You are in: eMedicine Specialties > General Surgery > Abdomen Temporary Abdominal Closure TechniquesArticle Last Updated: Jan 26, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Critical Care Units, Trinity Mother Francis Health System Luis G Fernandez is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of General Surgeons, American Society of Law Medicine and Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, and Undersea and Hyperbaric Medical Society Editors: Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: temporary abdominal closure, TAC, trauma damage-control celiotomy, damage control, damage-control celiotomy, damage-control surgery, damage control celiotomy, trauma damage control celiotomy, damage control surgery, abdominal compartment syndrome, ACS, intra-abdominal pressure, IAP, positive pressure ventilation, positive end expiratory pressure, intrathoracic pressure, central venous pressure, intracerebral pressure, intracranial pressure, abdominal wall, viscera, fascia, zipper closure, Wittmann Patch, synthetic mesh closure, polytetrafluoroethylene closure, marlex mesh, absorbable mesh, silastic closure, primary delayed fascial closure, Fabian protocol, Sure-Closure system, Sure-Closure Skin Stretching System, vacuum-assisted closure, VAC, vacuum-assisted fascial closure, VAFC, intraperitoneal silo, IP silo BASIC PRINCIPLESSection 2 of 10
  Trauma Damage-Control Celiotomy: Context and Perspective Over the past 2 decades, the way in which trauma surgeons approach a person with multiple severe injuries has undergone an evolution. Trauma surgeons no longer attempt to fix it all during the initial operation. Literature reflects the cumulative experience of trauma surgeons, confirming the following principles: conservative operative techniques and short operative times, even when all organ repairs have not been completed, increase survival in civilian and military patients with multiple trauma. These principles hold true for all affected regions of the body, including the abdominal cavity and its contents, the focus of this article. Damage-control principles are typically applied to patients who have multiple severe injuries. These patients are commonly hypothermic, acidotic, and coagulopathic. Under these circumstances, a deliberate, staged, reoperative approach is optimal. The 3 commonly recognized stages of damage-control celiotomy are as follows:
Those who may require damage-control celiotomy are patients who are hypotensive (BP <90 mm Hg) with the following abdominal or pelvic traumatic injuries:
Although the organ-specific operative techniques are beyond the scope of this article, patients who undergo damage-control celiotomy are at risk for the development of multiple, life-threatening complications in the early postoperative period. The chief complication in the postoperative period is abdominal compartment syndrome (ACS). ABDOMINAL COMPARTMENT SYNDROMESection 3 of 10
BackgroundACS is a condition that elevates intra-abdominal pressure (IAP), adversely affects end-organ physiology, and disrupts patient homeostasis. ACS was described as early as the 1800s; however, only in the last 10-15 years has ACS been consistently recognized in the surgical and medical patient population. The reported incidence of ACS is 10-15%, and, if left untreated, it is uniformly fatal. With diagnosis and treatment, the mortality rate is 46-66%. CausesACS is most often encountered during the early postoperative course and commonly discovered in patients who have undergone damage-control celiotomy with primary fascial closure and intra-abdominal packing for coagulopathy. ACS may be found in people with the following conditions:
The aforementioned conditions may lead to decreased blood flow to the abdominal wall and organs. This derangement of cellular perfusion initiates cytokine release, destabilizing cell membranes and ultimately leading to cellular edema and cell death if not reversed. This process is clinically manifested by organ swelling, leading to secondary pressure effects on the respiratory, cardiovascular, and central nervous system when the IAP rises above a critical level. See Media files 2-3. Additional causes of IAP include the following:
The aforementioned conditions either directly or indirectly increase IAP in patients who are critically ill with ACS. Pathophysiologic ChangesCerebral Changes Elevated IAP results in elevated intrathoracic pressure, leading to elevated central venous pressure and causing an increase in intracerebral pressure. The Monroe-Kellie doctrine states that this increase in intracranial blood volume results in elevation of intracranial pressure. During resuscitation and vascular volume expansion, intracerebral pressure and cerebral perfusion pressure may increase transiently; however, these pressures will ultimately fall if abdominal pressure continues to increase. Due to a concomitant decrease in caval venous return, this will ultimately cause a fall in cardiac output that will negatively impact intracerebral perfusion pressure. This fall in ICP may be transient as well if intrathoracic pressure increases due to increased IAP. This can cause increased intracerebral pressure due to increased internal jugular/superior caval venous pressure. In a porcine model, Bloomfield et al have demonstrated significant effects of elevated IAP upon the central nervous system (CNS); elevated IAP resulted in increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP). The