In the early 1980s, Kron et al. 1 showed in an. Surgical management of abdominal compartment syndrome

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1 This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either EXPERT OPINION Surgical management of abdominal compartment syndrome O., S. CIMBANASSI, S. BOATI, G. BASSI Trauma Team-Emergency Department, Niguarda Ca Granda Hospital, Milan, Italy ABSTRACT Background. The majority of intensive care physicians recognize the clinical significance of intra-abdominal hypertension on the outcome of critically ill patients. Abdominal compartment syndrome (ACS) is defined as an intraabdominal pressure (IAP) >20 mmhg with ongoing organ failure. However, there is no consensus regarding the indications for surgical. Methods. A review of personal data and the English literature from 1989 to 2010 focusing on surgical management of ACS. Results. Opening the abdomen is the most effective method to reduce IAP and is the treatment of choice for ACS when IAP is constantly higher than 30 mmhg with ongoing organ failure refractory to medical therapy. A vertical midline incision is the most popular method of surgical, but bilateral subcostal incisions may be indicated in certain conditions. Surgical always obtains a significant decrease in the IAP with physiological improvement, but the effects on organ function are controversial. Negative pressure devices are the most effective for temporary abdominal closure with a higher rate of primary fascial closure and lower risk of fistulas. When primary fascial closure is not feasible, a planned ventral hernia and spontaneous granulation with or without biologic mesh are the preferred methods for the reconstruction of abdominal wall integrity. Conclusion. Modern surgical techniques for opening the abdomen in patients with ACS refractory to medical therapy result in physiologic improvement with less treatment-related complications, but recuperation of organ dysfunction is variable. (Minerva Anestesiol 2011;77:457-62) Key words: Intensive care - Intra-abdominal hypertension - Abdominal compartment syndrome. In the early 1980s, Kron et al. 1 showed in an experimental and clinical study that intra-abdominal pressure (IAP) could be used as a criterion for life-saving surgical. In 1989, the term abdominal compartment syndrome (ACS) was coined by Fietsam et al. 2 to describe physiologic consequences on ventilatory pressure, central venous pressure and urine output due to massive abdominal distension after surgery for a ruptured aortic aneurysm. The author demonstrated in four patients the dramatic improvement of physiological variables after decompressive laparotomy directly performed in the intensive care unit. During the 1990s, numerous studies were published on the topic of ACS, and now the majority of clinicians know how to measure IAP and recognize the clinical significance of intra-abdominal hypertension (IAH) and ACS. Presently, ACS is defined as an IAP >20 mmhg associated with new organ dysfunction or failure. 3 When medical treatment to reduce IAH has failed, opening the abdomen is a surgical option where the peritoneal cavity is opened or deliberately left open to treat or to prevent the development of ACS. 4 Vol No. 4 MINERVA ANESTESIOLOGICA 457

2 Which patients are at risk for ACS? ACS has been recognized to occur in a wide variety of patient populations. The 2004 International ACS Consensus Conference defined risk factors for IAH/ACS 3 as 1) diminished abdominal wall compliance, typically after abdominal surgery with tight fascial closure, especially in patients with a high body mass index (>30 kg/m 2 ), after incisional hernia repair and after abdominal burns; 2) increased intraluminal contents, for example, gastro-intestinal paresis or obstruction; 3) increased intraperitoneal or retroperitoneal contents, abdominal organ injury or pathology, as damage control surgery for trauma with packing, pelvic ring disruption with retroperitoneal hematoma, hemoperitoneum from non-operative treatment of organ injury, pancreatitis and other causes of abdominal sepsis or abdominal aortic aneurysm repair; 4) capillary leak, as it occurs in the setting of systemic inflammation and/or massive fluid/blood resuscitation of more than 5 liters of crystalloids/ colloids or more than 10 packed red blood cells within 24 hours. In all these cases, IAH is the result of tissue and bowel wall edema. Primary ACS is defined 5 as a condition associated with Figure 1. Steps for a home-made vacuum assisted closure technique. A) Fenestrated polyethylene sheet on viscera; B) moist surgical towels with silicone drains; C) adherent polyethylene sheet for sealing the wound. a disease of the abdominal-pelvic region often requiring a surgical intervention or an interventional radiology procedure. Secondary ACS is a condition that originates from extra-abdominal, extra-pelvic pathology, such as bowel edema from massive resuscitation following non-abdominal injury. Tertiary or recurrent