequences that need early recognition and prompt treatment both in the intensive care unit and in the operating room. The article aims to review literature on “open abdomen,” describe the challenges in such cases, and proposes a guideline for the intensivist in managing a patient with an OA.

How to cite this article: Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020;24(Suppl 4):S193–S200.

ICU Management of Trauma Patients

OBJECTIVES

To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.

DATA SOURCES AND STUDY SELECTION

A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.

DATA EXTRACTION AND DATA SYNTHESIS

The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.

CONCLUSIONS

The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.

Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol

BACKGROUND

Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS.

METHODS

We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications.

RESULTS

The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration.

CONCLUSIONS

A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis.

Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure

BACKGROUND

Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function.

METHODS

We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury.

RESULTS

The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003).

CONCLUSION

Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury.

LEVEL OF EVIDENCE

Prognostic study, level II.

"Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference

To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.

Open Abdomen in Trauma and Critical Care

The open abdomen technique and temporary abdominal closure after damage control surgery is fast becoming the standard of care for managing intra-abdominal bleeding and infectious or ischemic processes in critically ill patients. Expansion of this technique has evolved from damage control surgery in severely injured trauma patients to use in patients with abdominal compartment syndrome due to acute pancreatitis and other disorders. Subsequent therapies after use of the open abdomen technique and temporary abdominal closure are resuscitation in the intensive care unit and planned reoperation to manage the underlying cause of bleeding, infection, or ischemia. Determining the need for this potentially lifesaving intervention and managing the wound after the open abdomen has been created are all within the realm of critical care nurses. Case studies illustrate the implementation of the open abdomen technique and patient management strategies.

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.

"Second-look" laparotomy: warranted, or contributor to excessive open abdomens?

INTRODUCTION

The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.

METHODS

This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis.

RESULTS

During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups.

CONCLUSION

Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.

Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma

Background

Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain.

Methods

The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation.

Results

Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m²vs. Drain-Use: 29.1 kg/m², P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs. 2.8 days, P<0.0001). There were no significant differences in the 30-day hospital readmission rate or incidence of 30-day wound dehiscence, draining wound, incision & drainage (I & D), or bleeding between both patient groups.

Conclusions

Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.

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

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

Acute Kidney Injury Following Exploratory Laparotomy and Temporary Abdominal Closure

BACKGROUND

Acute kidney injury (AKI) following exploratory laparotomy and temporary abdominal closure (TAC) is poorly understood but clinically significant. We hypothesized that the prevalence of AKI would be highest 96 h following TAC, early hypoxemia would predict AKI, and that AKI would be an independent predictor of mortality.

METHODS

We performed a retrospective analysis of 251 acute care surgery patients managed with TAC by negative pressure wound therapy (NPWT). Kidney Disease: Improving Global Outcomes AKI stages were assessed on admission, initial TAC, and following TAC at 48 h, 96 h, and 7 d. Multivariate regression was performed to identify risk factors for AKI and inpatient mortality.

RESULTS

Fifty-seven percent of all patients developed AKI within 7 days of laparotomy (stage 1: 14%, 2: 21%, 3: 22%). The prevalence of AKI peaked 48 h following TAC, and stage correlated with inpatient mortality (stage 0: 7%, 1: 13%, 2: 19%, 3: 37%, P < 0.001). Overall mortality was 14%. Factors predictive of stage 2 or 3 AKI at 48 h included age >65 years (OR 2.6 [95% CI 1.4-4.9]), NPWT output >30 mL/h from first TAC to 48 h (2.0 [1.1-3.9]), and three parameters at initial laparotomy: mean arterial pressure <60 mm Hg (2.9 [1.0-8.5]), temperature <36°C (2.1 [1.1-3.8]), and anion gap >21 mEq/L (1.9 [1.0-3.7]). AKI was an independent predictor of inpatient mortality (5.5 [2.5-11.8]).

