A new era in the management of open abdomen

Witsarut Jirapongsakorn, MD

Burapat Sangthong, MD

Department of Surgery, Faculty of Medicine

Prince of Songkla University

Introduction

pen abdomen (OA) is an important step of damage control surgery (DCS)1 in trauma surgery due

the improvement of patient outcomes. The purpose of DCS2 is to limit the operative time, permitting

the patient to return to the intensive care unit for resuscitation. In general surgery, acute

compartment syndrome (ACS)2 is a result of intra-abdominal injury (primary) or splanchnic

reperfusion after massive resuscitation. This may include sepsis or pancreatitis. It causes patients to have a low

urine output, as well as hypotension and an increase in ventilator pressure. Open abdomen for decompression, ,

is also an essential treatment for in this category of patient.

The goal in the management of patients, after OA is closure of the fascial defect as early as stable

clinical conditions allow, without ACS because the risks associated with OA include; fluid or electrolyte

imbalance, systemic inflammatory response, gastrointestinal fistula and adhesions3. (Table1)

Risks associated with open abdomen

Local effects Systemic effects

Gastrointestinal fistula formation Systemic inflammatory response

Intra-abdominal abscesses Derangement of fluid and electrolyte balance

Abdominal infection Sepsis

Adhesions causing bowel obstruction Capillary leak

Adhesions precluding subsequent surgery

and/or primary closure

Catabolic state

Fascial retraction -

Table.1 Complications of the open abdomen technique3

The traditional treatment to close the fascial defect is to make a skin graft on the granulated open

abdomen (Fig. 1-A) resulted as a ventral hernia (Fig. 1-B). Abdominal wall reconstruction is carried out within

the next 6-12 months by; evaluation of sagging by pinch testing. However, this approach is associated with the

increased cost of medical care4, adhesions, atrophic muscle5 and a risk of enterocutaneous fistula6. Cheatham et

al.7 reposted significantly decreased perceptions of physical, social, and emotional health in patients awaiting

abdominal wall reconstruction.

Figure 1 : Mature granulation tissue in an open abdomen, which is then covered with

a split-thickness skin graft8

O

Recently, the temporary abdominal closure

(TAC) technique has also been an important treatment

to help the patient with open abdomen for above

reasons. (An indication for TAC is provided in

Table 2.)

Indications for Temporary Abdominal Closure

Damage control

Severe hemorrhage

Hypothermia, coagulopathy, acidosis

Delayed definitive operation secondary to patient’s physiologic state

Intra-abdominal hypertension or compartment syndrome

Questionable visceral viability

Planned acute reoperation

Severe intra-abdominal sepsis

Triage

Table 2 Indications for temporary abdominal closure9

An ideal TAC should have the following concepts

(8) :

Easily contain the bowel and abdominal viscera

Allows room for expansion of abdominal cavity

Protects the fascia and viscera and prevents

fascial retraction

Evacuates infectious materials

Contains and quantifies fluid loss

Prevents adhesion

Has a good primary fascial closure rate

Temporary abdominal closure technique

The management of the open abdomen has been developed for more than 30 years.(Table 3)

Overview and characteristic of the temporary abdominal closure technique

Technique Description Mechanism

Vacuum-assisted

Closure

A perforated plastic sheet covers the viscera then a reticulated

polyurethrane sponge is placed over the plastic. The wound is covered

by an airtight seal which pierced by a suction drain that is connected to

a suction pump.

The negative pressure supplied by the suction

pump keeps constant tension on the fascial

edges It also collects excess abdominal fluid

and helps to resolve edema.

Vacuum pack A perforated plastic sheet covers the viscera then damp surgical towels

or laparotomy pads and surgical drains are placed. An airtight seal

covers the wound and negative pressure is applied through the drain.

The negative pressure keeps constant tension

on the fascial edges and collects an excess

fluid.

Artificial burr

(Wittmann patch)

Two opposite Velcro sheets (hooks and loops) are sutured to the fascial

edge and connected in the middle of abdomen.

This technique allows for easy access and

reapproximation of the fascial edges.

Dynamic

retention

sutures

The viscera are covered with a barrier sheet. Horizontal sutures are

placed through a large-diameter catheter and through entire both sides

of abdominal wall in an extraperitoneal plane.

These sutures keep tension and may be

gradually tightened to allow staged

reapproximation of abdominal wall. May be

combined with a vacuum system.

