Another Trick in the Wall

Love is just a hole in the wall.

Rod Stewart

Welcome back guys!!!

Let’s start, as always, with a case scenario!

You and your team are in the trauma bay and a patient just arrives:

A – 25 y.o. male;
T – 35 minutes ago;
M – motorcyclist hit on the left side by a car at 80 km/h;
I – suspected left pneumothorax, abdominal injuries, pelvic ring instability;
S – BP 85/40 mmHg, Sat 92% in room air, HR 135 bpm, GCS 13 (E3V4M6), breathing frequency 23/min;
T – 500cc of Ringer, pelvic binder, spine board, and rigid collar.

You and your team perform the primary survey:

A – stable airway, trachea in line, the cervical collar on-site;
B – reduced breath sounds on the left side with the presence of subcutaneous emphysema, Sat 99% with O₂ support;
C – BP 80/40mmHg, HR 130 bpm, abdomen tender with positive Blumberg sign, pelvic pain at palpation, pelvic binder correctly positioned, normal legs and arms. Massive transfusion protocol initiated (first pack of blood + plasma + tranexamic acid ongoing);
D – GCS 13 (E3V4M6), pupils equal and reactive to lights, no lateralizing signs;
E – not done due to instability.

eFAST – no sliding on the left thorax with a small amount of fluid, positive FAST in the abdomen on three quadrants, no pericardial fluid;
Chest XR – small hemopneumothorax on the left side with multiple fractured ribs;
Pelvis XR – lateral compression of the pelvis with fracture of the anterior ring lateral compression type II, closed symphysis, pelvic binder correctly positioned.

Here if you want to refresh the ATMIST formula and/or the ABCDE protocol.

Now, the patient is highly unstable although we are still lacking the ABG. We hope we are all on the same page!
Due to the fact the OR is right next to the Trauma bay, you rush the patient in the theatre together with the whole team.
While the pt is being intubated, an intercostal drain is inserted in the left thorax with an output of air and 200 cc of blood.

During the trauma laparotomy you find:

• Hemoperitoneum of 2 L;
• Spleen laceration of grade IV, splenectomy performed;
• Sigmoid laceration grade V (explosion injury);
• A not expanding hematoma in zone 2 of the retroperitoneum (probably kidney);
• Liver hematoma grade II on the left lobe;
• Small pelvic hematoma not expanding from the left iliac crest.

Finally, you catch up with the anesthetist and he reports that the patient is still unstable, he’s on noradrenaline, a second pack of the massive transfusion protocol is ongoing, he’s still acidotic with a pH of 7.2, Lac 8 and BE -10. The ROTEM report is still pending.

And now the question for you, dear pizza lover… What would you do? We will focus on the colon as we know that both the retroperitoneal hematoma (not expanding) and the liver hematoma can be left alone. Your possible choices are:

1. To repair the colon with an end to end anastomosis (Knight-Griffen technique);
2. To resect the colon and perform a Hartmann procedure (i.e. end colostomy).

Actually, there is another and better solution here! Let’s see…

You’ve probably already heard about the surgical paradigm that says: “the decision is more important than the incision”. In fact, most of the posts in this blog (up to now) are focused on how to manage the patient before going to the OR. Similarly, when you are trying to get over a difficult operation, your ability to decide the right thing to do in the operating field could be the watershed between a triumph and a defeat. Thus, there are some occasions in which you may even decide not to definitively close the patient’s abdomen at the end of the operation.

In the last decades, open abdomen (OA) management has gained more and more popularity among surgeons, especially the ones dedicated to trauma and emergency surgery.

The first attempts date back to the first half of the XX century, but only recently this technique has reached a considerable spread and some kind of standardization in its indications and management.

By now you are asking yourself: “but what the hell is an open abdomen?”

An OA is a non-anatomic setting, in which, at the end of the surgical operation, the abdominal fascial edges are intentionally left un-approximated, applying a temporary closure to the laparotomy. This strategy may help severely deranged patients to get over a systemic shock until they may be able to get back to OR to complete the operation and, if possible, achieve a definitive approximation of the surgical margins.

The current indications for the OA technique are the prevention and treatment of abdominal compartment syndrome, severe peritonitis, especially when complicated by septic shock, as well as specific disease processes such as acute pancreatitis and ruptured abdominal aortic aneurysm or acute mesenteric ischemia. Last but not least, the OA is a fundamental step of the Damage Control Management strategy.

Avoiding an immediate closure of the abdomen allows the surgeon to perform the life-saving procedure during the first operative time (e.g. control of hemorrhage and contamination) postponing definitive surgery to another surgical time (generally 48 to 72 hours later), after the patient’s general conditions have improved. Moreover, coming back to the surgical field is useful to check if the procedures done during the first operation are successful (e.g. hemostasis, viscus vitality, etc…). During the second operation, the surgeon may accomplish what was left behind by completing an organ resection, performing an anastomosis, and, if possible, definitively closing the abdomen.