CONCLUSIONS

AKI is common following TAC, reaches greatest prevalence 48 h after initial laparotomy, and is associated with increased mortality. NPWT fluid loss is a risk factor for AKI that is unique to TAC patients.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Peritoneal cavity lavage reduces the presence of mitochondrial damage associated molecular patterns in open abdomen patients

BACKGROUND

Mitochondrial damage-associated molecular patterns (mtDAMPs), such as mitochondrial DNA and N-formylated peptides, are endogenous molecules released from tissue after traumatic injury. mtDAMPs are potent activators of the innate immune system. They have similarities with bacteria, which allow mtDAMPs to interact with the same pattern recognition receptors and mediate the development of systemic inflammatory response syndrome (SIRS). Current recommendations for management of an open abdomen include returning to the operating room every 48 hours for peritoneal cavity lavage until definitive procedure. These patients are often critically ill and develop SIRS. We hypothesized that mitochondrial DAMPs are present in the peritoneal cavity fluid in this setting, and that they accumulate in the interval between washouts.

METHODS

We conducted a prospective pilot study of critically ill adult patients undergoing open abdomen management in the surgical and trauma intensive care units. Peritoneal fluid was collected daily from 10 open abdomen patients. Specimens were analyzed via quantitative polymerase chain reaction (qPCR) for mitochondrial DNA (mtDNA), via enzyme immunoassay for DNAse activity and via Western blot analysis for the ND6 subunit of the NADH: ubiquinone oxidoreductase, an N-formylated peptide.

RESULTS

We observed a reduction in the expression of ND6 the day after lavage of the peritoneal cavity, that was statistically different from the days with no lavage (% change in ND6 expression, postoperative from washout: -50 ± 11 vs. no washout day, 42 ± 9; p < 0.05). Contrary to expectation, the mtDNA levels remained relatively constant from sample to sample. We then hypothesized that DNAse present in the effluent may be degrading mtDNA.

CONCLUSION

These results indicate that the peritoneal cavity irrigation reduces the presence of mitochondrial DAMPs in the open abdomen. It is possible that increased frequency of peritoneal cavity lavage may lead to decreased systemic absorption of mtDAMPs, thereby reducing the risk of SIRS.

LEVEL OF EVIDENCE

Prospective study, Case Series, Level V.

Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management

The term "open abdomen" refers to a surgically created defect in the abdominal wall that exposes abdominal viscera. Leaving an abdominal cavity temporarily open has been well described for several indications, including damage control surgery and abdominal compartment syndrome. Although beneficial in certain patients, the act of keeping an abdominal cavity open has physiologic repercussions that must be recognized and managed during postoperative care. This review article describes these issues and provides guidelines for the critical care physician managing a patient with an open abdomen.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay

INTRODUCTION

Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome.

METHODS

From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models.

RESULTS

Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality.

CONCLUSION

There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Temporary abdominal closure for trauma and intra-abdominal sepsis: Different patients, different outcomes

BACKGROUND

Temporary abdominal closure (TAC) after damage control surgery (DCS) for injured patients has been generalized to septic patients. However, direct comparisons between these populations are lacking. We hypothesized that patients with intra-abdominal sepsis would have different resuscitation requirements and lower primary fascial closure rates than trauma patients.

STUDY DESIGN

We performed a 3-year retrospective cohort analysis of patients managed with TAC for trauma (n = 77) or intra-abdominal sepsis (n = 147). All patients received negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-hour intervals.

RESULTS

At presentation, trauma patients had higher rates of hypothermia (31% vs. 18%), severe acidosis (27% vs. 14%), and coagulopathy (68% vs. 48%), and septic patients had higher vasopressor infusion rates (46% vs. 27%). Forty-eight hours after presentation, septic patients had persistently higher vasopressor infusion rates (37% vs. 17%), and trauma patients had received more red blood cell transfusions (6.0 U vs. 0.0 U), fresh frozen plasma (5.0 U vs. 0.0 U), and crystalloid (8,290 vs. 7,159 ml). Among patients surviving to discharge, trauma patients had higher primary fascial closure (PFC) rates (90% vs. 76%). For trauma patients, independent predictors of failure to achieve PCF were ≥2.5 L NPWT output at 48 hours, ≥10 L crystalloid administration at 48 hours, and ≥10 U PRBC + FFP at 48 hours. For septic patients, relaparotomy within 48 hours predicted successful PFC; requirement for ≥3 diagnostic/therapeutic laparotomies predicted failure to achieve PFC.

