Emergency General Surgery,  Trauma Surgery

How to Close the Pandora’s Box – Part 1

He can’t decide whether to leave his visor half-open or half-closed.

Murray Walker

Hello again…

So, what can we use when we find ourselves during an operation where we already know we’ll have to come back again in 48 h? Just put some swaps on top of the abdomen and wrap it as a chicken burrito?! or maybe not…

When we have to face certain situations we may elect to leave the abdomen open and review it shortly. During the open abdomen (OA) management, Temporary Abdominal Closure (TAC) methods are required to protect abdominal organs from external infectious sources, limit dehydration and heat loss, and aid in wound healing and resolution of inflammation. Ideally, TAC should be easy to perform and rapidly reversible. It should prevent evisceration, preserve the abdominal fascia, and avoid retraction of margins, prevent adherence formation, drain peritoneal fluids, reduce bacterial load, reduce cytokine rate and permit easy fascial closure. Last but not least, TAC is a risk factor for the development of abdominal compartment syndrome. An ideal closure method should be able to prevent it.

As you can imagine, when releasing intra-abdominal pressure, the tensile strength to the abdominal wall is reduced, resulting in retraction of deep fascia and mesenteries. This can lead to difficulties in achieving definitive closure due to loss of domain. Negative pressure wound therapy and dynamic fascial traction are effective ways to prevent this phenomenon. 

Temporary Abdominal Closure Methods

In the 1980s, planned relaparotomy was a popular approach to patients with abdominal sepsis. In that setting, the abdomen was closed between operations until laparotomic margins could no longer be approximated. Then, the abdomen would be left open and packed with gauze or sutured with non-absorbable mesh to prevent evisceration. This gave way to exorbitant rates of entero-atmospheric fistulae formation.

Luckily we have evolved a bit…

Newer TAC systems often include negative pressure-assisted closure methods fashioned by the surgeon during the operation and commercial kits. Negative pressure wound therapy (NPWT) with continuous fascial traction is suggested as the preferred technique for temporary abdominal closure; whereas temporary abdominal closure without negative pressure (e.g. Bogota bag) can be applied in low resource settings accepting a lower delayed fascial closure rate and higher intestinal fistula rate.

Bogota Bag

The Bogota Bag is the most rudimentary temporary closure method used in current practice and the one associated with the overall highest rate of complications. Because of its simplicity and affordability, it is the go-to TAC method in low-resource settings.

Mattox described the technique as “a simple but desperate technique […] It consists of the use of available empty plastic intravenous bags to expeditiously and inexpensively bridge the abdominal wall skin in a patient with abdominal compartment syndrome“. 

This system is inexpensive and readily available. Its application is intuitive and rapid. Being transparent, it allows some assessment of intestinal viability. However, it does not provide traction to the wound edges and allows the fascial edges to retract laterally, resulting in difficult fascial closure under significant tension. The Bogota bag does not prevent damage to the fascial edges, nor does it allow for control of fluid loss. Moreover, the abdomen remains filled up with a toxin- and cytokine-rich fluid, perpetuating the systemic inflammatory response.

Patch-Based Techniques

Patch-based closure methods interpose a layer of prosthetic material to span the distance between the wound margins. Being sutured into place, patches minimize fascial retraction. Nonetheless, these techniques lack the advantage of effluent control and are thus often used in conjunction with a negative pressure system.

A polytetrafluoroethylene patch can also be used for temporary closure. The patch is anchored to the fascia laterally, and serial plication of the patch at the midline progressively brings the fascial edges together.

Velcro adhesive sheet technique is a patch-based system described for the first time in 1990 and improved into the commercially available Wittmann-Patch. It consists of 2 adhering sheets of biocompatible polymeric material with hooks on one side and a meshwork of loops on the other. The sheets are sutured to the fascial edges. To close the abdomen, the overlapping sheets are compressed to stick together. A negative pressure system is usually added above it. This method allows to progressively pull the fascia towards the midline as the intra-abdominal pressure decreases; therefore, it can also be considered a dynamic fascial closure technique. This technique preserves the abdominal wall domain but does not allow effective drainage of any intra-abdominal fluid. 

Negative Pressure Wound Therapy

Negative pressure systems apply negative pressure on the abdominal cavity, counteracting the lateral forces responsible for the retraction of the fascia and mesenteries that cause loss of domain. Still, adjunctive techniques of fascial traction may provide additional help to pull fascial edges towards the midline.