ACS is the condition that develops after resolution of primary or secondary ACS initially treated with medical or surgical management. Laparostomy may be a therapeutic option for every type of ACS. When is surgery indicated? Initial treatment of ACS is always non-operative due to the significant morbidity associated with opening the abdomen. The following strategies are suggested as part of the World Society for the Abdominal Compartment Syndrome guidelines: 3 1) improvement of abdominal wall compliance with sedation, analgesia, neuromuscular blockade and a supine body position; 2) evacuation of intraluminal contents by, for example, gastro-colonic with tubes or endoscopy and prokinetic agents such as erythromycin, metoclopramide or neostigmine; 458 MINERVA ANESTESIOLOGICA April 2011

3 3) evacuation of intra-abdominal contents using percutaneous catheter with intraperitoneal fluid or blood removal; 4) correct positive fluid balance with diuretics or extracorporeal techniques and hypertonic or colloid-based resuscitation protocols; and 5) should all these measures fail, surgical techniques with a negative pressure dressing to relieve IAH should be considered, always taking into consideration the benefit-to-risk ratio. There is no consensus regarding the indications for surgical treatment of ACS, and a critical threshold value of IAP cannot be applied to decision making. Clinical experience suggests that surgery should be indicated for an IAP consistently higher than 30 mmhg or an abdominal perfusion pressure (APP) lower than 50 mmhg associated with ongoing organ failure refractory to medical treatment. 6, 7 Some authors 8, 9 suggest the prophylactic use of opening the abdomen in patients who undergo abdominal surgical emergencies and are at risk for visceral and retroperitoneal edema due to inflammation, shock and fluid resuscitation. However, the protocol for this prophylactic open abdomen procedure should be based on an intra-operative value of IAP at least >12 mmhg after fascial closure attempt. The value of 12 mmhg has been empirically selected because it represents the upper limit of a normal IAP. Techniques for opening the abdomen For primary ACS, the best choice for surgical is obviously to re-open the existing recent abdominal incision. For secondary ACS and in general for patients without recent operations, there are several options. A midline vertical incision is the most commonly used method, however for some cases, a bilateral subcostal incision is preferable. 10 For example, in acute necrotizing pancreatitis, the subcostal approach ameliorates exposure of the pancreas, facilitates a necrosectomy and allows for selective open treatment of the supramesocolic and paracolic regions. Another option is a subcutaneous vertical linea alba incision, which leaves the peritoneum intact and has less complications and a significant advantage for nursing during the Table I. Physiologic changes 24 hours after surgical in 29 post-injury patients with primary ACS. Mean age 36±9, male 22 (75.9%), mean time from injury to days 10±4. Before After acute phase. 11 Surgical produces a prompt decrease in IAP, which is often reduced by 50%, but its effects on organ function and survival are still debated. In our unpublished clinical series (Table I), 29 patients operated on for an abdominal solid organ injury developed primary ACS, defined as an IAP >20 mmhg with ongoing organ failure refractory to medical therapy. The surgical, always performed through a pre-existing midline incision, produced a marked reduction in the IAP with a decrease in the lactate level and an increase in urine output after 24 hours, but without a change in the PaO 2 /FiO 2 ratio. In a collective review of 250 cases of consecutive laparostomy for ACS, surgical produced similar physiological changes, but respiratory function remained severely impaired in all patients 12. In another study, in our series of 35 patients 13 who underwent preventive laparostomy at the time of first operation after injury or peritonitis, mortality was higher in patients with prolonged periods of an open abdomen (Table II). Surviving patients had a period of an open abdomen that was shorter than that of non-surviving patients, Vol No. 4 MINERVA ANESTESIOLOGICA 459 P value MAP (mmhg) 69.5± ±5.6 NS HR (bpm) 113±15 95±7 <0.05 CVP (mmhg) 7.0± ±0.9 NS Lactate (mmol/l) 8.15± ±1.5 <0.05 PaO 2 /FiO 2 258±8 266±1 NS Urine output(ml/h) 82.5± ±8.8 <0.05 IAP (mmhg) 26.7± ±2.5 <0.05 APP (mmhg) 41.0± ±6.3 <0.05 APACHE II 26±4 20±5 NS APP indicates abdominal perfusion pressure (APP = MAP-IAP) Causes of ACS: Liver injury and previous damage control surgery, 6 patients. Pelvic fracture with retroperitoneal hematoma, 11 patients. Combination of pelvic fracture with abdominal solid organ injury, 4 patients. Kidney injury with retroperitoneal hematoma, 3 patients. Peritonitis due to hollow viscus perforation, 2 patients. Severe pancreatitis from pancreatic injury, 2 patients. Abdominal aorta injury, 1 patient.

