Top

Langenbeck's Archives of Surgery

Published in:

01-01-2015 | Original Article

Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction

Authors: A. Willms, C. Güsgen, S. Schaaf, D. Bieler, M. von Websky, R. Schwab

Published in: Langenbeck's Archives of Surgery | Issue 1/2015

Abstract

Background

The open abdomen has become an accepted treatment option of critically ill patients with severe intra-abdominal conditions. Fascial closure is a particular challenge in patients with peritonitis. This study investigates whether fascial closure rates can be increased in peritonitis patients by using an algorithm that combines vacuum-assisted wound closure and mesh-mediated fascial traction. Moreover, fascial closure rates for patients with peritonitis, trauma or abdominal compartment system (ACS) are compared.

Methods

Data were collected prospectively from all patients who underwent open abdomen management at our institution from 2006 to 2012. All patients were treated under a standardised algorithm that combines vacuum-assisted closure and mesh placement at the fascial level.

Results

During the study period, 53 patients (mean age 53 years) underwent open abdomen management for a mean duration of 15 days. Indications for leaving the abdomen open were peritonitis (51 %), trauma (26 %), and ACS or abdominal wall dehiscence (23 %). The fascial closure rate was 79 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. Mortality was 13 %. No patient developed an enteroatmospheric fistula or abdominal wall dehiscence after closure. The mean duration of treatment was significantly longer in peritonitis patients (20 days) than in patients without peritonitis (10 days) (p = 0.03). There were no significant differences in fascial closure rates between patients with peritonitis (87 %), trauma (85 %), and ACS or abdominal wall dehiscence (100 %) (p = 0.647).

Conclusions

Regardless of the underlying pathology, high fascial closure rates can be achieved using a combination of vacuum-assisted closure and mesh-mediated fascial traction.

Open Abdomen Advisory Panel, Campbell A, Chang M et al (2009) Management of the open abdomen: from initial operation to definitive closure. Am Surg 75(11 Suppl):S1–S22PubMed

Burlew CC (2012) The open abdomen: practical implications for the practicing surgeon. Am J Surg 204(6):826–835PubMedCrossRef

Scott BG, Welsh FJ, Pham HQ et al (2006) Early aggressive closure of the open abdomen. J Trauma 60(1):17–22PubMedCrossRef

Diaz JJ, Cullinane DC, Dutton WD et al (2010) The management of the open abdomen in trauma and emergency general surgery: part 1—damage control. J Trauma 68(6):1425–1438PubMedCrossRef

Smith BP, Adams RC, Doraiswamy VA et al (2010) Review of abdominal damage control and open abdomens: focus on gastrointestinal complications. J Gastrointest Liver Dis 19(4):425–435

Rasilainen SK, Mentula PJ, Leppäniemi AK (2012) Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg 99(12):1725–1732PubMedCrossRef

Quyn AJ, Johnston C, Hall D et al (2012) The open abdomen and temporary abdominal closure systems—historical evolution and systematic review. Colorectal Dis 14(8):e429–e438PubMedCrossRef

Acosta S, Bjarnason T, Petersson U et al (2011) Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction. Br J Surg 98(5):735–743PubMedCrossRef

Verdam FJ, Dolmans DE, Loos MJ et al (2011) Delayed primary closure of the septic open abdomen with a dynamic closure system. World J Surg 35(10):2348–2355PubMedCentralPubMedCrossRef

10.

Dietz UA, Wichelmann C, Wunder C et al (2012) Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia. Hernia 16(4):451–460PubMedCentralPubMedCrossRef

11.

Willms A, Güsgen C, Schreyer C, Becker HP, Schwab R (2011) Prevention of small bowel fistulas during open abdominal treatment: lessons learned. Zentralbl Chir 136(6):592–597PubMedCrossRef

12.

Scott BG, Feanny MA, Hirshberg A (2005) Early definitive closure of the open abdomen: a quiet revolution. Scand J Surg 94(1):9–14PubMed

13.

