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Miller BT, Ellis RC, Maskal SM, Petro CC, Krpata DM, Prabhu AS, Beffa LR, Tu C, Rosen MJ. Abdominal Wall Tension and Early Outcomes after Posterior Component Separation with Transversus Abdominis Release: Does a "Tension-Free" Closure Really Matter? J Am Coll Surg 2024; 238:1115-1120. [PMID: 38372372 DOI: 10.1097/xcs.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Ventral hernias result in fibrosis of the lateral abdominal wall muscles, increasing tension on fascial closure. Little is known about the effect of abdominal wall tension on outcomes after abdominal wall reconstruction. We aimed to identify an association between abdominal wall tension and early postoperative outcomes in patients who underwent posterior component separation (PCS) with transversus abdominis release (TAR). STUDY DESIGN Using a proprietary, sterilizable tensiometer, the tension needed to bring the anterior fascial elements to the midline of the abdominal wall during PCS with TAR was recorded. Tensiometer measurements, in pounds (lb), were calibrated by accounting for the acceleration of Earth's gravity. Baseline fascial tension, change in fascial tension, and fascial tension at closure were evaluated with respect to 30-day outcomes, including wound morbidity, hospital readmission, reoperation, ileus, bleeding, and pulmonary complications. RESULTS A total of 100 patients underwent bilateral abdominal wall tensiometry, for a total of 200 measurements (left and right side for each patient). Mean baseline anterior fascial tension was 6.78 lb (SD 4.55) on each side. At abdominal closure, the mean anterior fascial tension was 3.12 (SD 3.21) lb on each side. Baseline fascial tension and fascial tension after PCS with TAR at abdominal closure were not associated with surgical site infection, surgical site occurrence, readmission, ileus, and bleeding requiring transfusion. The event rates for all other complications were too infrequent for statistical analysis. CONCLUSIONS Baseline and residual fascial tension of the anterior abdominal wall do not correlate with early postoperative morbidity in patients undergoing PCS with TAR. Further work is needed to determine if abdominal wall tension in this context is associated with long-term outcomes, such as hernia recurrence.
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Affiliation(s)
- Benjamin T Miller
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Ryan C Ellis
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Sara M Maskal
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Clayton C Petro
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - David M Krpata
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Ajita S Prabhu
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Lucas Ra Beffa
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, OH (Tu)
| | - Michael J Rosen
- From the Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH (Miller, Ellis, Maskal, Petro, Krpata, Prabhu, Beffa, Rosen)
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De Laet IE, Malbrain MLNG, De Waele JJ. A Clinician's Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients. Crit Care 2020; 24:97. [PMID: 32204721 PMCID: PMC7092484 DOI: 10.1186/s13054-020-2782-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Inneke E De Laet
- Intensive Care Unit and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium
| | - Manu L N G Malbrain
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Campus Jette, Jette, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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Abstract
Critical illness and injury affect the gastrointestinal tract almost uniformly. Complications include the sequelae of direct intestinal injury and repair, impaired motility, intra-abdominal hypertension, and ulceration, among others. Contemporary clinical practice has incorporated many advances in the prevention and treatment of gastrointestinal complications during critical illness. This article discusses the epidemiology, risk factors, means of diagnosis, treatment, and prevention of some of these compilations.
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Affiliation(s)
- Rowan Sheldon
- Madigan Army Medical Center, Department of Surgery, General Surgery, MCHJ-CLS-G, Tacoma, WA 98431, USA
| | - Matthew Eckert
- Madigan Army Medical Center, Department of Surgery, General Surgery, MCHJ-CLS-G, Tacoma, WA 98431, USA.
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Cristaudo A, Jennings S, Gunnarsson R, Decosta A. Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis. Am Surg 2017. [DOI: 10.1177/000313481708300220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Adam Cristaudo
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ronny Gunnarsson
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Alan Decosta
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Department of Surgery, Cairns Hospital, Cairns, Queensland, Australia
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Kirkpatrick AW, Nickerson D, Roberts DJ, Rosen MJ, McBeth PB, Petro CC, Berrevoet F, Sugrue M, Xiao J, Ball CG. Intra-Abdominal Hypertension and Abdominal Compartment Syndrome after Abdominal Wall Reconstruction: Quaternary Syndromes? Scand J Surg 2016; 106:97-106. [DOI: 10.1177/1457496916660036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: Reconstruction with reconstitution of the container function of the abdominal compartment is increasingly being performed in patients with massive ventral hernia previously deemed inoperable. This situation places patients at great risk of severe intra-abdominal hypertension and abdominal compartment syndrome if organ failure ensues. Intra-abdominal hypertension and especially abdominal compartment syndrome may be devastating systemic complications with systematic and progressive organ failure and death. We thus reviewed the pathophysiology and reported clinical experiences with abnormalities of intra-abdominal pressure in the context of abdominal wall reconstruction. Material and Methods: Bibliographic databases (1950–2015), websites, textbooks, and the bibliographies of previously recovered articles for reports or data relating to intra-abdominal pressure, intra-abdominal hypertension, and the abdominal compartment syndrome in relation to ventral, incisional, or abdominal hernia repair or abdominal wall reconstruction. Results: Surgeons should thus consider and carefully measure intra-abdominal pressure and its resultant effects on respiratory parameters and function during abdominal wall reconstruction. The intra-abdominal pressure post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate intra-abdominal pressure rise after abdominal wall reconstruction including temporizing paralysis of the musculature either temporarily or semi-permanently, pre-operative progressive pneumoperitoneum, permanently removing visceral contents, or surgically releasing the musculature to increase the abdominal container volume. In patients without complicating shock and inflammation, and in whom the abdominal wall anatomy has been so functionally adapted to maximize compliance, intra-abdominal hypertension may be transient and tolerable. Conclusions: Intra-abdominal hypertension/abdominal compartment syndrome in the specific setting of abdominal wall reconstruction without other complication may be considered as a quaternary situation considering the classification nomenclature of the Abdominal Compartment Society. Greater awareness of intra-abdominal pressure in abdominal wall reconstruction is required and ongoing study of these concerns is required.
