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

A prospective multicentre study evaluating the outcomes of the abdominal wall dehiscence repair using posterior component separation with transversus abdominis muscle release reinforced by a retro-muscular mesh: filling a step

BACKGROUND

This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh.

METHODS

Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study.

RESULTS

The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh.

CONCLUSION

Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117.

Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

BACKGROUND

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.

METHODS & CASE REPORT

We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.

DISCUSSION & CONCLUSION

The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

PURPOSE

The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.

METHODS

Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB.

RESULTS

A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008-0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65-0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255-0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24-0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29-32.39; P < 0.0001).

CONCLUSION

Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial

INTRODUCTION

The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention.

MATERIALS AND METHODS

A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan.

RESULTS

At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively.

CONCLUSION

The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Interrupted sutures prevent recurrent abdominal fascial dehiscence: a comparative retrospective single center cohort analysis of risk factors of burst abdomen and its recurrence as well as surgical repair techniques

Background

Burst abdomen (BA) is a severe complication after abdominal surgery, which often requires urgent repair. However, evidence on surgical techniques to prevent burst abdomen recurrence (BAR) is scarce.

Methods

We conducted a retrospective analysis of patients with BA comparing them to patients with superficial surgical site infections from the years 2015 to 2018. The data was retrieved from the institutional wound register. We analyzed risk factors for BA occurrence as well as its recurrence after BA repair and surgical closure techniques that would best prevent BAR.

Results

We included 504 patients in the analysis, 111 of those suffered from BA. We found intestinal resection (OR 172.510; 22.195–1340.796, p < 0.001), liver cirrhosis (OR 4.788; 2.034–11.269, p < 0.001) and emergency surgery (OR 1.658; 1.050–2.617; p = 0.03) as well as postoperative delirium (OR 5.058; 1.349–18.965, p = 0.016) as the main predictor for developing BA. The main reason for BA was superficial surgical site infection (40.7%). 110 patients received operative revision of the abdominal fascial dehiscence and 108 were eligible for BAR analysis with 14 cases of BAR. Again, post-operative delirium was the patient-related predictor for BAR (OR 13.73; 95% CI 1.812–104-023, p = 0.011). The surgical technique of using interrupted sutures opposed to continuous sutures showed a preventive effect on BAR (OR 0.143, 95% CI 0.026–0,784, p = 0.025). The implantation of an absorbable IPOM mesh did not reduce BAR, but it did reduce the necessity of BAR revision significantly.

Conclusion

The use of interrupted sutures together with the implantation of an intraabdominal mesh in burst abdomen repair helps to reduce BAR and the need for additional revision surgeries.

Management of abdominal wound dehiscence: update of the literature and meta-analysis

PURPOSE

Abdominal wound dehiscence (AWD) is associated with significant morbidity and mortality. We aimed to provide a contemporary overview of management strategies for AWD.

METHODS

PubMed, EMBASE, the Cochrane library and a clinical trials registry were searched from 2009 onwards using the key words "abdominal wound dehiscence", "fascial dehiscence" and "burst abdomen". Study outcomes included surgical site infection (SSI), recurrence, incisional hernia and 30-day mortality. Studies reported by the EHS clinical guidelines on AWD were included and compared with. OpenMetaAnalyst was used for meta-analysis to calculate statistical significance and odds ratios (OR).

RESULTS

Nineteen studies were included reporting on a total of 632 patients: 16 retrospective studies, one early terminated randomized controlled trial, one review and the European Hernia Society guidelines. Nine studies reported use of synthetic mesh (n = 241), two of which used vacuum-assisted mesh-mediated fascial traction (VAWCM) (n = 19), six without VAWCM (n = 198) and one used synthetic mesh with both VAWCM (n = 6) and without VAWCM (n = 18); two used biological mesh (n = 19). Seven studies reported primary suture closure (n = 299). Three studies reported on an alternative method (n = 91). Follow-up ranged between 1 and 96 months. Meta-analysis was performed to compare the primary suture group with the synthetic mesh group. Heterogeneity was low to moderate depending on outcome. The overall SSI rate in the primary suture group was 27.6% versus 27.9% in the synthetic mesh group, resulting in mesh explantation in five patients; OR 0.65 (95% CI 0.23-1.81). Incisional hernia rates were 11.1% in the synthetic mesh group (19/171) and 30.7% in the primary suture group (67/218); OR 4.01 (95% CI 1.70-9.46). Recurrence rate did not show a statistically significant difference at 2.7% in the synthetic mesh group (3/112), compared to 10.2% in the primary suture group (21/206); OR 1.81 (95% CI 0.18-17.80). Mortality rates varied between 11.2% and 16.7% for primary suture group versus synthetic mesh; OR 1.85 (95% CI 0.91-3.76).

CONCLUSION

Included studies were of low to very low quality. The use of synthetic mesh results in a significantly lower rate of incisional hernia, whereas SSI rate was comparable to primary suture repair.