4 Table II. Comparison between survival and days of open abdomen (OA) in 35 patients. Survived patients N. (%) 24 (68.6) Not survived patients N. (%) 11 (31.4) Total N. (%) 35 (100) Before 1-10 (median 3, IQR 3) 1-48 (median 17, IQR 16) 1-48 (median 4, IQR 4.5) After and this difference was significant (P<0.05) using Wilcoxon s rank sum test. The impression is that reducing the IAP is useful for improving the physiology in critically ill patients with ACS or those at risk for IAH, but the outcomes are principally related to the evolution of the underlying illness. Temporary abdominal closure (TAC) techniques P value IQR: interquartile range. The days of OA between survived and non survived patients were significantly different (P<0.05) at rank sum test. In an open abdomen, exposed viscera need to be protected to prevent fistula formation. 14 Moreover, the TAC technique should optimize the feasibility of a primary fascial closure. Several alternative methods have been proposed. The use of towel clips or a skin-edge running suture to approximate the skin to the midline is rapid and inexpensive. Problems include poor drainage, skin damage and little room for an increase in abdominal contents. It is used today only after damage control laparotomy with packing in patients who are in profound hemorrhagic shock to generate a tamponade effect in the cavity. 15 The Bogota Bag is a plastic silo simply made from a three-liter cystoscopy bag cut into an oval shape and sewn to the skin with a running suture that contains the abdominal viscera and allows for the expansion of abdominal contents. This technique is rapid and inexpensive but is associated with leakage of peritoneal fluids from the bag-skin suture, leaving the bed wet and allowing the fascial edges to pro- gressively retract, thereby reducing the possibility of a future primary fascial closure. 16 Since the 1990s, mesh closure has been popularized; these devices are sutured to the fascial edges using various types of materials: polypropylene, vicryl, polytetrafluoroethylene, or GoreTex. Some meshes have been equipped with a zipper or Velcro closure for easy entrance into the abdomen. Mesh closure has the principal advantage of permitting a progressive approximation of fascial edges by reducing mesh size, but the most important problem has been the incidence of enteric fistula formation, with a reported range from 15% to 50% (especially when using polypropylene mesh). 17 Vacuum assisted closure (VAC) therapy (KCI, Inc, San Antonio, TX, USA) 18 uses a computer-controlled device that maintains a pre-selected negative pressure through a reticulated polyurethane foam dressing applied over the viscera. The result is a reduction in the intra-abdominal pressure with a reduction in the size of the wall defect, decreased bowel edema and active removal of fluid and inflammatory products from the peritoneal cavity. Retrospective analysis described a high primary fascial closure rate, from 86% to 92%, and a low incidence of enteric fistulas, from 0% to 9%. 19 VAC therapy is an expensive technique and, in some institutions, a home-made type of negative abdominal pressure dressing (NAPD) is often used. In brief, it consists of a fenestrated polyethylene sheet over the viscera covered by moist surgical towels, two silicone drains, surgical towels to cover the drains and finally an adherent polyethylene sheet that seals the wound (Figure 1). Continuous suction of mmhg is applied and negative pressure obtained with advantages similar (but not equal) to those obtained by a commercial VAC: a fascial closure rate higher than 50% and a fistula formation rate lower than 5% has been described for NAPD. 20 A technique combining vacuum-dressing and temporary velcro-mesh has been described. Gradual approximation of the fascial edges is obtained by tensioning of the mesh, which is then removed with a primary fascial closure. 21 Our preference today is toward the use of home-made NAPD for a presumed short-period open abdomen, such 460 MINERVA ANESTESIOLOGICA April 2011

5 as for a preventive laparostomy after a trauma laparotomy, while we reserve a commercial VAC for more complex cases, particularly in an open abdomen for an infected peritoneal cavity. Closure of the open abdomen The goal of opening the abdomen is to minimize the effects of IAH and to prevent ACS, but it also permits the restoration of abdominal wall integrity. New negative pressure dynamic devices are associated with better results in terms of primary fascial closure. When fascial closure is not feasible, it is possible to allow for granulation to grow from fascial edges and place a skin graft for coverage. Delayed closure of an open abdomen increases the rate of enteric fistulas. In this case, standard therapy with bowel rest and intravenous nutrition is started and fistula output is controlled by a suction drain, to prevent further skin and tissue erosion, until peri-fistula granulation and skin ensue. Small fistulas heal spontaneously, usually after a few weeks. For larger fistulas, surgical closure is needed, usually after 6 to 12 months, only when the abdominal wall is amenable for definitive coverage 22. When fascial closure is impossible, it seems better to try to close the skin and allow for a programmed ventral hernia (the skin is intentionally the only coverage of the abdominal contents). The ventral hernia may be subsequently treated with a delayed abdominal wall reconstruction using pedicular or microvascular flaps or a prosthetic biologic mesh that may be skin grafted over granulation tissue. 