Overview on Temporary Abdominal Closure Techniques: A Review

Open abdomen (OA) is becoming more common, primarily to prevent intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) following emergency abdominal surgery. The purpose of temporary abdominal closure (TAC) techniques is no longer just abdomen coverage; fluid regulation and early fascial closure are now important considerations. TAC techniques for leaving the abdomen open are numerous. The ideal one should be simple to apply and remove, allow for quick access to a surgical second opinion, drain secretions, ease primary closure with acceptable morbidity and mortality, allow for easy nursing, and, finally, be readily available and inexpensive. Over the years, several TAC methods have been proposed. In this review, we overview different techniques for temporary abdominal closure and its advantages and disadvantages.

The open abdomen

This chapter introduces the concept of the open abdomen and describes the various aetiologies of this complex condition, including the rationale for elective laparostomy in damage control surgery and as a treatment for abdominal compartment syndrome. The significance of the open abdomen is described in terms of its local and systemic complications, which form the basis of the established classification. Important considerations in the acute systemic management of patients with this condition are outlined, and methods of temporary abdominal closure are described. Advantages and disadvantages of these alternatives, including the use of negative-pressure wound therapy, are discussed.

Application of pie-crusting technique to facilitate closure of open abdomen after decompressive laparotomy

We present the case of a 23-year-old man who developed abdominal compartment syndrome secondary to severe pancreatitis and required decompressive laparotomy and pancreatic necrosectomy. Despite application of a temporary abdominal closure system (ABThera Open Abdomen Negative Pressure Therapy), extensive retroperitoneal oedema and inflammation continued to contribute to loss of domain and prevented primary closure of the skin and fascia. The usual course of action would have involved reapplication of ABThera system until primary closure could be achieved or sufficient granulation tissue permitted split-thickness skin grafting. Though a safe option for abdominal closure, application of a skin graft would delay return to baseline functional status and require eventual graft excision with abdominal wall reconstruction for this active labourer. Thus, we achieved primary closure of the skin through the novel application of abdominal wall ‘pie-crusting’, or tension-releasing multiple skin incisions, technique.

DEVELOPMENT OF OPEN ABDOMEN DEVICE BASED ON BIODESIGN METHODOLOGY

Open Abdomen (OA) therapy, is purposely leaving the fascial edges of the abdomen un-approximated after a laparotomy. During the OA therapy, there must be a temporary abdominal closure (TAC) device installed in the patient to achieve abdominal closure gradually without affecting its safety. However, the actual TAC devices have some gaps in terms of functionality or usability, therefore a new device is proposed. Intending to design a usable and functional technique for patients all over the world, the BioDesign Innovation Process was used. This iterative methodology focuses on healthcare needs, invention, and concept development with three main phases: Identify, Invent and Implement. At the end of these phases, the team successfully developed two new abdominal closure techniques that fill in the gaps of functionality and usability, using a simulator that realistically mimicked the physical and mechanical properties of an open abdomen. In terms of functionality, the novel techniques showed safe installation, operational security, secure grip, low invasiveness and control of intra-abdominal pressure. In terms of usability, the devices showed better results in efficiency, effectiveness and easy re-exploration than the control group.

Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis?

AIM: To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS: We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS: The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION: NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer’s instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.

Vacuum-Assisted Abdominal Closure in Surgical Emergency: A Single Institution Experience Treating a Cohort with a Prevalence of Faecal Peritonitis

Vacuum-assisted abdominal closure (VAAC) has evolved as a promising method for treatment of emergent surgical patients. The aim of the study was an assessment of the complication rate and outcomes following routine application of VAAC in a cohort of patients suffering predominantly with peritonitis of the lower gastrointestinal tract (GIT) origin. The prospectively collected data was analysed retrospectively, including demographic data, aetiological factors, comorbid conditions and severity of the disease. The indications for VAAC included complicated intra-abdominal infection, purulent peritonitis with sepsis and/or risk of increased intra-abdominal pressure. In total, 130 patients were managed with VAAC. The median age was 63.5 years, with a predominance of male patients (61.5%). Systemic inflammatory response was present in 68.5%, the median C-reactive protein (CRP) was 239.58 mg/l, Procalcitonin (PCT) level 7.02 ng/ml, and lactate 1.84 mmol/l before intervention. The median Sequential Organ Failure Assessment (SOFA) score was 4 and the Mannheim Peritonitis Index was 26. Sepsis developed in 87.0% of patients, and 43.8% had septic shock. VAAC was applied in 58.5% due to a perforation of the lower GIT, in 26.1% due to perforation of the upper GIT, and in 15.4% for other reasons. A median of two (interquartile range, IQR 1–3) VAAC system changes were performed in a period of 7 (IQR 4–11) days. In 88.6% of cases, multiple types of microorganisms were present. The application of VAAC resulted in a significant decrease of the postoperative SOFA score, and CRP, PCT and lactate levels (p < 0.001). The complications included a “frozen abdomen”, enterocutaneous fistula, intraabdominal abscess and bleeding in 7.7%, 5.4% and 6.0% cases, respectively. Primary abdominal closure was accomplished in 76.2%, resulting in a 23.1% mortality rate. VAAC was found to be safe in the treatment of abdominal sepsis including in patients with faecal peritonitis. Complete abdominal closure can be achieved in the majority of patients resulting in a lower mortality rate.

Standard Urine Collection Bag as an Improvised Bogotá Bag as a Temporary Abdominal Closure Method in an Open Abdomen in Preventing Abdominal Compartment Syndrome

Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.