Dynamic closure techniques for treatment of an open abdomen: an update

BACKGROUND

The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain as it is associated with a high incidence of complications and poor outcomes. The objective is to perform a systematic review on dynamic closure techniques for fascial closure during open abdomen management.

METHODS

An electronic database search was conducted involving 4 different databases (MEDLINE (PubMed), SCOPUS, WEB OF SCIENCE (WOS) and EMBASE). All studies that described dynamic closure techniques in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest.

RESULTS

Thirteen studies were included in the final synthesis. Overall methodological quality was low with a high number of retrospective observational studies and low number of patients. All included studies are observational cohort studies. No studies reported on the use of either Wittmann patch, dynamic retention sutures or ABRA system. Two studies reported on the ABRA system in combination with Negative Pressure Wound Therapy (NPWT), while 9 reported on mesh-mediated fascial traction (MMFT) combined with NPWT. Other types of fascial traction, either by dynamic suture lines or by a self-made silastic tube system, and NPWT were reported in 2 studies. Overall closure rates are 93.2% for the ABRA system + NPWT versus 72.0% for the mesh-mediated fascial traction + NPWT.

CONCLUSION

Careful selection and good management of OA patients will avoid prolonged treatment and facilitate early fascial closure. Future research should focus on comparison of different temporary dynamic closure techniques to evolve toward best treatment options, in terms of both fascial closure rates and long-term incisional hernia rates.

Open abdomen management and outcomes: two case reports from western Kenya and a review of literature from Africa

The open abdomen (OA) is clinically indicated for attenuating the effects of select intra-abdominal insults that may lead to high intra-abdominal pressure with fascial closure. Despite the high incidence of conditions warranting OA in Africa, there are few reports on its use and outcomes. A retrospective chart review was performed for two patients managed with an OA at the Moi Teaching and Referral Hospital. For comparison, a literature review on related studies from Africa was performed. One patient had an anastomotic leak, while the other had a perforated gastric ulcer. A Bogotá bag was used for temporary abdominal content containment. There was no mortality in our series and fascial closure was achieved in one patient. Upon review of studies from Africa, overall mortality stood at 44%, while 25% of surviving patients underwent fascial closure. The use of OA in Africa is associated with high mortality and low rates of fascial closure. Our limited experience shows this technique is a viable treatment option in an attempt to bridge a patient to abdominal closure during critical illness.

Burst abdomen in pregnancy: A proposed management algorithm

Management of the burst abdomen is complex due to the co-morbidities associated with it. When coupled with intraabdominal sepsis and pregnancy, it becomes even more difficult due to the ethical issues that have to be considered when managing both mother and child. Due to the paucity of literature on this subject, a management algorithm has been proposed which aims at tackling this delicate issue. However, the major consideration in the management of these cases is that decisions are to be made based on optimization of the condition of the mother.

The Open Abdomen Route by EuraHS: introduction of the data set and initial results of procedures and procedure-related complications

INTRODUCTION

Open abdomen management has become a well-established strategy in the treatment of serious intra-abdominal pathologies. Key objectives are fistula prevention and high fascial closure rates. The current level of evidence on laparostoma is insufficient. This is due to the rareness of laparostomas, the heterogeneity of study cohorts, and broad diversity of techniques. Collecting data in a standardised, multicentre registry is necessary to draw up evidence-based guidelines.

MATERIALS AND METHODS

In order to improve the level of evidence on laparostomy, CAMIN (surgical working group for military and emergency surgery) of DGAV (German Society for General and Visceral Surgery), initiated the implementation of a laparostomy registry. This registry was established as the Open Abdomen Route by EuraHS (European Registry of Abdominal Wall Hernias). Key objectives include collection of data, quality assurance, standardisation of therapeutic concepts and the development of guidelines. Since 1 May 2015, the registry is available as an online database called Open Abdomen Route of EuraHS (European Registry of Abdominal Wall Hernias). It includes 11 categories for data collection, including three scheduled follow-up examinations.

RESULTS

As part of this pilot study, all entries of the first 120 days were analysed, resulting in a review of 82 patients. At 44%, secondary peritonitis was the predominant indication. The mortality rate was 22%. A comparison of methods with and without fascial traction reveals fascial closure rates of 67% and 25%, respectively (intention-to-treat analysis, p < 0.03). Inert visceral protection was used in 67% of patients and achieved a small bowel fistula incidence of only 5.5%.

DISCUSSION

Optimising laparostomy management techniques in order to achieve low incidence of fistulation and high fascial closure rates is possible. The method that ensures the best possible outcome-based on current evidence-would involve fascial traction, visceral protection and negative pressure. The laparostomy registry is a useful tool for quickly generating sufficient evidence for open abdomen treatment.

Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique

Wound dehiscence is a serious postoperative complication, with an incidence of 0.5–3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of “intentional open abdomen” was described and both clinical entities share common pathophysiological and clinical pathways (“postoperative open abdominal wall”). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as “frozen abdomen,” where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the “Coliseum technique” for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of “malignant” frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair.

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.