The Abdominal Compartment Syndrome Andre R. Campbell, MD, FACS, FACP, FCCM Professor of Surgery, UCSF Endowed Chair of Surgical Education San Francisco General Hospital
Outline Case presentations Review literature Abdominal Compartment Syndrome and Intra-Abdominal Hypertension Suggest techniques that can be used to deal with these problems
Damage Control Principles Damage Control Surgery Abdominal Compartment Syndrome Closure of the Abdomen
Balogh Z et al. World J Surgery 2009 33:1134-41
Balogh Z et al. World J Surgery 2009 33:1134-41
Noosa Heads Australia December 2004 170 leaders from around the world Defined and updated the literature on this important clinical problem Consensus definition were developed Intraabdominal Hypertension occurred in 35% of ICU patients Approximately 5% developed ACS Sugrue Curr Opin Crit Care 2005:11:333-338
Abdominal Compartment Syndrome Defined Normal IAP is 5mm Hg Can be non-pathological in the obese mm Hg is the way to express the pressure Measure at end expiration No abdominal contractions Gold standard intermittent indirect measurement is the bladder Abdominal Perfusion Pressure(APP)= MAP IAP Sugrue Curr Opin Crit Care 11:333-338, 2005
Abdominal Compartment Syndrome Intra-Abdominal Hypertension: IAP of 12mm Hg recorded 4-6 hours apart on three different occasions A APP of 60 mm Hg or less recorded by a minimum standard measurements two times 1-6 hours apart
Abdominal Compartment Syndrome Pressure of 20 mm Hg or great with or without APP below 50 mm Hg recorded by minimum of three standard measurements 1-6 hours apart and single or MOF Primary Abdominal Compartment Syndrome: Associated with injury or disease of the abdominopelvic region that frequently requires early surgical or angio intervention or that develops after abdominal surgery(organ injury requiring damage control, secondary peritonitis, bleeding pelvis fracture, massive retroperitoneal hematoma liver transplantation. Sugrue Curr Opin Crit Care 2005:11:333-338
Abdominal Compartment Syndrome Secondary ACS: Conditions that do not originate in the abdomen capillary leak, burns, and other conditions requiring massive resuscitation» 13 series reported in the literature Kirkpatrick et al JACS 2006 Apr;202(4):668-79 Tertiary ACS: Recurrent ACS develops after therapeutic surgical or medical treatment or primary or secondary ACS after decompressive laparotomy or after definitive closure
Grading of Intra-Abdominal Hypertension Grade I II III IV IAP(mm Hg) 12-15 16-20 21-25 >25
Intra-Abdominal Hypertension Causes Trauma or hemorrhage Abdominal surgery Retroperitoneal bleed Peritonitis: secondary or tertiary Laparoscopy or pneumoperitoneum Repair of a large hernia Abdominal binding with postoperative velcro to prevent hernias Massive fluid resuscitation more than 5 liters in 24 hours Ileus: paralytic, pseudo obstructive Post operative rupture aneurysms
Pathogenesis- IAH Can occur in surgical and non-surgical patients Probably multifactorial in nature Capillary leak Shock with ischemia reperfusion injury release of vasoactive substances oxygen free radicals massive increase in extracellular volume occurs
Abdominal Compartment Syndrome Abdominal Wall Abnormalities: Reduced abdominal wall blood flow Local ischemia and edema»can reduce abdominal wall compliance»acs is exacerbated Wound complications can result»herniation, dehiscence, necrotizing faciitis Saggit et al, J Trauma, 45:3:597-608 1998
Abdominal Compartment Syndrome Pulmonary Dysfunction: High ventilatory pressures, hypoxia, hypercarbia Reduced static and dynamic lung compliance Increased peak pressures Reduced TLC, FRC, Residual volume V/Q abnormalities and hypoventilation»hypoxia and hypercarbia Saggit et al, J Trauma, 45:3:597-608 1998
Abdominal Compartment Syndrome Pulmonary Dysfunction (continued): PVR increases»reduced oxygen tension and increased intra-thoracic pressure Animal models show recent hemorrhage exacerbates cardiopulmonary effects Obesity hypoventilation syndrome»makes acute phase worst Saggit et al, J Trauma, 45:3:597-608 1998