23 Conclusions IAH and ACS are emerging problems in critically ill patients, and IAP monitoring in intensive care units after emergency surgery and advanced resuscitation techniques is becoming standard care. 24, 25 Meticulous care of the bowel with the application of modern dressing systems minimizes trauma and prevents fistula formation. Primary fascial closure is often possible. When not feasible, prolonged periods of treatment are necessary with extensive medical and nursing care. However, in regards to these highly complex cases, the last decade has seen a remarkable improvement in the ability of the surgeon and the intensive care physician to deal with this challenge of modern medicine, resulting in an increase in the survival and functional outcomes of patients. References 1. Kron IL, Harman PK, Nolan SP: The measurement of intra-abdominal pressures as criterion for abdominal reexploration. Ann Surg 1984;199: Fietsam R Jr, Villalba M, Glover JL, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured aortic aneurism repair. Am Surg 1989;55: Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J et al. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. II: Recommendations. Intensive Care Med 2007;33: Leppaniemi A. Laparostomy: why and when? Crit Care 2010;14: Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J et al. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I: Definitions. Intensive Care Med 2006;32: Malbrain ML. Abdominal perfusion pressure as a prognostic marker in intraabdominal hypertension. In: Vincent JL, editor. Yearbook of intensive care and emergency medicine. Berlin, Heidelberg, New York: Springer; p Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: a superior parameter in the assessment of intraabdominal hypertension. J Trauma 2000;49: Mayberry JC. Prevention of abdominal compartment syndrome. In: Ivatury RR, Cheatham ML, Malbrain ML, Sugrue M, editors. Abdominal compartment syndrome. Landes Biomedical, Georgetown p Mentula P, Leppaniemi A. Prophylactic open abdomen in patients with postoperative intraabdominal hypertension. Critical Care 2010;14: Leppaniemi A. Surgical management of abdominal compartment syndrome; indications and techniques. Scand J Trauma Resuscitation Em Med 2009;17: Leppaniemi A, Hienonen P, Siren J, Kuitunen A, Lindstrom O, Kempainen E. Treatment of abdominal compartment syndrome with subcutaneous anterior abdominal fasciotomy in severe acute pancreatitis. World J Surg 2006;30: De Waele JJ, Hoste EA, Malbrain ML. Decompressive laparotomy for abdominal compartment syndrome a critical analysis. Crit Care 2006;10:R Boati P, Chiara O, Cimbanassi S, Bassi G. Preventive laparostomy. Proceedings of the Second Meeting of the World Society of Emergency Surgery, July 1-3, Bologna, Italy. 14. Fischer PE, Fabian TC, Magnotti LJ, Schroeppel T, Bee TK, Maish GO 3rd et al. A ten year review of enterocutaneous fistulas after laparotomy for trauma. J Trauma 2009;67: Tremblay LN, Feliciano DV, Schmidt J, Cava RA, Tchorz KM, Ingram WL et al. Skin only or silo closure in the critically ill patients with open abdomen. Am J Surg 2001;182: Fernandez L, Norwood S, Roetger R, Wilkins HE 3rd. Vol No. 4 MINERVA ANESTESIOLOGICA 461

6 Temporary intravenous bag silo closure in severe abdominal trauma. J Trauma 1996;40: Fansler RF, Taheri P, Cullinane C, Sabates B, Flint LM. Polypropilene mesh closure of the complicated abdominal wound. Am J Surg 1995;170: Argenta LC, Morykwas MJ. Vacuum assisted closure: a new method for wound control and treatment. Clinical experience. Ann Plastic Surg 1997;38: Suliburk JW, Ware DN, Balogh Z, McKinley BA, Cocanour CS, Kozar RA et al. Vacuum-assisted closure achieves early fascial closure of open abdomen after severe trauma. J Trauma 2003;55: Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. Vacuum pack technique of temporary abdominal closure. A 7 years experience with 112 patients. J Trauma 1990;30: Petersson U, Acosta S, Bjork M. Vacuum-assisted wound closure and mesh-mediated fascial traction a novel tech- nique for late closure of the open abdomen. World J Surg 2007;31: Goetter CE, Rotondo MF, Schwab CW. Surgical management of the open abdomen after damage control or abdominal compartment syndrome. In: Ivatury RR, Cheatham ML, Malbrain ML, Sugrue M, editors. Abdominal compartment syndrome. Georgetown: Landes Biomedical; p Jemigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G. Staged management of giant abdominal wall defects: acute and long terms results. Ann Surg 2003;238: Malbrain ML. You don t have any excuse, just start measuring abdominal pressure and act upon it!. Minerva Anestesiol 2008;74: Biancofiore G, Bindi ML. Measurement and knowledge of intra-abdominal pressure in Italian Intensive Care Units. Minerva Anestesiol 2008;74:5-9. This study was presented at SMART, Milan, 2010 May 27. Received on April 30, Accepted for publication on November 11, Corresponding address: O. Chiara, Trauma Team Emergency Department, Niguarda Ca Granda Hospital, piazza Ospedale Maggiore 3, Milan, Italy. ochiara@yahoo.com. 462 MINERVA ANESTESIOLOGICA April 2011