Plastic silo

(Bogota´ bag)

A sterile X-ray film cassette bag or sterile 3-L urology irrigation bag is

sutured between the fascial edges or the skin.

An easy technique that allows for easy access,

protect the abdominal content and prevent

retraction of fascial edge.

Mesh/sheet An absorbable or nonabsorbable mesh or sheet is sutured between the

fascial edges.

As swelling resolved, the mesh or sheet may

be reduced in size to allow for

reapproximation.

Loose packing The abdominal cavity is packed then the fascial defect is covered by

standard wound dressing only.

This technique is simple but has no prevention

of fascial retraction.

Skin

Approximation

The skin is closed over the fascial defect with towel clips or a running

suture.

It can provide the protection of viscera but the

towel clips obstruct radiological imaging and

do not prevent fascial retraction or IAH.

Zipper A mesh or sheet with a sterilized zipper is sutured between the fascial

edges.

This technique is comparable to the

mesh/sheet and allows for easy access and

prevention of retraction of abdominal wall.

Table 3. Various methods of temporary abdominal closure10, IAH; intra-abdominal hypertension

Simple packing (Fig. 2)

This surgical technique was the most commonly used

technique in the 1980s and was a performed by

placing moist and sterile gauzes directly over the

abdominal contents. Previous studies11 reported

morbidity and mortality rate decreased but there were

problems with evisceration, fluid and electrolyte loss

as well as fistula formation .

Skin-only closure (Fig. 3)

This technique was also a commonly used technique

in previous eras by, approximating the skin with towel

clips or sutures, which were placed 2-3 cm apart. It is

the most rapid of the temporary abdominal closure

techniques. However, this type of technique

frequently resulted in ACS 13-36% due to; visceral

edema12. Skin injury from retraction may also occur

and produce a problem in later abdominal wall

reconstruction2, 13. Today the skin-only closure is used

for two scenarios. One, as a temporary measure in the

operating room to resuscitate to a second look

operation, and secondly as a trial of fascial

approximation2.

Plastic silo (Bogota bag) (Fig. 4)

This technique can be used as a first-line treatment

for TAC by; suturing a non-permeable barrier,

including sterile plastic sheeting, silo or a 3L

genitourinary irrigation bag , to the skin or fascia.

Advantages are that it is easy to apply, there is also a

prevention of evisceration and desiccation2, 6, 13. The

rates of primary closure range from 12-82% but it can

be time-consuming and might not prevent adhesions,

fluid loss or the retraction of muscle. Entericutaneous

fistula rates range from 0-14.4%6,14. Manterola et al.15

found that 60 % of patients, who undergoing

relaparotomy followed by, a laparostomy using the

Bogota bag, developed a ventral hernia within a 48

month follow-up.

Mesh (Fig. 5)

There were reports in the use of absorbable and

permanent synthetic repair materials for patients with

TAC by, suturing prostheses to the fascial edges, then

gradually tightening these during reoperation3.

Permanent synthetic mesh was sutured to both the

fascial edges to protect abdominal wall tissues from

injury when repetitive surgical procedures were

performed as well as which to prevent any retraction

of the fascia. Polypropylene mesh (PP, Martex) with

porous structure is appropriate for growth of

microvascular vessels and convenient for topical

Figure 3 : Skin-only closure technique

Figure 4 : Plastic silo (Bogota´ bag ) technique

(Courtesy of Siripong Chewathanakornkul, M.D.)

Figure 5 : Mesh technique, Vicryl mesh

growth factor. Yuan et al.16 reported the microvascular

densities, thickness of granulation tissue, and

fibroblast counts were the highest for polypropylene

mesh closure when compared with polyethylene

sheeting. Although, the primary closure rates are

ranged from; 33-89 %, fistula rates range from;6.6-

14.7%17-20. Hence, a non-adherent barrier should be

placed between the viscera and fascia to prevent

formation of fistulas. Some microporous materials

such as; polytetrafluoroethylene (ePTFE) , were

developed for preventing adherence to tissue21 but

there were still high infection rates22. Thus, both PP

and PTFE should not be placed in a contaminated

environment. Absorbable mesh such as; polyglactin

910 (Vicryl) and polyglycolic acid (Dexon) ,was later

developed later. These materials have large

interstices that allow for drainage, so there are more

resistant to infection18. They also stimulate fibrous

granulation tissue along with epidermal cell

proliferation23. However, there were reports in fistula

formation rates, which ranged 5-11% and intra-

abdominal abscess24.