CONCLUSIONS

Traumatic injury and intra-abdominal sepsis are associated with distinct pathophysiologic insults, resuscitation requirements, and outcomes. Failure to achieve primary fascial closure in trauma patients was attributable to the triad of hypothermia, acidosis, and coagulopathy; failure to achieve fascial closure in septic patients was dependent upon operative course. Indications and optimal techniques for TAC may differ between these populations.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Practice Patterns for the Use of Antibiotic Agents in Damage Control Laparotomy and Its Impact on Outcomes

BACKGROUND

The purpose of this study was to identify practice patterns associated with the use of antimicrobial agents with damage control laparotomy (DCL) and the relationship with post-operative intra-abdominal infection (IAI) rates.

PATIENTS AND METHODS

The study was a retrospective review of trauma patients undergoing laparotomy at a Level 1 trauma center in 2010. Patients undergoing DCL versus those primarily closed (PCL) were compared for antimicrobial use (ABX) and its correlation with IAI rates (p < 0.05). Deaths with length of stay <5 days were excluded.

RESULTS

A total of 121 patients were identified (28 DCL, 93 PCL). The DCL group was more severely injured (Injury Severity Score [ISS]: 31.4 ± 15 DCL vs. 18 ± 12.7 PCL, p < 0.001) with more small and large bowel injuries (SLBI), although not statistically significant (53.6% DCL vs. 35.5% PCL, p = 0.12). Practice patterns of ABX administration in terms of pre-operative (94.6% PCL vs. 69.2% DCL, p = 0.0012) and post-operative administration (PCL: 50.5% none, 21.5% one day, 28% long term >1 d; DCL: 21.4% none, 25.0% one day, 53.6% long term >1 day, p = 0.0130) were significant. Regression analyses demonstrated that neither ISS nor DCL was an independent predictor of infection, but pre-operative ABX was a negative predictor (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.05-0.91, p = 0.037), while post-operative ABX (OR 6.7, 95%CI 1.33-33.8, p = 0.044) and SLBI (OR 3.45, CI 1.03-11.5, p = 0.02) were positive predictors of infection with an receiver operating characteristic of 0.81.

CONCLUSION

Significant variations exist in the use of ABX in DCL and PCL. These variations may lead to deleterious results from both lack of initial pre-operative coverage and prolonged ABX use. The decrease in infection rates with pre-operative ABX yet significant increase with continued post-operative use even in the presence of SLBI suggests the need for a more standardized approach. With the increase in DCL and the open abdomen, more research is needed to clearly establish ABX protocols in this patient population.

Acute traumatic coagulopathy and trauma-induced coagulopathy: an overview

Hemorrhage is the most important contributing factor of acute-phase mortality in trauma patients. Previously, traumatologists and investigators identified iatrogenic and resuscitation-associated causes of coagulopathic bleeding after traumatic injury, including hypothermia, metabolic acidosis, and dilutional coagulopathy that were recognized as primary drivers of bleeding after trauma. However, the last 10 years has seen a widespread paradigm shift in the resuscitation of critically injured patients, and there has been a dramatic evolution in our understanding of trauma-induced coagulopathy. Although there is no consensus regarding a definition or an approach to the classification and naming of trauma-associated coagulation impairment, trauma itself and/or traumatic shock-induced endogenous coagulopathy are both referred to as acute traumatic coagulopathy (ATC), and multifactorial trauma-associated coagulation impairment, including ATC and resuscitation-associated coagulopathy is recognized as trauma-induced coagulopathy. Understanding the pathophysiology of trauma-induced coagulopathy is vitally important, especially with respect to the critical issue of establishing therapeutic strategies for the management of patients with severe trauma.