mechanism is a functional obstruction of jugular venous drainage due to the elevated pleural pressures and CVP. As previously mentioned, the increase in intracranial blood volume results in elevation of the ICP (the Monroe-Kellie doctrine). Abdominal decompression has resulted in a return toward baseline for ICP and an improvement in the CPP. Head injury and concomitant abdominal injury is a frequently encountered clinical scenario. This observation (confirmed clinically) is important. Decompressive celiotomy in patients such as these has resulted in a dramatic reduction in ICP. Abdominal decompression in these patients has resulted in a return toward baseline for ICP and an improvement in CPP. Ophthalmologic Changes Increased IAP can cause the rupture of retinal capillaries, resulting in the sudden onset of decreased central vision (Valsalva retinopathy). Valsalva retinopathy has been described in a number of settings in which a sudden increase in IAP or intrathoracic pressure has occurred. The retinal hemorrhage usually resolves within days to months, and no specific treatment is necessary. If a patient with ACS develops visual changes, Valsalva retinopathy should be considered and an appropriate ophthalmic examination should be performed. Cardiovascular Changes Increased IAP may cause the following problems:
An increase of IAP to greater than 15 mm Hg results in the following:
Pulmonary Changes ACS may lead to pulmonary complications.
Renal Changes ACS can lead to acute renal failure.
Increased IAP causes the following:
Ureteral obstruction does not occur with increased IAP. Increased IAP up-regulates the juxtaglomerular apparatus, causing the following:
Abdominal Wall/Viscera Changes Increased IAP results in the following:
Monitoring and Measuring IAPThe most direct and accurate measurements of IAP are via a cannula placed percutaneously into the peritoneum. Indirect IAP is monitored through transfemoraly placed inferior-caval venous lines, nasogastric tubes, rectal tubes, and, most commonly, Foley catheters. The most accurate and simple way to determine the IAP is indirectly by measurement of the bladder pressure using a Foley catheter. The bladder pressure is essentially equivalent to the IAP. To measure the bladder pressure, the following steps must be completed:
Release of ACSMorris et al and other investigators have noted that the sudden release of ACS may lead to an ischemia-reperfusion injury, causing acidosis, vasodilatation, cardiac dysfunction, and cardiac arrest. Morris et al have also recommended that, prior to the release of the abdominal cavity, the patient should be preloaded with 2 L of 0.45% normal saline, 50 g/L of mannitol, and 100 mEq of sodium bicarbonate crystalloid solution. Vasodilators, such as dobutamine or phosphodiesterase inhibitors, may also be beneficial. PREVENTION AND TREATMENT OF ACSSection 4 of 10
Leaving the abdominal incision open during surgery prevents ACS. ACS more commonly presents in the early postoperative period (24-72 h); however, it can present later than this time frame. Temporary Abdominal Closure The techniques of temporary abdominal closure (TAC) are varied, each with its own advantages and disadvantages. All techniques face a similar challenge: the management of the open abdomen. No prospective randomized studies are available to compare the effectiveness of these various techniques or to validate the concept of the open abdomen protocol. However, retrospective data in the form of case and cohort studies do exist. These data consistently show that maintaining the open abdomen protocol in high-risk groups has been effective in reducing mortality in a clinical setting. The benefits of TAC include the following:
Strategy Pearls
TYPES OF TEMPORARY ABDOMINAL CLOSURESSection 5 of 10
Towel Clipping the Skin Edges One of the simplest and fastest forms of temporary closure of the abdomen is towel clipping the skin edges. Towel clips are placed 1 cm apart and 1 cm away from each side of the skin edge. Up to 30 standard perforating towel clips may be required to close an incision. The incision may then be covered with an adherent plastic drape (eg, Vi-Drape, Steri-Drape). Covering the incision decreases manipulation of the towel clips while transferring the patient. This technique may be used in the rapid temporary closure of thoracic or groin incisions in patients with trauma injuries who are in unstable condition and in patients undergoing general surgery. See Media files 5-6. Open Packing of the Abdomen Open packing of the abdomen, a form of TAC, has been used for more than 2 decades at the Detroit Receiving Hospital. The abdominal wall defect and the exposed viscera are covered with rayon cloth. This rayon cloth is then covered with gauze dressing. Widely spaced, retention-type sutures are placed, encompassing all layers of the abdominal wall, and tied above the gauze packing. As bowel edema diminishes, the gauze dressing is removed and the retention sutures are gradually tightened until the incision can be closed. Bender et al reported successful fascial closure in 15 of 17 patients who survived beyond the initial 24 hours. Zipper Closures First described by Leguit in 1982, zipper closures were popularized by Stone et al in their open abdomen approach for pancreatic abscess. See Media file 7. Wittmann Patch The approach using the Wittmann Patch (STARSURGICAL, Inc, Burlington, Wis) was first reported