One hundred percent fascial approximation with sequential abdominal closure of the open abdomen

Transcription

1 The American Journal of Surgery 192 (2006) HowIdoit One hundred percent fascial approximation with sequential abdominal closure of the open abdomen C. Clay Cothren, M.D. a,b, *, Ernest E. Moore, M.D. a,b, Jeffrey L. Johnson, M.D. a,b, John B. Moore, M.D. a,b, Jon M. Burch, M.D. a,b a Department of Surgery, Denver Health Medical Center, 777 Bannock St., MC 0206, Denver, CO 80204, United States b University of Colorado Health Sciences Center, Denver, CO, United States Manuscript received November 17, 2005; revised manuscript April 27, 2006 Abstract Background: Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure. Methods: After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect. Results: Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was days (range 4 16) and average number of laparotomies to closure was (range 3 8). All patients attained primary fascial closure. Conclusion: We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen Excerpta Medica Inc. All rights reserved. Keywords: Open abdomen; Trauma; Damage control surgery; Abdominal compartment syndrome; Closure Damage control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Although the initial focus has been the decrease in postinjury mortality, it is time to refine techniques to minimize morbidity and cost of care. Multiple techniques have been introduced to obtain fascial closure for the open abdomen. Vacuum-assisted closure (VAC) has decreased but not eliminated the use of either split-thickness skin grafts to cover the exposed bowel or mesh (prosthetic or biologic) approximation of the fascia. The success rate of primary fascial closure in the majority of * Corresponding author. Tel.: ; fax: address: clay.cothren@dhha.org studies ranges from 30% to 67% [1 7], although 2 studies have reported fascial approximation of 88% and 92% with VAC [8,9]. We performed a modification of the VAC technique that provided constant fascial tension. We hypothesized that this would result in a higher rate of primary fascial closure, hence obviating the morbidity of the open abdomen and cost of either complex abdominal reconstruction or biologic mesh insertion. Technique At the initial exploration for either postinjury damage control, primary or secondary abdominal compartment syndrome, or abdominal catastrophes, temporary closure of the abdomen is accomplished by a subfascial 1010 Steri-Drape (3M Health /06/$ see front matter 2006 Excerpta Medica Inc. All rights reserved. doi: /j.amjsurg

2 239 Fig. 1. Initial white sponge placement and skin protection. The white sponges are positioned over the bowel and stapled together (solid arrow); the white sponge patchwork is then placed under the midline fascia. The fascial edges are then placed under tension using interrupted number 1-PDS sutures spaced approximately 5 cm apart (dashed arrow) (A). The sticky clear plastic VAC covering covers the entire white sponge patchwork and the adjacent 5 to 10 cm of skin (B). One to 2 plastic drapes may be needed to cover the silo of white sponges plus enough of the skin surrounding the midline wound (C). The central portion is removed by cutting along the wound edges; the white sponge is uncovered while the skin is protected from the black wound VAC sponge (D). Care, St. Paul, MN), blue towel or laparotomy pad coverage, Jackson-Pratt (JP) (Bard, Covington, GA) drain placement, and Ioban (3M Health Care) coverage. After this initial temporary closure and subsequent normalization of the patient s physiology, we begin the sequential closure technique. The technique proposed by Miller et al [3] was modified to employ the VAC white sponges combined with black sponges. We begin by covering the bowel with the white sponges rather than a 1010 drape. Multiple white sponges are overlapped like patchwork. To prevent bowel from extruding between the white sponge edges, we staple the edges together with a skin stapler (Fig. 1). The white sponges not only cover the bowel but are placed under the fascial edges as well. The fascia is then placed under moderate tension over the white sponges with number 1-polydioxanone sutures (PDS) sutures. The PDS are full-thickness fascial bites ( 1.5 cm) placed approximately 5 cm apart in an interrupted fashion. The sticky clear plastic VAC covering is then placed over the entire white sponge patchwork and the adjacent 5 to 10 cm of skin. The central portion of the clear plastic is removed by cutting along the wound edges, leaving only that which is adherent to the skin (this will protect the skin from the black wound VAC sponge). One to 2 large black VAC sponges are placed on top of the white sponges and plastic-protected skin (there is no need to trim the black sponges to fit the wound edges with this technique). The black sponges are affixed with an occlusive dressing, and standard suction tubing is placed (Fig. 2). Patients are returned to the operating room (OR) for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect. Fascial sutures are placed using number 1-PDS in an interrupted fashion from both the superior and inferior directions until tension precludes further closure; skin is closed over the fascial closure with skin staples (Fig. 3). Only after partial fascial closure is the