Abdominal Compartment Syndrome Intracranial Derangement: Increased ICP reduces CPP»Shown in animal models and human studies Elevated ICP secondary to increased CVP, and intrathoracic pressure Surgical decompression reduces this affects Chronic elevations in ICP implicated in pseudotumor cerebri- obesity»responds to bariatric surgery Saggit et al, J Trauma, 45:3:597-608 1998
Abdominal Compartment Syndrome Measurements of IAP: Gastric Pressure Inferior Vena Cava Pressure Urinary Bladder Pressure» Gold Standard
Techniques for closure of the Abdomen Skin approximation Bogota bag Vicryl mesh Dexon mesh Open-Steri-Drape Modified removal prosthesis-marlex with zipper or Wittman Patch Vacuum assisted closure Rutherford, EJ et al Cur Prob Surg 2004:41:821-876
Comparison of Choices for Abdominal Closure Sugrue Curr Opin Crit Care 11:333-338, 2005
Open Abdominal Cases Incidence estimated in the literature to be 10-23%» Retrospective studies in the literature New techniques allows fascial closure in 70-80% of cases Less morbidity and mortality if the fascia can be closed primarily- no need for a large second operation Technique of vacuum pack closure described by Barker using JPs for suction Argenta described use of wound vac on chronic wounds clinically subsequently applied to abdominal wound closure Barker DE et al. J Trauma 2000:48:201-207 Miller PR, et al J Trauma 2002:53:843-849 Argenta LC, Morykwas MJ Ann Plastic Surg 2000:45:3:332-4
Alien Physiology
Case Presentation 46 yo obese man with abdominal pain One hour after arrival he had a cardiac arrest in the CT scanner BMI: 58 wt: 365 lbs Shock and hypotensive CT massive free air in the abdomen no PE Exp Lap 4/15/2005 A series of problems ensued with the patient Shock, renal failure, respiratory failure, 4 cardiac arrests on the night of admission 4 pressors Massive hemorrhage on Activated Protein C Developed Abdominal Compartment Syndrome
Management of the Open Abdomen 21 patients(48%) were closed at > 9 days (range 9-21 days) 2 patients had a fascial dehiscence that was subsequently closed One patient developed a ventral hernia that was repaired Conclusion:»VAC assisted closures resulted in significantly higher fascial closure rates eliminating the need for hernia repair in most patients Miller PR et al. Ann Surg 2004:239:608-616
Management of the Open Abdomen Early aggressive closure of the open abdomen Retrospective review of 37 patients Vacuum assisted closure and alloderm used Mean time with open abdomen was 21.7 days(6-45) Alloderm used if the abdominal wall could not be closed No fistulas, no intraabdominal complications or graft loss All survived to discharge No hernia formation noted Superficial wound infection occurred in 2 patients treated with wet to dry dressings Conclusions Early closure possible with vacuum pack, vacuum assisted wound closure and Alloderm Scott, BG et al, J of Trauma 2006:60:17-22
Other ways to close the abdomen Acellular cadaveric dermis(alloderm) Intact human skin Structural components of the dermal extracellular scaffold that enable it to recellularize and revascularize Integrates into surround tissue Mainly used in chronic hernia situation with failed mesh repairs Buinewicz et al, Ann Plast Surg 2004:52:188-194
Retrospective review of one hospitals experience 26 months and 35 patients in the study Profoundly ill trauma patients Six died, 29 discharged 86% were closed using the vac at a mean of 7+1 day! No patients developed evisceration, abscess, or wound infection Four who failed closure 2 fistulas Suliburk et al, J of Trauma 2003;55:1155-1160
Conclusions The Abdominal Compartment Syndrome is real! Difficult cases to manage Must be on a mission to close the patient ASAP Do not do it as the last case of the day Many options for management Some recommend dealing with fistulas or stomas before definitive repair Oblique releases can help reduce fascial tension
Conclusions Be prepared for problems to develop! Vacuum assisted closure allows can help close over 80% or more of these cases Geometry problem Get help when needed Some patients you will not be able to close