by Teichman et al, Wittmann et al, and Aprahamian et al. As bowel edema resolves, the excess Velcro-biocompatible patch material is removed and the fascial edges are approximated. Tension closure is accomplished by the adherence of the overlapping Velcro-like sheets. The major advantage of this approach is the ease of access for repeated surgical interventions and the capacity to apply tension to the midline fascia, which helps prevent lateral retraction of the aponeurotic edges, allowing for definitive delayed primary closure in most cases (see Media files 8-10). Synthetic Mesh ClosurePolytetrafluoroethylene Closure The polytetrafluoroethylene (PTFE) 2-mm biocompatible prosthetic abdominal wall graft is strong and watertight and creates a bed for granulation tissue, which may be covered with a split-thickness skin graft when the prosthesis is removed. PTFE is expensive, and similar outcomes may be achieved with less costly absorbable mesh or silastic (silo) dressing changes. See Media file 11. Marlex Mesh (Polypropylene) Several authors have reported the use of marlex mesh in the setting of a contaminated wound (eg, fasciitis, intra-abdominal sepsis). Healing has been reported, even in wounds where frank purulent discharge is present. Although short-term successes have occurred, numerous long-term complications have been reported with marlex mesh. These complications include increased incidence of postoperative wound sepsis, increased incidence of enteric fistulas, and significant decreased survivability of split-thickness skin grafts. The experience recorded by Voyles et al, Stone et al, and Jones et al strongly suggests that permanent rigid-type prosthetic mesh should not be inserted in the setting of abdominal wall defects with associated contamination from the gastrointestinal tract secondary to trauma, intra-abdominal sepsis, or necrotizing infections involving the abdominal wall. See Media file 12. Absorbable Mesh Synthetic absorbable mesh has been used extensively in TACs. Polyglactin (Vicryl) and polyglycolic acid (Dexon) have been in the surgical armamentarium for approximately 25 years. This type of prosthetic mesh implant has been used in the repair of traumatic liver, splenic, and renal injuries and in pelvic floor repair in the setting of abdominal peroneal resection of the rectum. Although early burst strength (at 8 wk) is comparable to that of permanent mesh, as the mesh is absorbed (at 10-12 wk), hernias inevitably develop in most patients. As described by Bender et al, the mesh is applied loosely over the abdominal contents and then covered with fine mesh gauze packing, maintaining the bowel below the absorbable mesh and within the abdominal contents. This may decrease bowel wall distention, thinning, and subsequent desiccation, which may decrease the incidence of enterocutaneous fistula. The choice between the use of either Vicryl mesh or Dexon mesh is primarily determined by the surgeon's preference. However, Brasel et al have reported some advantage in the use of Dexon mesh. This mesh has wider interstices that Brasel et al believe may allow for more efficient drainage of intra-abdominal fluid and, thus, may decrease potential delayed complications (eg, abdominal distention, ileus, abscess). See Media files 13-14. Silastic (Plastic) Closures A presterilized (gas), soft 3-L plastic cystoscopy fluid irrigation bag is cut and shaped to cover the abdominal incision and extruded viscera. This bag is either stapled or sutured to the skin edges of the wound with a standard (wide) skin stapling device or monofilament, nonabsorbable suture, thus preserving the fascia. Sterile, antibiotic-soaked towels (using Kantrex) may be applied over the silo, which is then covered with an iodine-impregnated adhesive plastic drape. An alternative is to apply sterile towels over the silo and to secure them with a Montgomery abdominal wound binder, being careful not to create increased abdominal pressure while securing the dressing. The wound is inspected and the dressing is changed every 24 hours (or as needed). Intravenous (IV)/cystoscopy bag silos may be replaced in the ICU setting using standard sterile surgical technique and equipment. This technique is a variation of the silon (silo) closure used for the repair of gastroschisis and omphalocele. In hospitals in Colombia, South America, IV bag closure (also known as the Bogotá Bag) has been used extensively and successfully. See Media files 15-18. Silastic closures are fast and effective temporary closure modes and have some significant cost benefits, as reported by Fernandez, Norwood, and Roettger et al. See Media files 19-21. Methods of Definitive Abdominal Wall ReconstructionPrimary Delayed Fascial Closure Primary delayed facial closure (between 5-10 d) may be attempted if the abdominal cavity can be closed without significant elevation of IAP. A high index of suspicion for recurrent ACS must be maintained. Elevated peak airway pressure or plateau pressures (>30 mm Hg), increased urinary catheter bladder pressures (>25 mm Hg), and accompanying deteriorating clinical parameters (eg, abdominal distension, decreased urine output) should prompt a careful reevaluation of the patient and consideration for decompressive celiotomy. Fabian Protocol Fabian et al have published their experience with their eponymous protocol. The patients are subsequently brought back for definitive reconstruction, usually within 6-12 months.
