Emergency General Surgery,  Trauma Surgery

How to Close the Pandora’s Box – Part 2

Closing time, every new beginning
Comes from some other beginning’s end.

Semisonic

And here we are again…

Last time we talked about how to pack and manage an open abdomen… Today we are going to explore which are the possible complications of an open abdomen, and how and when to definitively close it…

Let’s start…

Complications of OA Management

The cause of complications and other causes of morbidity and mortality in OA patients are multifactorial. It is not only a matter of index procedure and TAC method. Patient-related variables including comorbidities and physiological function in the perioperative period may and will modify the risk of developing complications during or after OA management. 

Dressing Failure

The temporary dressing used to keep the intra-abdominal contents from eviscerating can fail. Minor failures, such as leakage from the edge of the dressing, may require bolstering the dressing with tape or other occlusive materials. On the other hand, a complete evisceration of the bowel constitutes a major dressing failure. And yes… the only thing you have to do is to remake the dressing… very annoying, especially if you have to redo it multiple times per day and night!

Intra-abdominal Infection

Intra-abdominal infections and abscesses are well-described complications of the open abdomen technique. As you can imagine, if the abdomen is left open, the probability of an intra-abdominal collection is high (consider also where the suction of the negative pressure therapy doesn’t/cannot reach properly).

Entero-atmospheric Fistula (EAF)

An entero-atmospheric fistula is the most serious and challenging complication in OA.

Enteric fistula is defined as any leakage of the enteric contents from the lumen of the gastrointestinal tract (excluding created stoma). EAFs may drain in the abdomen or outside of it. These complications can occur independently or together. EAF is the most common complication in the setting of an open abdomen. The rates vary from 5% to around 10% across different indications for OA.

Any damage to the bowel can lead to a fistula! The exposed bowel is at risk of fistulization. The large open surface area results in fluid and protein loss, while the healing process consumes calories and proteins. The metabolic imbalance that follows promotes fistulization. Local inflammation and sepsis contribute as well…

The key components of management of patients with an EAF include sepsis control, nutritional support, and local wound care. Nutritional support helps prevent malnutrition and should be started as soon as possible, provided the bowel is sufficiently long (>75 cm).

When the EAF occurs, the local control of the fistula is extremely difficult because no collection bag can be applied directly on an OA. Its output may be controlled with a baby bottle nipple applied over the fistula opening with a layer of colostomy paste to seal. A catheter can be placed through a hole on the nipple tip, and an NPWT is placed over/around the exposed viscera to promote granulation. A Foley catheter may be advanced and inflated into the fistula opening to improve diversion in a large, high-output fistula. 

Another popular method of fistula control is the floating stoma: a colostomy bag is applied over a plastic silo with an opening sutured to the margins of the leaking bowel. Recently, the VAC chimney technique has been described. A chimney is created with a sponge dressing, and a plastic tube is placed inside the chimney. A conventional VAC is then applied to cover the OA with the negative-pressure connector directly placed over the chimney. Definitive surgical repair can be ideally achieved 6 to 12 months later.

Obviously, the patients with an EAF will also have metabolic derangements due to the loss of nutrients (the same seen in proximal ileostomy)… The nutritional aspect must always be properly assessed and followed.

Early abdominal closure is the single best approach to reduce the rate of these fistulas. And, if it occurs, we hope you have a very skilled MacGyver in your team… 

Frozen Abdomen

Adhesions are a common complication of any surgical intervention in the abdomen. Contact of injured surfaces causes inflammation with subsequent deposition of fibrin. As a consequence, adjacent damaged structures become connected. In the OA, tissue injury is diffuse, and so are wound healing processes. As you can imagine, the longer the abdomen stays open, the more the bowel becomes fragile and the bowel loops stuck together making it impossible to do anything with them. At this stage, adhesions between the bowel loops and the fixity of the intestines to the abdominal wall are so tight that any attempt to release the adhesions by physical manipulation is highly likely to result in major bowel injuries. It is therefore important to stop attempting adhesiolysis not to risk bowel injuries. At this stage, the only thing is to try to close the abdomen as soon as possible and wait.

Ventral Hernia

This is the most common late complication of an open abdomen. Ten percent of people who have definitive closure after an open abdomen develop a ventral hernia by 21 months. These hernias can develop as a result of infection, fascial necrosis, or loss of domain as the abdominal muscles contract away from their normal medial position (as any “normal” incisional hernia). 

By the way, the longer the abdomen stays open, the greater the extent of retraction. If fascia and muscles retract too far, re-approximation of the wound margins becomes impossible. When this happens, a planned ventral hernia is the traditional approach to definitive closure. With this method, an absorbable biological mesh or a skin graft is applied to bridge the distance between the wound margins; the wound is thus allowed to granulate. Definite operative reconstruction by split-thickness skin grafting or component separation is usually deferred for 6 to 12 months.

Definitive Closure

Finally our main goal… We have left the abdomen open and now we want to close it: the definitive fascial closure. Its achievement depends on several factors, which can be related to the patient, the procedures, and factors relating to the OA management itself (e.g. the duration of OA and TAC method, complications…).

The percentage of all complications, including EAF and abdominal sepsis, is significantly increased in patients closed after 8 days vs. those patients closed before 8 days from the index surgery.

Across different indications and TAC methods, the literature has reported definitive closure rates of around 80%.

Following the stabilization of the patient, early definitive closure reduces the complications associated with the OA. The closure should be achieved without tension to reduce as much as possible the risk of abdominal compartment syndrome. 

In the end, this is how we can close our patient’s abdomen:

  • Direct closure as a “simple” laparotomy;
  • Progressive closure of the fascia along with the multiple revisions (in each reoperation some stitches are done, advancing from the wound ends to the center!);
  • Use a biological mesh in between the fascial edges;
  • Use a mesh-mediated technique to traction the fascial edges to the center (the mesh is attached to the fascial edges, cut in the middle when needed, and trimmed to create traction towards the middle; when the fascial edges are almost closed you can remove the mesh… or maybe not);
  • Use the mesh mediated fascial traction and leave the mesh there (on the top of a closed fascia) or interpone a biological mesh;
  • Use a “planned ventral hernia” technique when everything fails (start crossing your fingers and prepare for an entero-atmospheric fistula!).

Now… this is the end of this two-part post. We hope we were able to give you a proper and satisfactory overview of the subject…

See you next time…

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 2. Surgical Pizza. Published on October 31, 2021. Accessed on January 12, 2022. Available at [https://surgicalpizza.org/trauma/how-to-close-the-pandora-box-part-2/].

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