The OA has some issues itself and could be difficult to manage. In the last years, many efforts have been made by surgeons to find the best Temporary Abdominal Closure (TAC) system. During the lapse between the operations, abdominal organs must be protected from external infectious sources and possible mechanical damage. Moreover, the TAC should limit dehydration and heat loss, and aid the wound healing and resolution of inflammation. Ideally, TAC should be easy to perform and rapidly reversible. It should prevent evisceration, preserve the abdominal fascia, avoid retraction of the edges, prevent adherence formation, drain peritoneal fluids, reduce bacterial load, reduce intraperitoneal cytokine rate and allow easy fascia closure.

Now, let’s have a quick look at the most commonly used TAC.

First of all, we have the Bogotà Bag. This was firstly used in several institutions in the Eighties in Colombia and it is formed by laying a transparent sterile sheat (in the beginning an irrigation bag was used) that is sutured to the fascial edges or the skin. This system is cheap and readily available. Its application is intuitive and rapid. Nowadays, because of its simplicity and affordability, it is still used in low-resource settings.

In 1995 Brock, Barker and Burns introduced in literature the first description of a vacuum-assisted TAC technique. This system, known as Vacuum Pack or Barker’s VAC, is composed of a surgical towel placed under the fascia on which are posed silicone drains. An adhesive, iodophor-impregnated polyester drape is positioned over the towel, the drains, and the skin to seal the wound. The drains are connected to continuous wall suction. The negative pressure can reduce the lateral forces responsible for fascial retraction. Moreover, the suction controls abdominal fluid production.

Over the last decades, industrial kits for Negative Pressure Wound Therapy (NPWT) have been launched on the market. These kits contain a perforated silicone sheet to place between the bowel loops and the abdominal wall. Then, a sponge is trimmed and used to fill the subcutaneous abdominal defect. In the end, the entire wound is closed by a self-adherent skin drape that is connected to a suction port. Industrial systems are more expensive than “self-made” ones, but they provide a more uniform suction throughout the peritoneal cavity and they may be more effective in preventing intra-abdominal fluid accumulation.

As stated by the WSES guidelines, negative pressure wound therapy, especially in association with continuous fascial traction, should be considered the Gold Standard technique for TAC.

What is the continuous fascial traction you ask? Don’t worry, we’ll shortly come up with a post exactly on this issue…

The OA management is very helpful, but it is not just shining gold! Here is a “short” list of complications it may cause: repeated operations, bowel perforations, entero-atmospheric fistulas, ventral hernias, bleeding, deep abdominal collections, etc… Moreover, after weeks of treatments, nobody assures you to be able to close the two fascial edges together! A real hell!

Now… where were we?

We have left our patient unstable in the OR with a perforated sigma… but now we know what to do before leaving the field to the orthopods.

We’ll go for an OA management with a Barker’s pack (it’s cheaper than the commercial kit and we hope to close the patient during the first review laparotomy):

First, we staple the sigma proximally and distally to the perforation.  Then, we “home-make” our first layer of the pack with a plastic sheet and a laparotomy swab, laying it on the great omentum with the plastic layer touching it. Above this, we place 2 more swabs with two Jackson-Pratt drainages in between (a nasogastric tube or a clisma fleet tube can be also used). Above all, we close the abdomen with a layer of plastic sheets and start the suction through the drains.

Now the orthopods can proceed with their damage control approach to the pelvis with external fixation. Afterward, the patient will go to the ICU to continue the resuscitation, hoping he’ll be fine…

To sum-up… The OA management is very useful and simple, it lets you leave an operation halfway and restart it again later… Pay attention to not use it too often!!! As we said, it has strict indications and it carries major complications… Use it wisely!

See you next time…

Namasté!

References

1. Hirshberg A, et al. Top Knife: the art & craft in trauma surgery. Shrewsbury, UK: Tfm Pub Ltd; 2015.
2. Boffard KD. Manual of Definitive Surgical Trauma Care. 5^th Ed. Boca Raton, FL: CRC Press; 2019.
3. Demetriades D, et al. Atlas of Surgical Techniques in Trauma. 1^st Ed. Cambridge, UK. Cambridge University Press; 2015.
4. Sartelli M, et al. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. WJES 2015;10:35.
5. Acosta S, et al. Vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy – a systematic review. Anaesthesiol Intensive Ther 2017;49:139-45.
6. Coccolini F, et al. The role of open abdomen in non-trauma patients: WSES Consensus Paper. WJES 2017; 12:39.
7. Coccolini F, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. WJES 2018; 13:7.

How to Cite This Post

Del Zotto G, Marrano E, Bellio G. Another Trick in the Wall. Surgical Pizza. Published on September 26, 2021. Accessed on September 10, 2023. Available at [https://surgicalpizza.org/trauma/another-trick-in-the-wall/].