Wittmann patch (Fig. 6)

This technique is also called ―artificial burr‖ and

consists of a hook and loop sheet (Velcro). This

technique is performed by placement of a non-

adherent barrier, which has multiple holes, allowing

for egress of fluid between the bowel and parietal

peritoneum (Fig. 6-A). The Wittmann patch is sewn

to the opposing edges of the fascia, then brought into

the midline of the abdomen to apply pressure

(Fig. 6-B). Peak airway pressures are also checked to

ensure that they do not increase > 10%. Sterile gauzes

and drains are applied (Fig. 6-C). Adhesive draping is

used to seal the abdominal wall (Fig. 6-D).

The suction dressing is changed, and the patch is also

tightened every 1-3 days25. The advantages of the

Wittmann patch are to decrease abdominal distension,

gradually approximating the fascia, rapid and safe

reentry into the abdomen and as well as which to

prevent loss of abdominal domain3. Previous

studies25, 26 showed the primary fascial closure rates

range from; 78-100%. The overall complication rates

remain relatively low and the fistula rates are; 0-4.2%.

However, it is still expensive and also perceptible

tissue injury and subject to infections25.

Vacuum-assisted closure (VAC) or Vacuum-pack

closure (Fig. 7)

This was described by Barker et al. in 199927 by,

creating a negative-pressure bag to decompress

abdominal pressure, preventing adhesions and

minimize retraction of abdominal fascia, or loss of

abdominal domain. The key features of VAC mostly

include8 :

A fenestrated inner layer : An pliable material

that is placed on top of the viscera to prevent

adhesion formation, this also contains the

abdominal contents and allows for fluid

movement.

Figure 7: Barker vacuum-pack technique

Figure 6: Wittmann patch technique 25

o A middle layer of foam, or towel : This layer

helps to generate suction to remove infectious

effluent and keeps the bowel moist.

o A Suction mechanism with major force

o An outer layer : An adhesive drape is applied

to create an airtight seal.

After completion of abdominal exploration, a

polyethylene sheet is perforated multiple times. It is

placed on top of the peritoneal viscera and beneath the

parietal peritoneum. Moist, sterile surgical towels are

then placed over the sheet to prevent the protrusion of

abdominal viscera. Two 10-French flat silicone drains

are placed over the towels. The entire abdominal wall

is covered with adhesive draping. Each drain tube is

connected to a suction source at 100-150 mmHg

continuous, negative pressure. VAC is changed every

2-3 days until physical stabilization is achieved for

closing of the abdominal wall8, 13, 27. Barker et al.27, on

evaluation of a retrospective study, in the use of the

vacuum pack technique of TAC for 7 years, it was

reported that 55.4% of 112 patients could go on to

primary closure. The complications from

enterocutaneous fistula and intrabadominal abscess

are about 4.5% .

Currently, there are several commercial

equipments available. KCI ABthera negative-

pressure dressing3 (Fig. 8) is also commonly used as

a negative-pressure dressings systems. It consists of a

large visceral protective layer, which includes a

polyurethane film-covered central sponge, with six

arms of polyurethane sponge that can drain fluid from

the gutters, the pelvis and loops of the bowel. Other

parts of the system include a sponge that occupies the

defect between the two edges of the open abdominal

wall, then an adhesive drape is placed to create an

airtight seal. Recently, Cheatham et al.28, who

conducted the comparison between Barker's

vacuum-packing technique and the ABThera system,

found that the ABThera System had a significantly

higher 30-day primary fascial closure rate as well as a

lower 30-day mortality rate. . In contrast, the study,

which was conducted by Kirkpatrick et al.29, showed

no difference between patients using the ABThera or

Barker’s vacuum pack, as to the improvement in

peritoneal fluid drainage, fascial closure rates, or

markers of systemic inflammation. However, it still

costly due to the high costs of commercial dressing,

and the system cannot be placed over a protruding

viscera. There are some studies30 that reported if; the

treatment exceeds 3 weeks, it is also very difficult to

close the fascia.