See Media files 22-23. CLOSURE OF ABDOMINAL WALL (CREATION OF VENTRAL HERNIA)Section 6 of 10
Sure-Closure SystemThe Sure-Closure Skin Stretching System is a patented, disposable, molded device made of stainless steel and plastic parts and used to provide sufficient skin in advance of closures for fasciotomies and trauma repairs of various types, including closure of the open abdomen. Use of the Sure-Closure Skin Stretching System can minimize the need for more extensive secondary wound closure techniques. The device is attached intraoperatively by first inserting needles parallel to the wound edges. These needles serve to distribute tension forces over the length of the incision. Gauges on the device monitor the applied forces, ensuring a safe and permanent skin stretching. The device allows the surgeon to take advantage of the inherent viscoelastic properties of the skin by mechanically stretching the skin and allowing it to relax under tension; the surgeon then has sufficient skin to affect a suitable closure. The device comes in sizes of 50 mm and 75 mm. The 50-mm device is designed for smaller skin defects with uneven surfaces, while the 75-mm device is designed for larger skin defects with relatively flat, even surfaces. The Sure-Closure Skin Stretching System was first described by Hirshowitz et al and has been used extensively in the plastic, orthopedic, cancer, general surgical, and trauma patient population. In a comparative clinical study of the Sure-Closure Skin Stretching System with more conventional wound closure techniques, Narayanan et al found that, in their study cohort, they were able to demonstrate a cost reduction trend (p <.05). In their cost analysis, they included the costs of the following: operating room time, operating room supplies, anesthesia, monitoring, recovery room time, wound care supplies, pharmacy charges, and hospital room and board. They also noted above average healing of the wounds at 1 month and 3 months, with better cosmesis than comparable conventionally closed wounds. This experience has been confirmed by other reported clinical studies. Using the Sure-Closure device potentially offers the following:
By using the Sure-Closure Skin Stretching System, the surgeon is able to close most cases of skin defects that would more commonly require secondary wound closure techniques, such as myocutaneous flaps or skin grafts. Sure-Closure System Application The Sure-Closure device accomplishes skin stretching by using 2 intradermal needles in conjunction with a tension rod that connects 2 self-aligning U-arms. The device contains a graduated tension indicator that registers after 1 kg of force is applied. The Sure-Closure system has a built-in safety clutch mechanism that prevents excessive tension by limiting the total force to 3 kg. The device is used in the setting of the following:
See Media files 24-27. Vacuum Assisted Closure®Fascial Vacuum Assisted Closure® (V.A.C.®) therapy (Kinetic Concepts, Inc, San Antonio, Tex) is a relatively new concept in the management of the open abdomen that allows for fascial closure as long as 1 month after the initial laparotomy. This avoids the need and attendant operative risks incurred with abdominal wall reconstruction in the future. The main functional component of V.A.C.® is the use of a nonadherent, polyethylene sheet to cover the exposed viscera and the placement of a polyurethane sponge under controlled negative pressure. The polyethylene sheet helps prevent visceral-abdominal wall adhesions that inhibit movement of the abdominal wall. The polyurethane sponge, when placed under negative pressure (suction), provides the countertraction required to inhibit abdominal wall retraction and creates an environment where approximation of the abdominal wall may occur. Miller et al reported excellent results in the use of this system. They reviewed 646 patients with trauma injuries who underwent laparotomies, of which 148 patients required management of an open abdomen over a 5-year period (1996-2001). Of these 148 patients, 85 survived to closure. Patients treated with the open abdomen technique who were unable to undergo fascial closure by early postoperative period (POD 9) were treated with a fascial V.A.C.® technique. Patients treated with planned hernia (HERNIA group, Fabian protocol) were compared with those undergoing fascial closure 9 or more days after the initial laparotomy (LATE group). All of the patients in the LATE group underwent fascial V.A.C.