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Modern Management of the Open Abdomen
“A Cautionary Tale”Grand Rounds
December 16, 2010
SUNY, Downstate
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Case
• HPI: 41 yo M BIBA; stabbed in left back while walking out of a shopping center.
• PMH/PSH: GSW to head.
• PE revealed 1-2 cm deep left paraspinal stab wound ~2 cm in length.
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Imaging
• CT: L2 transverse process fracture; left perinephric stranding.
• CT Angio: expanding hematoma; free blood around liver and spleen.
• Aortography: no active bleeding
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CTdownstatesurgery.org
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CTdownstatesurgery.org
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Hospital Course
• 10/3 – Initial exploration
• 10/12 – IVC filter placement
• 10/14 – Tracheostomy
• 10/23 – IR Coil
• 11/18 – STSG
• 12/13 – Discharge
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Patientdownstatesurgery.org
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Patientdownstatesurgery.org
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Pathways to Open Abdomen
Open Abdomen
Damage Control
/ Trauma
Septic Dehiscence
Compartment Syndrome
Necrotizing fascitis
Unresolved Intra-
abdominal Processes
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Surgical Issues
• Fluid losses
• Logistical burden
• Fistula formation
• Infection
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Ideal Barrier Characteristics
• Contain and protect viscera
• Atraumatic
• Simple
• Easy application
• Inexpensive
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Temporary Closure Techniquedownstatesurgery.org
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Temporary Closure Techniquedownstatesurgery.org
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Temporary Closure Techniquedownstatesurgery.org
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Open Abdomen as a Healing Wound
• Primary intention– Fascial reapproximation without tension
• Secondary intention– “Frozen abdomen”
– Loss of peritoneal space 10-14 days
• Delayed primary closure– Accommodate the conditions for closure by
secondary intention
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Planned Ventral Hernia
Stage IProsthetic insertion
• 14-21 days
Stage IIProsthetic removal
• 2 days
Stage IIIPlanned
ventral hernia
• 6-12 Months
Stage IVDefinitive
reconstruction
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Planned Ventral Herniadownstatesurgery.org
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Planned Ventral Herniadownstatesurgery.org
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Component Separationdownstatesurgery.org
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Component Separationdownstatesurgery.org
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Component Separationdownstatesurgery.org
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Mesh
• Absorbable– Inexpensive
– Decreased incidence of infection
– Decreased incidence of fistula formation
• Biologic– Immunologically inert
– Suitable for infected wounds
– One stage closure
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Preservation of Peritoneal Spacedownstatesurgery.org
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Preservation of Peritoneal Spacedownstatesurgery.org
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Preservation of Peritoneal Spacedownstatesurgery.org
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Convergence of 3 Concepts
Negative Pressure Wound
Therapy
Physiology of Open Abdomen
Progressive Wound Closure
Fluid Management/Logistics
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Negative Pressure Wound Therapydownstatesurgery.org
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Negative Pressure Wound Therapy
• Garner, et. al., 2001 – 13/14, 92%
• Miller, et. al., 2002 – 59/83, 71%
• Stonebrook, et. al., 2003 – 10/15, 67%
• Sulibrook, et. al., 2003 – 25/29, 86%
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Adverse Outcomes
• Rao M, et. al. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9(3):266-268.
• Starr-Marshall K. Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae; the St Marks experience. Colorectal Dis. 2007;9(6):573.
• Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development. The American Journal of Surgery. 2008;196(1):1-2.
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FDA Public Health Notification
• “Serious Complications Associated with Negative Pressure Wound Therapy Systems”
• Date: November 13, 2009
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FDA NPWT Contraindications
• necrotic tissue with eschar present• untreated osteomyelitis• non-enteric and unexplored fistulas• malignancy in the wound• exposed vasculature• exposed nerves• exposed anastomotic site• exposed organs
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Take-aways
• Consideration of the open abdomen as a healing wound
• Evolution of open abdominal wound closure
• Risks and benefits associated with NPWT
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References• Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous
fistula may be associated with higher mortality from subsequent fistula development. The American Journal of Surgery. 2008;196(1):1-2.
• Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP. Complex Abdominal Wall Reconstruction: A Comparison of Flap and Mesh Closure. Ann Surg. 2000;232(4):586-596.
• Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen: a quiet revolution. Scand J Surg. 2005;94(1):9-14.
• Miller PR, Thompson JT, Faler BJ, Meredith JW, Chang MC. Late fascial closure in lieu of ventral hernia: the next step in open abdomen management. J Trauma. 2002;53(5):843-849.
• Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg. 1994;219(6):643-653.
• Koss W, Ho HC, Yu M, et al. Preventing Loss of Domain: A Management Strategy for Closure of the “Open Abdomen” During the Initial Hospitalization. Journal of Surgical Education. 66(2):89-95.
• Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast. Reconstr. Surg. 2000;105(2):731-738; quiz 739.
• Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9(3):266-268.
• Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma. 2000;48(2):201-206; discussion 206-207
• Starr-Marshall K. Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae; the St Marks experience. Colorectal Dis. 2007;9(6):573.
• Sailes FC, Walls J, Guelig D, et al. Ventral Hernia Repairs: 10-Year Single-Institution Review at Thomas Jefferson University Hospital. Journal of the American College of Surgeons.
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