Pliakos I, Papavramidis TS, Mihalopoulos N et al (2010) Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery 148(5):947–953PubMedCrossRef

14.

Hatch QM, Osterhout LM, Podbielski J et al (2011) Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma 71(6):1503–1511PubMedCrossRef

15.

Miller RS, Morris JA, Diaz JJ, Herring MB, May AK (2005) Complications after 344 damage-control open celiotomies. J Trauma 59(6):1365–1371, discussion 1371–4PubMedCrossRef

16.

Joels CS, Vanderveer AS, Newcomb WL et al (2006) Abdominal wall reconstruction after temporary abdominal closure: a ten-year review. Surg Innov 13(4):223–230PubMedCrossRef

17.

Pantelis D, Jafari A, Vilz TO et al (2012) Abdominal wall components separation method for closure of complicated abdominal hernias. Chirurg 83(6):555–560PubMedCrossRef

18.

Smith LA, Barker DE, Chase CW et al (1997) Vacuum pack technique of temporary abdominal closure: a four-year experience. Am Surg 63(12):1102–1107, discussion 1107–8PubMed

19.

López-Cano M, Pereira JA, Armengol-Carrasco M (2013) “Acute postoperative open abdominal wall”: nosological concept and treatment implications. World J Gastrointest Surg 5(12):314–320PubMedCentralPubMedCrossRef

20.

Regner JL, Kobayashi L, Coimbra R (2012) Surgical strategies for management of the open abdomen. World J Surg 36(3):497–510PubMedCrossRef

21.

van Hensbroek BP, Wind J, Dijkgraaf MG et al (2009) Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg 33(2):199–207CrossRef

22.

Barker DE, Green JM, Maxwell RA et al (2007) Experience with vacuum-pack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients. J Am Coll Surg 204(5):784–792, discussion 792–3PubMedCrossRef

23.

Stevens P (2009) Vacuum-assisted closure of laparostomy wounds: a critical review of the literature. Int Wound J 6(4):259–266PubMedCrossRef

24.

Banwell PE, Musgrave M (2004) Topical negative pressure therapy: mechanisms and indications. Int Wound J 1(2):95–106PubMedCrossRef

25.

Wondberg D, Larusson HJ, Metzger U, Platz A, Zingg U (2008) Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: low primary closure rate. World J Surg 32(12):2724–2729PubMedCrossRef

26.

Bee TK, Croce MA, Magnotti LJ et al (2008) Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma 65(2):337–342, discussion 342–4PubMedCrossRef

27.

Oetting P, Rau B, Schlag PM (2006) Abdominal vacuum device with open abdomen. Chirurg 77(7):586, 588–93PubMedCrossRef

28.

Padalino P, Dionigi G, Minoja G et al (2010) Fascia-to-fascia closure with abdominal topical negative pressure for severe abdominal infections: preliminary results in a department of general surgery and intensive care unit. Surg Infect (Larchmt) 11(6):523–528CrossRef

29.

Dubose JJ, Scalea TM, Holcomb JB et al (2013) Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 74(1):113–120, discussion 1120–2PubMedCrossRef

30.

Salman AE, Yetisir F, Aksoy M et al (2014) Use of dynamic wound closure system in conjunction with vacuum-assisted closure therapy in delayed closure of open abdomen. Hernia 18(1):99–104PubMedCrossRef

31.

Björck M (2012) Vacuum and mesh-mediated fascial traction for primary closure of open abdomen in critically ill surgical patients. Br J Surg 99(12):1732–1733PubMedCrossRef

32.

Suliburk JW, Ware DN, Balogh Z et al (2003) Vacuum-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 55(6):1155–1160, discussion 1160–1PubMedCrossRef

33.

Tsuei BJ, Skinner JC, Bernard AC, Kearney PA, Boulanger BR (2004) The open peritoneal cavity: etiology correlates with the likelihood of fascial closure. Am Surg 70(7):652–656PubMed

34.

Bosscha K, Hulstaert PF, Visser MR, van Vroonhoven TJ, van der Werken C (2000) Open management of the abdomen and planned reoperations in severe bacterial peritonitis. Eur J Surg 166(1):44–49PubMedCrossRef

35.