3 240 Fig. 2. Initial black sponge placement. The black sponge is placed horizontally across the wound (A), and 2 large black sponges may be required to cover the entire white sponge patchwork and plastic-protected skin (B). The black sponges are affixed with an occlusive dressing (C); there is no need to trim the black sponges to fit the wound edges with this technique. The standard suction tubing is carefully tunneled into the black sponge and covered with a medium Tegaderm (3M Health Care, St. Paul, MN) to prevent air leakage and appropriate negative suction (D). white sponge slowly removed from under the closed fascia for replacement. As the fascial defect closes, the number of white sponges used diminishes. Hence, the number of white sponges can be used as a rough measurement of the size of the patient s open abdomen (ie, patients with significant bowel and retroperitoneal edema may require 6 to 8 white sponges at the first VAC placement, which are then sequentially decreased). Of note, the abdomen is not re-explored nor is the bowel eviscerated at each return to the OR. Rather, the fascial sutures are placed and the white sponges slowly removed. Only if there is concern for an intra-abdominal abscess should a complete washout of the abdomen be performed after the second trip to the OR. Once partial fascial closure is accomplished (the superior and inferior fascial sutures placed until the fascia cannot be pulled together without tension), new white and black sponges are placed in the same technique to form a sandwich. Hence, each time the patient goes to the operating room, the superior and inferior fascia is closed several centimeters, and the number of white sponges required diminishes. Gastrostomy and needle-catheter jejunostomy tubes may be placed before complete VAC closure, typically at the second VAC change day, and should exit the abdominal wall lateral to the aforementioned closure (as visualized in Fig. 3). Eventually, the entire length of the fascia is closed using interrupted sutures, followed by closure of the skin with skin staples. Case Series Patients undergoing this technique for open abdomen since its introduction in January 2005 at our level I trauma center were reviewed. Fourteen patients underwent sequential abdominal closure during the study period: 9 because of damage-control surgery (8 trauma and 1 general surgery)

4 241 Fig. 3. Partial fascial closure and second VAC placement. Superior fascial approximation is accomplished with interrupted number 1-PDS sutures (A), with a resultant decrease in the remaining fascial defect. Gastrostomy and needle-catheter jejunostomy tubes are seen exiting the lateral abdomen. The overlying skin is closed with skin staples, and the remaining fascia again put under midline tension using spaced interrupted sutures (B). Skin protection (C) is followed by placement of a single large black sponge (D). This sequence of closure is repeated until complete fascial closure. and 5 because of secondary abdominal compartment syndrome (3 trauma, 1 pancreatitis, and 1 ruptured abdominal aortic aneurysm). The majority were men (79%) with a mean age of years. Average time to closure was days (range 4 to 16), and average number of laparotomies to closure was (range 3 to 8). Patients undergoing postinjury damage-control surgery had an average of 2.7 (range 1 to 5) intra-abdominal injuries and 3.1 (range 1 to 5) additional injuries. Primary fascial closure was attained in all patients. Comments Management of the open abdomen has become an obligatory conundrum for general and trauma surgeons performing damage-control surgery. Although there is decreased mortality in these critically ill patients, the trade-off is morbidity of the resultant open abdomen. Although techniques have evolved to assist in the delayed closure of these patients abdomens, all would agree that primary fascial closure is the ideal. We propose a modification of the previously described VAC technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen. References [1] Tremblay LN, Feliciano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001; 182: [2] Stonerock CE, Bynoe RP, Yost MJ, et al. Use of a vacuum-assisted device to facilitate abdominal closure. Am Surg 2003;69: [3] Miller PR, Thompson JT, Faler BJ, et al. Late fascial closure in lieu of ventral hernia: the next step in open abdomen management. J Trauma 2002;53: [4] Navsaria PH, Bunting M, Omoshoro-Jones J, et al. Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique. Br J Surg 2003;90:

5 242 C.C. Cothren et al. / The American Journal of Surgery 192 (2006) [5] 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: [6] Cipolla J, Stawicki SP, Hoff WS, et al. A proposed algorithm for managing the open abdomen. Am Surg 2005;71: [7] Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen; a quiet revolution. Scand J Surg 2005;94:9 14. [8] Miller PR, Meredith JW, Johnson JC, et al. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially decreased. Ann Surg 2004;239: [9] Suliburk JW, Ware DN, Balogh Z, et al. Vacuum-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 2003;55: