Modern Management of the Open Abdomen A Cautionary Tale. Grand Rounds December 16, 2010 SUNY, Downstate
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1 Modern Management of the Open Abdomen A Cautionary Tale Grand Rounds December 16, 2010 SUNY, Downstate
2 Case HPI: 41 yo M BIBA; stabbed in left back while walking out of a shopping center. PMH/PSH: GSW to head. PE revealed 1-2 cm deep left paraspinal stab wound ~2 cm in length.
3 Imaging CT: L2 transverse process fracture; left perinephric stranding. CT Angio: expanding hematoma; free blood around liver and spleen. Aortography: no active bleeding
4 CT
5 CT
6 Hospital Course 10/3 Initial exploration 10/12 IVC filter placement 10/14 Tracheostomy 10/23 IR Coil 11/18 STSG 12/13 Discharge
7 Patient
8 Patient
9 Pathways to Open Abdomen Compartment Syndrome Septic Dehiscence Necrotizing fascitis Damage Control / Trauma Open Abdomen Unresolved Intraabdominal Processes
10 Surgical Issues Fluid losses Logistical burden Fistula formation Infection
11 Ideal Barrier Characteristics Contain and protect viscera Atraumatic Simple Easy application Inexpensive
12 Temporary Closure Technique
13 Temporary Closure Technique
14 Temporary Closure Technique
15 Open Abdomen as a Healing Wound Primary intention Fascial reapproximation without tension Secondary intention Frozen abdomen Loss of peritoneal space days Delayed primary closure Accommodate the conditions for closure by secondary intention
16 Planned Ventral Hernia Stage I Prosthetic insertion days Stage II Prosthetic removal 2 days Stage III Planned ventral hernia 6-12 Months Stage IV Definitive reconstruction
17 Planned Ventral Hernia
18 Planned Ventral Hernia
19 Component Separation
20 Component Separation
21 Component Separation
22 Mesh Absorbable Inexpensive Decreased incidence of infection Decreased incidence of fistula formation Biologic Immunologically inert Suitable for infected wounds One stage closure
23 Preservation of Peritoneal Space
24 Preservation of Peritoneal Space
25 Preservation of Peritoneal Space
26 Convergence of 3 Concepts Physiology of Open Abdomen Negative Pressure Wound Therapy Fluid Management/Logistics Progressive Wound Closure
27 Negative Pressure Wound Therapy
28 Negative Pressure Wound Therapy Garner, et. al., /14, 92% Miller, et. al., /83, 71% Stonebrook, et. al., /15, 67% Sulibrook, et. al., /29, 86%
29 Adverse Outcomes Rao M, et. al. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9(3): Starr-Marshall K. Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae; the St Marks experience. Colorectal Dis. 2007;9(6):573. Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development. The American Journal of Surgery. 2008;196(1):1-2.
30 FDA Public Health Notification Serious Complications Associated with Negative Pressure Wound Therapy Systems Date: November 13, 2009
31 FDA NPWT Contraindications necrotic tissue with eschar present untreated osteomyelitis non-enteric and unexplored fistulas malignancy in the wound exposed vasculature exposed nerves exposed anastomotic site exposed organs
32 Take-aways Consideration of the open abdomen as a healing wound Evolution of open abdominal wound closure Risks and benefits associated with NPWT
33 References Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development. The American Journal of Surgery. 2008;196(1):1-2. Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP. Complex Abdominal Wall Reconstruction: A Comparison of Flap and Mesh Closure. Ann Surg. 2000;232(4): Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen: a quiet revolution. Scand J Surg. 2005;94(1):9-14. Miller PR, Thompson JT, Faler BJ, Meredith JW, Chang MC. Late fascial closure in lieu of ventral hernia: the next step in open abdomen management. J Trauma. 2002;53(5): Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg. 1994;219(6): Koss W, Ho HC, Yu M, et al. Preventing Loss of Domain: A Management Strategy for Closure of the Open Abdomen During the Initial Hospitalization. Journal of Surgical Education. 66(2): Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast. Reconstr. Surg. 2000;105(2): ; quiz 739. Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9(3): 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(2): ; discussion Starr-Marshall K. Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae; the St Marks experience. Colorectal Dis. 2007;9(6):573. Sailes FC, Walls J, Guelig D, et al. Ventral Hernia Repairs: 10-Year Single-Institution Review at Thomas Jefferson University Hospital. Journal of the American College of Surgeons.
One hundred percent fascial approximation with sequential abdominal closure of the open abdomen
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