Challenges of Complex Open Abdominal Wound Management in Trauma: A Novel Use of Chitosan and Hyaluronic Acid as a 3-Dimensional Scaffold to Overcome Resilient Open Abdomen Infections

Case presentation of a novel method for the management of complex open abdomen technique. This Mmethod includes the combination of chitosan, hyaluronic acid and negative pressure wound therapy. Patient was initially managed with traditional operating room wash-outs and packing. Implementation of novel method achieved closure in 17 days with split-thickness-skin-graft.

Emergent laparotomy and temporary abdominal closure for the cirrhotic patient

BACKGROUND

Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients.

METHODS

We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals.

RESULTS

At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients.

CONCLUSIONS

Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.

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.

Anatomical, physiological, and logistical indications for the open abdomen: a proposal for a new classification system

Background

A systematic approach to the appropriate use of the open abdomen strategy has not been described. We propose three fundamental reasons for the use of this strategy, anatomical, physiological and logistical. Anatomical reasons pertain to the inability to bring the fascial edges together including soft tissue defects. Physiological reasons relate to features of systemic dysfunction. Logistical reasons involve any anticipated abdominal re-intervention while preserving fascia. These categories occur either as a single reason or in any combination.

Methods

A single-center prospective observational study of patients with open abdomens in trauma and acute abdomen. Surgeons were asked to select from the three reasons (single or any combination of) their motivation for using the open abdomen upon completion of the initial operation. Patients were compared using the non-parametric Wilcoxon two-sample test or Kruskal-Wallis test. Chi-square or Fisher’s exact test was used for categorical variables; Statistical significance set at P-value ≤ 0.05.

Results

Forty-five consecutive patients with open abdomens were evaluated (Jan. 1- Dec. 31, 2012). Mean age was 38.8 years, 32 were male, 39 (86.7 %) sustained trauma. The most common single reason for the open abdomen was physiological (24.4 %), 33 patients had multiple reasons, the most common combination being anatomical and physiological (22.2 %). A physiological reason was linked to: lower pH, higher lactate, and lower systolic blood pressure on admission (p < 0.05). A logistical reason was associated with earlier primary fascial closure, intra-operative packing, and bowel left in discontinuity. Logistic regression and adjusted odds ratio of primary fascial closure was: physiological (0.08, 95 % CI, 0.01–0.92, p = 0.043); logistical (6.03, 95 % CI, 1.13–32.29, p = 0.036); and anatomical (0.83, 95 % CI, 0.16–4.18, p = 0.816).

Conclusion

We defined three basic indications for the use of the open abdomen, anatomical physiological and logistical. These indications establish a practical and comprehensive terminology that could help to promote appropriate use of the open abdomen.

Managing the open abdomen: negative pressure closure versus mesh-mediated fascial traction closure: a randomized trial

PURPOSE

To compare the effectiveness of abdominal wall closure using the vacuum-assisted closure (NPC) as described by Barker et al. with an institutional protocol using a double polyvinyl bag in the first surgery, which is changed in subsequent surgeries to a polyvinyl bag placed over the bowel loops and a prolene mesh attached to the abdominal fascia (MMFC).

METHODS

Randomized controlled trial. Patients with open abdomen (OA) due to a traumatic or a medical cause were included in the study. Variables studied included demographics, indication for surgery, number of interventions, hospital length of stay (HLOS), ICU length of stay, abdominal wound care costs, complication rates, and method and time to definitive fascial closure.

RESULTS

From June 2011 to April 2013, 75 patients were enrolled in the study. Patients who died within 48 h were excluded; therefore, 53 patients in total were assessed. NPC achieved fascial closure in 75% of patients, and MMFC achieved closure in 71.9% of patients. The closure rates in patients with OA secondary to medical causes (80% by NPC vs. 71.4% by MMFC) or traumatic causes (70% by NPC vs. 73.7% by MMFC) were similar in both treatment groups. There were no differences between the groups with respect to cause of OA, complications, length of hospital stay, or the length of stay in the intensive care unit.

CONCLUSION

MMFC is a method comparable to NPC for the temporary management of OA that results in similar closure and complication rates.