Elsevier

Journal of Surgical Education

Volume 66, Issue 2, March–April 2009, Pages 89-95
Journal of Surgical Education

Original report
Preventing Loss of Domain: A Management Strategy for Closure of the “Open Abdomen” During the Initial Hospitalization

https://doi.org/10.1016/j.jsurg.2008.12.003Get rights and content

Background

In the management of the abdominal compartment syndrome resulting in an open abdomen, the so-called “planned ventral hernia” is considered an acceptable outcome. We describe a technique of surgical management of the abdominal wound that allows fascial closure in most cases during the initial admission.

Methods

Consecutive trauma patients with abdominal compartment syndrome managed with an open abdomen over a 3-year period were identified. Medical records and the trauma data registry were reviewed for demographics, injury characteristics, operative treatment, timing and type of wound management, closure of the abdomen, and outcome.

Results

From January 2004 to January 2007, 23 patients underwent management with an open abdomen. The mechanism of injury was blunt in 83% of patients and penetrating in 17%. All 18 survivors underwent primary fascial closure of the abdomen using a vacuum- and tie-assisted technique of wound closure. The mean time to closure was 11 ± 4.4 days (range, 4-18 days). In all, 9 complications occurred in 7 patients, which included 1 reoperation for abscess after fascial closure. There was no dehiscence and no fistula. The Apache II score was 19.3 ± 6.9 (range, 7-30), and the injury severity score was 32.3 + 10.6 (range, 9-50).

Conclusions

A technique of managing the open abdomen that prevents fascial retraction results in a high primary closure rate with an acceptable rate of short-term complications.

Introduction

Trauma surgeons initially described the abdominal compartment syndrome (ACS) as the end result of untreated intra-abdominal hypertension in the 1980s.1, 2, 3, 4 Its deleterious effects on splanchnic perfusion and cardiopulmonary function require immediate intervention.5, 6 Treatment by release of the abdominal wall via laparotomy, packing, and leaving the abdomen open is now the standard approach essential to survival.7, 8, 9 The open abdomen also occurs after damage control laparotomy when the abdominal contents are too edematous for fascial closure—the abdomen is then left open to prevent abdominal compartment syndrome.10, 11

The advent of the vacuum-pack technique altered the tactical approach to this challenging situation: A decrease in wound complications was noted, and it became possible to close the abdomen without creating a planned ventral hernia.12, 13, 14, 15, 16 However, in many cases, fascial closure during the initial admission is not feasible. Clinical observation shows that leaving an abdomen open for a prolonged period of time leads to retraction of the fascia and “shrinking” of the abdominal wall relative to the viscera. Many techniques of abdominal closure using prosthetic mesh or different matrix compounds have been described.17, 18, 19, 20 All techniques result in a ventral hernia, which eventually requires elective repair with inherent risks and complications.21

We describe a strategy of managing the open abdomen that prevents the loss of domain. By the use of gradual fascial approximation with ties in conjunction with vacuum-assisted dressing changes (which can be done at the bedside), a primary fascial closure is possible during the index hospitalization in most cases. This technique prevents the need for additional operative procedures and may improve the quality of life.

Section snippets

Patients

The Institutional Review Board for the protection of human subjects in research approved this study. Patients with the diagnosis of ACS over a 3-year period from January 2004 to January 2007 were identified from the Trauma Data Registry. Medical records were reviewed for demographics, injury characteristics, operative management (including the timing and type of abdominal wound management and the timing of abdominal closure), and patient outcome.

Operative Management

In the first year of the study period, temporary

Patients

Over a 3-year period from January 2004 to January 2007, 99 trauma laparotomies were performed. A total of 23 of these were managed with an open abdomen because of ACS (TABLE 1, TABLE 2). Thirteen patients were male and 10 were female. The mean age was 40 + 21.4 years (range, 13-85 years). The mean injury severity score was 32 ± 10.6 (range 9-50), and the Apache II score was 19.3 ± 6.9 (range, 7-30). The mechanism of injury was penetrating in 4 patients (17%) (3 stab wounds and 1 gunshot wound)

Discussion

The principle of managing the abdomen without closing the abdominal wall layers over the visceral contents evolved from the usage of damage control laparotomy.7, 22, 23 As cumulative experience in the management of the open abdomen grew, and its physiological consequences with regard to wound healing became increasingly recognized, techniques for temporary closure evolved.

The early series published on management of the open abdomen and ACS described an approach that resulted in so-called

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