Vacuum-assisted wound closure and mesh-

mediated fascial traction (VAWCM) (Fig. 9)

Because of marked swelling to the viscera, a longer

treatment period is necessary. There is a novel

technique, for a late closure of the open abdomen,

which was described by Petersson et al.31. After

placing a perforated, plastic sheet on the abdominal

contents, two PP meshes are sutured to the fascial

edges. Theese are then, retracted and sutured into the

Figure 8: KCI ABthera negative-pressure dressing8

Figure 8: KCI ABthera negative-pressure dressing8

midline with No.0 monofilament, as a continuous

technique. The foam, or gauzes along with the suction

drains are then covered on the top of the meshes after

which, an adhesive drape is applied. Suction drains

are connected with a suction device with a

continuous, topical negative pressure of 100-150

mmHg. This VAC is changed every 2-3 days and the

meshes are tightened6, 31-33. Previous studies32, 33 found

that the delayed fascial closure rate ranged from; 78-

89%, and that the enteroatmospheric fistula rate

ranged from; 7-12%. Although, Bjarnason et al.34,

who studied in one-year follow-up

after open abdomen therapy with vacuum-assisted

wound closure and mesh-mediated fascial traction,

found that the incidence of incisional hernia, after 1

year in patients with VAWCM was high, most of

these cases were small and asymptomatic hernia was

corrected with minimal surgical repair. In conclusion,

the advantage of the VAWCM technique is a

synergistic method to facilitate closure of the

abdomen. It provides for a entirely clean abdominal

cavity, whilst also providing the abdominal wall to

move toward the midline, but it requires the need for

trained personnel to conduct dressing changes and

perform fascial traction.

Figure 9 : Vacuum-assisted wound closure and mesh-mediated fascial traction technique33

Sequential fascial closure

This technique is the modified the method proposed

by Miller et al.35. After stabilization of the patient’s

clinical conditions, the sequential closure technique

can be performed. Multiple white sponges are

overlapped on top of the viscera but beneath the

fascial edges and also stapled together using a skin

stapler. The fascia is sutured with No.1

polydioxanone sutures (PDS) as an interrupted

technique. The PDS are full-thickness fascial bites,

(>1.5 cm) placed about 5 cm apart in an interrupted

fashion. An adherent clear plastic VAC covering is

then placed over the all of the white sponges, and

adjacent to 5-10 cm of skin (Fig. 10-A, B). The

central part of the clear plastic is removed, whilst the

remaining plastic is adhered to the skin (Fig. 10-C).

Black, VAC sponges are then placed on top of the

white sponges (Fig. 10-D, E). Standard suction drains

along with and occlusive dressing are placed (Fig. 10-

D, E). VAC is changed every 2 days by; replacement

of the black and white sponges. The fascia is also

sutured with No.1 PDS in an interrupted technique

from both, superior and inferior directions without re-

exploration of the abdomen2,35. Burlew et al.35

reported that 100% patients, using the sequential

closure protocol after DCS, in a five-year study period

had fascial closure without complications. Moreover,

the element of timing to return to the operating room

(OR) is important because two-thirds of the protocol

failures in this study were due to a return to the OR of

more than 48 hours that provided for only 55% of the

patients fascial closure.

Figure 10: Sequential fascial closure2

Tension suture technique

There are various strategies to describe this technique

for prevention of fascial retraction36. Timing of the

application after, the resolution of systemic

inflammatory response and visceral edema, is

important due to; low frequency of intra-abdominal

pressure. A VAC technique may be used for this

reason36-38. Before, application of this technique the

surgical wound is debrided and adhesions are

carefully dissected. A non-adherent sheet is placed to

cover the viscera. Two fascial edges are sutured with

No.1 PDS in a continuous fashion. The interval

between the loops and the depth the sutures are

approximately 2 cm. The sutures are also locked with

metal bullets. Finally, a transparent occlusive

dressing36 (Fig.11) or VAC dressing37 is placed on the

wound. The sutures are tightened every 2-3 days by

sliding the bullet along the line, this is accomplished

without removing the sutures. Gäddnäs et al.36 who,

described this method, found that 81% of patients had

fascial closure without bowel fistula or erosion from

tension of the sutures. Moreover, Kafka-Ritsch et al. 37

found that 86% of critically ill patients, with dynamic

retention sutures and topical negative pressure, could

achieve fascial closure

Nowadays, dynamic retention sutures

technique is developed as commercial dressings for

ease of use. These are called ―Abdominal Re-

approximation Anchor (ABRA)‖. They are designed

to allow gradually re-approximation of abdominal

muscles coupled with fascia into the midline5,39-41.

