Original reportPreventing Loss of Domain: A Management Strategy for Closure of the “Open Abdomen” During the Initial Hospitalization
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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Cited by (26)
Abdominal compartment syndrome: Current concepts and management
2020, Revista de Gastroenterologia de MexicoManagement and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis
2016, InjuryCitation Excerpt :Fig. 1 summarises the evolution of study selection. Of the 711 records identified (after duplicates were removed) the full text of 91 studies was independently reviewed (AS, TB), 26 of these were found to meet our inclusion criteria [7,8,14,20–42]. Reasons for manuscript exclusion included: inclusion of non-trauma patients (46), review or case reports (8), unrelated research question or focused on a subpopulation (8), procedure/incision other than laparotomy (1) and duplicate data (2).
Fascial closure after open abdomen: Initial indication and early revisions are decisive factors - A retrospective cohort study
2015, International Journal of SurgeryCitation Excerpt :In contrast to earlier management strategies, temporarily covering the open abdomen with granulation tissue or a free skin graft and later abdominal wall reconstruction is no longer considered to be the best option for these patients [22,23]. Nowadays, early definitive fascial closure within the initial hospitalization seems to be the basis of preventing and reducing the risk of complications occurring after open abdomen [24,25]. However, factors influencing fascial closure are still unknown [26].
Controversies in the Care of the Enterocutaneous Fistula
2013, Surgical Clinics of North America