A towel adhered to an adhesive sheet or elastic sponge is placed to protect the abdominal viscera and an elastic self-adhesive sheet is secured to the lateral abdominal wall to which a suction system is incorporated. These wound systems are customizable and are excellent at controlling abdominal fluid.

The first vacuum-assisted TAC technique, known as Vacuum Pack, was introduced by Brock, Barker, and Burns in 1995. The Vacuum Pack technique is a towel-based system that uses a three-layer TAC. First, a fenestrated polyvinyl sheet is draped over the exposed viscera and tucked under the fascial edges. Next, a surgical towel is placed under the fascia; followed by two silicone drains placed on top of the towel. An adhesive, iodophor-impregnated polyester drape is positioned over the skin to seal the wound. The drains are connected to continuous wall suction at 100-150 mmHg.

Towel-based system dressings have gained wide acceptance because they are fast to apply, inexpensive, and atraumatic. Although the system effectively controls abdominal fluid, the suction provided throughout the abdomen is not as effective as that in commercial NPWT systems. A mild increase in intra-abdominal volume can be accommodated without resulting in increased intra-abdominal pressure because the system is relatively compliant. Another disadvantage of the technique is that the prevention of loss of abdominal domain seems limited.

Commercially available kits (e.g. AbThera and V.A.C. therapy) contain a perforated silastic sheet to place between the bowel and abdominal wall. A sponge is trimmed and used to fill the subcutaneous abdominal defect, and an outer self-adherent skin drape contains a suction port that is connected to a suction device. Sponge-based systems are more expensive than towel-based negative pressure systems but provide more uniform suction throughout the peritoneal cavity and may be more effective in preventing intra-abdominal fluid accumulation. Moreover, the kits come with proprietary canisters which allow easy measurement of fluid loss.

When using an NPWT TAC, the pressure settings should be individualized per patient. In cases with concerns about incomplete hemostasis, the application of high negative pressures may aggravate bleeding. In these cases an initial low negative pressure is advisable. In addition, placing polyurethane foam directly on the bowel may cause fistula formation. Extreme precaution must be taken to ensure the foam is not in contact with the bowel. Rather, a non-adherent layer should be placed completely over the bowel to protect it and allow fluid egress. Also, although rare, intraabdominal hypertension may occur in some cases during temporary abdominal wall closure. It is important that postoperatively the bladder pressure is monitored routinely during the first few hours of negative pressure dressing application.

Adjunctive Techniques

Adjunctive techniques help pull the fascia to the midline and facilitate primary fascial closure. 

Some of them use for dynamic fascial traction vessel loops placed to traction the skin, commercial fascial closure systems like Abdominal Re-approximation and Anchor System (ABRA), fascial tension sutures, and primary fascial release (relaxing incisions of the fascia of the oblique musculature) exists.

One additional innovation involves the placement of a new medical device for fascial traction on the thorax and anterior pelvic ring. This device is called Fasciotens (too experimental and complex for this post to explain in detail). We use it one time with very great results… But it doesn’t say it’s the panacea!

As you can imagine some of the TACs are used together and joined to get a better result (as a mesh attached to the fascial edges together with an NPWT system)!

Ok guys… That’s it for today… We don’t want to make it more complex and long than it is…

See you next time to end this journey…

Namasté…

References
  1. Coccolini F, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg 2018;13:1-16.
  2. Mattox KL. Introduction, background, and future projections of damage control surgery. Surg Clin North Am 1997;77:753-9.
  3. Brock WB, et al. Temporary closure of open abdominal wounds: the vacuum pack. Am Surg 1995;61:30-35.
  4. Demetriades D, et al. Total Management of the Open Abdomen. Surg Clin North Am 2014;94:131-53.
  5. Coccolini F, et al. Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA). Injury 2019;50:160-6.
  6. Chiara O, et al. International consensus conference on open abdomen in trauma. J Trauma Acute Care Surg 2016;80:173-83.
  7. Bruhin A, et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen. Int J Surg 2014;12:1105-14.
  8. Frazee RC, et al. Long-term consequences of open abdomen management. Trauma 2013;16:37-40.
  9. Huang Q, et al. Techniques for abdominal wall closure after damage control laparotomy: From temporary abdominal closure to early/delayed fascial closure – A review. Gastroenterol Res Pract 2016. DOI:10.1155/2016/2073260.
  10. 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.
How to Cite This Post

Marrano E, Bellio G. How to Close the Pandora’s Box – Part 1. Surgical Pizza. Published on October 16, 2021. Accessed on May 7, 2022. Available at [https://surgicalpizza.org/trauma/how-to-close-the-pandora-box-part-1/].

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