To Close or Not to Close: Managing the Open Abdomen

Abstract

No matter what your previous experience or surgical practice has been, you will extensively use and be exposed to damage control abdominal surgery and the open abdomen in combat or disaster surgery. If you are looking for level I, evidence-based medicine on how to approach and manage these patients, you are out of luck. You may have seen multiple different techniques of temporary abdominal closure and approaches to achieving definitive abdominal closure, many of which claim to be the optimal approach. Like most things in surgery, there is more than one way to achieve an excellent outcome for your patient. The critical factors are to develop a thorough understanding of the basic principles and pitfalls of open abdominal management, as well as your local capabilities and limitations. This chapter outlines a general approach to the open abdomen based on years of experience with combat casualties in the Iraq and Afghanistan conflicts. The basic principles outlined here are universal, but the details and techniques can and should be adapted or adjusted based on your individual situation and the realities on the ground.

Civilian Translation of Military Experience and Lessons Learned

• Ali Salim 

Key Similarities

• Goals of damage control surgery similar in civilian and military practice

• Technique for temporary coverage and progressive closure of the abdomen similar in civilian and military practice

Key Differences

• Indications for damage control are more expansive in the military experience and include the need to consider evacuation process.

• Planned ventral hernia repair uncommon in military practice.

Due in large part to lessons learned from our military colleagues, advances in trauma care have resulted in improved survival of many severely injured patients. As noted in the current chapter, these advances include “damage control surgery” or “abbreviated laparotomy” with abdominal packing and recognition of abdominal compartment syndrome . As part of damage control surgery, and for the treatment of the abdominal compartment syndrome, the abdomen is frequently left open. Damage control has been extended to the management of life-threatening intra-abdominal bleeding and severe intra-abdominal sepsis, resulting in an increased prevalence of the open abdomen among emergency surgery cases. Although the numbers of “open abdomens” are decreasing due to changes in resuscitation and transfusion practices, it still represents a complex and challenging surgical complication. Despite these difficulties, the civilian management of the open abdomen is very similar to the military experience .

Damage Control

Overall, about 10–15% of all laparotomies for trauma are managed with damage control techniques. Traditionally, damage control has been advocated for patients “in extremis” (those with exhaustion of physiological reserves and imminent irreversible shock and death), but with initiation of damage control earlier – before the patient becomes coagulopathic and “in extremis” – outcomes are improved. Although the indications are not as expansive as in the military (we do not have to worry about an evacuation process for our patients), we will also employ damage control for patients with bleeding from difficult anatomical areas, some complex injuries not amenable to easy surgical control, and for temporary stabilization before transfer to higher-level care. We have learned from our military colleagues that damage control should be considered early, before the patient reaches the “extremis” stage, taking into account the available resources, nature of the injuries, experience of the surgeon, clinical condition of the patient, and any comorbid conditions. Following damage control, the fascia or the skin should never be closed, as this would surely lead to intra-abdominal hypertension . However, the abdomen can be closed temporarily using one of the available materials and techniques. Important steps for the management of the open abdomen include temporary coverage that protects the viscera and allows serial access to the peritoneum, medial retraction of the fascia, progressive closure of the fascia, and, finally, definitive fascial closure during the initial hospitalization or in a delayed fashion as a planned ventral hernia repair .

Temporary Coverage

A wide variety of techniques have been described for temporary abdominal coverage. The vacuum pack technique is well described by the authors. It utilizes available equipment and is inexpensive. For this reason, even in civilian practice, the vacuum pack is occasionally used. Increasingly, one of the commercially available temporary abdominal closure kits utilizing negative pressure therapy is utilized. We favor the use of the ABThera® (KCI, San Antonio, Texas) wound vacuum device. The ideal coverage should be readily available, rapidly applied, allow repeat access to the abdomen, prevent loss of domain, preserve the fascia, and facilitate primary fascial closure. By utilizing constant negative pressure, both the vacuum pack and commercially available “wound V.A.C.™” fulfill all the necessary criteria mentioned above.

Progressive Closure

The ultimate goal with any open abdomen is to achieve primary fascial closure. This often occurs during a second operation. When the abdomen is not amenable to primary closure because of continued bowel edema or bleeding, several techniques have been described for progressive closure. The commercially available “wound V.A.C.™” applies constant medial tension on the fascial edges, presumably prevents fascial retraction, and facilitates primary fascial closure. Using this technique, primary fascial closure can be obtained in nearly 90% of open abdomens. Although the likelihood of achieving primary fascial closure decreases after 9 days of open abdominal management, the use of the abdominal “wound V.A.C.™” has allowed successful closure up to 49 days post injury.

The Wittmann Patch is a commercially available device that has also been employed for progressive closure to achieve primary fascial closure. It is used in a similar fashion as described with the Goretex Dualmesh®. This Velcro-type device is sewn into the fascia and allows for progressive fascial approximation. Unfortunately, there is a paucity of data regarding its use .

Definitive Closure

In civilian practice, there is a small subset of patients where primary fascial closure is not possible. For this group, a number of techniques have been described with varying degrees of success. Primary closure with a nonabsorbable prosthetic mesh (polyprolene, polypropylene, polytetrafluoroethylene) or nonabsorbable biological prosthesis (human and porcine acellular dermal matrix) has had fairly good results. However, no long-term results exist for the use of the biologics. Although uncommon in the military experience, closure with absorbable mesh or skin graft as a planned ventral hernia and later repair at 6–12 months either using nonabsorbable prosthetic mesh or a component fascial separation technique have both been very well described with excellent results.

Final Points

The open abdomen has become the standard of care in damage control procedures, the management of intra-abdominal hypertension , and in severe intra-abdominal sepsis. This approach has saved many lives but has also created new problems, such as severe fluid and protein loss, nutritional problems, entero-atmospheric fistulae, fascial retraction with loss of abdominal domain, and development of massive incisional hernias . Early definitive closure is the cornerstone in preventing or reducing the risk of these complications. The introduction of new techniques and materials for temporary and subsequent definitive abdominal closure has improved outcomes in this group of patients.