After, the surgical wound is surgically debrided and

adhesions are also dissected, a perforated silicone

sheet is placed between the viscera and abdominal

wall. Midline crossing elastic bands (elastomer) are

inserted through the incised full-thickness of the

abdominal wall approximately 5 cm from wound

margin, and aligned about 3-5 cm apart along the

wound length. The button anchors are used to fix the

elastomer at the insertion site, this keeps the tension.

An adhesive button tail is attached to the anchor to

prevent its displacement or tilting (Fig. 13). The

monitoring of the tension is by means of the black-

and-white calibration marks. Initial tension should be

set at approximately a 1.5 to 2 x stretch length of the

calibration marks. Occlusive dressing or VAC is

applied on the remaining defect39,40. Dressing changes

are performed as standard practice with abdominal

wall massage. An elastomer tension is adjusted as

physicians need to maintain the tension.

Reimer et al.41 showed that 61 % patients achieved

delayed primary closure, but the rates of hernia

Figure 11: Continuous retention sutures technique36

Figure 12: Abdominal Reapproximation Anchor system42

Figure 13 : Abdominal Reapproximation Anchor

technique42

formation were 26%, and the rates of enterocutneous

fistula formation were 9%. Verdam39 and Haddock40,

who combined this technique with VAC dressings,

found that delayed primary closure in patients with

OA could be achieved in 88% and 100% respectively.

However, the risk of hernia development was 25%

and 33% respectively, it was depended on the

extensive preoperative damage and infection of the

fascia41.

Evidence from temporary abdominal

closure in the present period

Recently, an attempt to reduce the time from a

TAC, to primary fascial closure in patients with OA

resulted in the development of various techniques of

TAC as previous mentioned. Regner et al.43 suggested

that there was a bimodal distribution of patients with

TAC. The first were able to close the abdomen within

4-7 days, giving a high rate of primary closure, while

the second group had a delayed (20-40 days) closure,

these having a lower, overall rate of closure. So, if

closure of the abdomen within 7 days, is not obstained

progressive, fascial closure equipment may be needed

such as; Wittmann patch, to obstain subsequential,

fascial closure.

There are multiple studies, which evaluate the

effectiveness of several TAC techniques. In a

systemic review study, which was conducted by Quyn et al. in 201244, it was found that the Wittmann

patch and VAC offered the best outcome in the group

of non-septic patients but a high delay in closure

soupled with a low mortality rate could be found

when VAC was used on septic patients. These results

were similar to the results of a systemic review study,

which was described by Atema et al.45. They

conducted the study in non-traumatic patients with

OA and found that the highest weighted fascial

closure rate was reported in groups of VAC with

continuous mesh or suture mediated fascial traction

(73.1%) and dynamic retention sutures (73.6%). The

fistula risk also dropped to 5.7% when VAC was

combined with continuous mesh or suture mediated

fascial traction. However, the overall quality of the

available evidence are still poor due to retrospective

studies and problems in data collections as to there

are no definite conclusion which type of TAC works

best in recent times.

Other general management of patients with OA,

concluded that nutritional support is also important for

recovery of the patient as well as overall wound

healing. From previous studies46-48 it was suggested

that it was safe for enteral feeding within 36 hours to

4 days due to improvement in rates of fascial closure

and infectious complication by adding 2 g of nitrogen

for every liter drained from the open abdomen2, 49.

Afterม normalization of the patient’s physiology

coupled with and good nutritional support, physicians

can close the abdominal defect, which has a small

gap, approximately 3 -7 cm. The methods for

definitive abdominal reconstruction in addition to the

choice of technique is dependent on; different patient

factors, defect sizes, and abdominal structures.

In conclusion

Damage control surgery or open abdomen

surgery is an important procedure in trauma

and general surgery. The goal of treatment

is to resuscitate and should be available to

ensure the fascial is closed as soon as

possible. Primary due to avoiding any long-

term complications.

Several techniques of temporary abdominal

closure had played an essential role for

theprevention of intra-abdominal adhesion,

infection and retraction of abdominal fascia

, so as to achieve delayed primary fascial

closure. Decision making methods are very

much dependant on physician-patient

factors and hospital supplements. After,

failure to close the abdomen within 5-7

days, the physician should consider bridging

devices. A review of recent studies suggests

that the Wittmann or VAC can be available

for used on TAC for non-septic patients but

VAC with continuous mesh or suture

mediated fascial traction is more suitable in

septic patients.

Nutritional support should also be

considered by; adding 2 g of nitrogen for

every liter drained from the open abdomen,

within 36 hours up to 4 days.

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