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Affiliation(s)
- A. W. Kirkpatrick
- Regional Trauma Services, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - D. Nickerson
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - D. J. Roberts
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - M. J. Rosen
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - P. B. McBeth
- Regional Trauma Services, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - C. C. Petro
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery and Liver transplantation, Ghent University Hospital, Ghent, Belgium
| | - M. Sugrue
- Letterkenny Hospital and the Donegal Clinical Research Academy, Donegal, Ireland
| | - Jimmy Xiao
- Regional Trauma Services, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - C. G. Ball
- Regional Trauma Services, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, University of Calgary, Calgary, AB, Canada
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6
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Clinical studies on intra-abdominal hypertension and abdominal compartment syndrome. J Trauma Acute Care Surg 2014; 76:234-40. [DOI: 10.1097/ta.0b013e3182a85f59] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit 2013; 19:524-33. [PMID: 23823991 PMCID: PMC3706408 DOI: 10.12659/msm.883966] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022] Open
Abstract
In this review we look into the historical development of open abdomen management. Its indication has spread in 70 years from intra-abdominal sepsis to damage control surgery and abdominal compartment syndrome. Different temporary abdominal closure techniques are essential to benefit the potential advantages of open abdomen management. Here, we discuss the different techniques and provide a new treatment strategy, based on available evidence, to facilitate more consistent decision making and further research on this complicated surgical topic.
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Lasanianos NG, Kanakaris NK, Dimitriou R, Pape HC, Giannoudis PV. Second hit phenomenon: existing evidence of clinical implications. Injury 2011; 42:617-29. [PMID: 21459378 DOI: 10.1016/j.injury.2011.02.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The last two decades extensive research evidence has been accumulated regarding the pathophysiology of trauma and the sequelae of interventions that follow. Aim of this analysis has been to collect and categorise the existing data on the so-called "second hit" phenomenon that includes the biochemical and physiologic alterations occurring in patients having surgery after major trauma. Articles were extracted from the PubMed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was utilised for quality assessment of the outcomes. Twenty-six articles were eligible for the final analysis, referring to a total of 8262 patients that underwent surgery after major trauma. Sixteen retrospective clinical studies including 7322 patients and 10 prospective ones, including 940 patients were evaluated. Several variables able to reproduce a post-operative second hit were identified; mostly related to pulmonary dysfunction, coagulopathy, fat or pulmonary embolism, and the inflammatory immune system. Indicative conclusions were extracted, as well as the need for further prospective randomised trials. Suggestions on the content and the rationale of future studies are provided.
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Affiliation(s)
- N G Lasanianos
- Academic Department of Trauma and Orthopaedics, LIMM Section Musculoskeletal Disease, Leeds Biomedical Research Unit, LGI, Clarendon Wing, Level A, Great George Street, LS1 3EX, Leeds, United Kingdom.
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Intra-abdominal hypertension: detecting and managing a lethal complication of critical illness. AACN Adv Crit Care 2010; 21:205-19. [PMID: 20431449 DOI: 10.1097/nci.0b013e3181d94fd5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intra-abdominal hypertension occurs in 50% of all patients admitted to the intensive care unit and is associated with significant morbidity and mortality. Intra-abdominal hypertension is defined as a sustained, pathologic rise in intra-abdominal pressure to 12 mm Hg or more. Patients with intra-abdominal hypertension may progress to abdominal compartment syndrome. Early identification and treatment of this condition will improve patient outcome. Patients at risk for intra-abdominal hypertension include those with major traumatic injury, major surgery, sepsis, burns, pancreatitis, ileus, and massive fluid resuscitation. Predisposing factors include decreased abdominal wall compliance, increased intraluminal contents, increased peritoneal cavity contents, and capillary leak/fluid resuscitation.
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