Perez D, Wildi S, Demartines N et al (2007) Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis. J Am Coll Surg 205(4):586–592PubMedCrossRef

36.

Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedCentralPubMedCrossRef

37.

Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196PubMedCrossRef

38.

Clavien PA, Sanabria JR, Strasberg SM (1992) Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 111(5):518–526PubMed

39.

Petersson U, Acosta S, Björck M (2007) Vacuum-assisted wound closure and mesh-mediated fascial traction—a novel technique for late closure of the open abdomen. World J Surg 31(11):2133–2137PubMedCrossRef

40.

Malbrain ML, Cheatham ML, Kirkpatrick A et al (2006) Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med 32(11):1722–1732PubMedCrossRef

41.

De Potter TJ, Dits H, Malbrain ML (2005) Intra- and interobserver variability during in vitro validation of two novel methods for intra-abdominal pressure monitoring. Intensive Care Med 31(5):747–751PubMedCrossRef

42.

Becker HP, Willms A, Schwab R (2007) Small bowel fistulas and the open abdomen. Scand J Surg 96(4):263–271PubMed

43.

Burlew CC, Moore EE, Biffl WL et al (2012) One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma Acute Care Surg 72(1):235–241PubMed

44.

Seternes A, Myhre HO, Dahl T (2010) Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure. Eur J Vasc Endovasc Surg 40(1):60–64PubMedCrossRef

45.

Demetriades D, Salim A (2014) Management of the open abdomen. Surg Clin N Am 94(1):131–153PubMedCrossRef

46.

Jannasch O, Tautenhahn J, Lippert H, Meyer F (2011) Temporary abdominal closure and early and late pathophysiological consequences of treating an open abdomen. Zentralbl Chir 136(6):575–584PubMedCrossRef

47.

Tukiainen E, Leppäniemi A (2011) Reconstruction of extensive abdominal wall defects with microvascular tensor fasciae latae flap. Br J Surg 98(6):880–884PubMedCrossRef

48.

Koss W, Ho HC, Yu M et al (2009) Preventing loss of domain: a management strategy for closure of the “open abdomen” during the initial hospitalization. J Surg Educ 66(2):89–95PubMedCrossRef

49.

Nagy KK, Fildes JJ, Mahr C et al (1996) Experience with three prosthetic materials in temporary abdominal wall closure. Am Surg 62(5):331–335PubMed

50.

Garner GB, Ware DN, Cocanour CS et al (2001) Vacuum-assisted wound closure provides early fascial reapproximation in trauma patients with open abdomens. Am J Surg 182(6):630–638PubMedCrossRef

51.

Ramirez OM, Ruas E, Dellon AL (1990) “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 86(3):519–526PubMedCrossRef

52.

Ferguson EJ, Oswanski MF, Stombaugh HA, Daniels RG (2011) Early definitive closure of abdomen using components separation technique after damage control surgery. Am Surg 77(4):E74–E75PubMed

53.

Roberts DJ, Zygun DA, Grendar J et al (2012) Negative-pressure wound therapy for critically ill adults with open abdominal wounds: a systematic review. J Trauma Acute Care Surg 73(3):629–639PubMedCrossRef

Title: Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction
Authors: A. Willms
C. Güsgen
S. Schaaf
D. Bieler
M. von Websky
R. Schwab
Publication date: 01-01-2015
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 1/2015
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-014-1240-4

At a glance: The STEP trials

Springer Medicine

Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2015

Surgical revision of hepaticojejunostomy strictures after pancreatectomy

Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre

Predictors of early stages of histological progression of branch duct IPMN

Predictive factors for survival and recurrence rate in patients with node-negative gastric cancer—a European single-centre experience

Subcutaneous application of gentamicin collagen implants as prophylaxis of surgical site infections in laparoscopic colorectal surgery: a randomized, double-blinded, three-arm trial

Surgery for common bile duct stones—a lost surgical skill; still worthwhile in the minimally invasive century?