® therapy. Fifty-nine patients underwent fascial closure, 37 patients before postoperative day 9 and 22 patients on or after postoperative day 9. Mean time to fascial closure in the LATE group was 21 days (range, 9-49 d). Injury severity scores, admissions base deficit, number of fistulas, number of operations, and mortality were similar between the HERNIA group and the LATE group. The incidence of abscess, wound dehiscence, and fistula in the LATE group and the HERNIA group were nearly identical. In both groups, the differences were not significant with respect to time in the intensive care unit, total hospital stay, incidence of acute respiratory distress syndrome, multiple organ failure, and death. The fascial closure rate (71.08%) reported compares favorably with the results previously published by Barker et al in their large review of fascial closure rates using the standard vacuum pack technique; the fascial closure rate in the previous study was 70%. Case Study In the following case study, Dennis E. Weiland, MD, and John M. Stein, MD (Scottsdale Health Care-Osborn, Scottsdale, Arizona), illustrate the abdominal V.A.C.® capabilities. A 25-year-old man was admitted with 2 gunshot wounds to the abdomen. Repair of liver laceration with abdominal washout was accomplished (see Media file 28). Postoperatively, the patient developed severe abdominal distention and respiratory distress. He required a decompression laparotomy for ACS. He was placed on suction drainage for 2 days. V.A.C.® therapy was initiated on day 3. The wound was closed by delayed primary closure 12 days after the initial decompression laparotomy. The diagnosis was ACS secondary to a gunshot wound to the abdomen. The prognosis was excellent once the skin was closed over the fascia. V.A.C.® therapy was as follows:
After discharge, the patient continued to have follow-up visits in the wound clinic. The open skin over the fascia will be closed either by contraction or by secondary closure. The original wound measured 30 cm X 15 cm at the time of the decompression laparotomy. The wound now measures 20 cm X 3-4 cm. See Media file 31. ACS AND ABDOMINAL HYPERTENSION NOT PRESENT, PATIENT REQUIRES REOPERATIONSection 7 of 10
Intraperitoneal Silo Among the trauma patient population, the more common indications for reoperations include bleeding, infection, presence of ACS, and reassessment of the abdomen for bowel viability or possible missed or delayed injury. The management of the severely contaminated abdomen, severe peritonitis, and intra-abdominal sepsis by an open approach has been discussed in the literature. First proposed by Steinberg, the intraperitoneal silo approach has been applied in several settings and surgical patient groups. In the September 1999 issue of Surgical Rounds, Fernandez et al described a technique that evolved from their experience with the use of the silastic silo closure for patients with ACS. They used the extraperitoneal silo in the intraperitoneal (IP) position in selected patients who did not have ACS and whose injuries would benefit from a second look procedure. Their patient population was summarized (see Media file 32). The approximate total hospital cost of the silo was $15.94 with an approximate patient cost of $57 (see Media file 33). Fernandez et al reported one death in the group (patient 3). They also reported one IP silo failure (patient 1) that developed a small bowel dehiscence. This patient underwent IP silo replacement in the ICU. Placement of IP Silo The technique of IP silo placement is simple and straightforward.
See Media files 34-42. CONCLUSIONSection 8 of 10
Several techniques in the surgical armamentarium are available to affect temporary closure of the open abdomen. One of the least expensive and rapid is the gas sterilized, 3-L, plastic, cystoscopy irrigation bag. This bag is commonly available, and its application is straightforward. In the author's opinion, it is the preferred initial method of temporary closure, particularly in patients who may require multiple reoperative interventions. Of the techniques described within this article, the Sure-Closure Skin Stretching System has the potential to obviate split-thickness skin grafting in the setting of the open abdomen, particularly if approximation of the skin can be achieved within the first 7-10 days. This Sure-Closure device facilitates the creation of a ventral hernia that may be repaired at a later date in an elective fashion. The Wittmann Patch and the abdominal V.A.C.® are inherently designed to affect not only a temporary closure but also a permanent fascial closure in most patients. The relative cost of these devices is small in comparison to the potentially decreased associated cost and morbidity of a second, planned abdominal wall reconstructive procedure commonly required in this patient population. The Wittmann Patch and the abdominal V.A.C.® system represent major advancements in surgical theory and are a welcome addition to the extant surgical doctrine. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
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