delayed closure of the open abdomen · septic dehiscence compartment ... temporary closure...

Modern Management of the Open Abdomen

“A Cautionary Tale”Grand Rounds

December 16, 2010

SUNY, Downstate

downstatesurgery.org

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.


Imaging

• CT: L2 transverse process fracture; left perinephric stranding.

• CT Angio: expanding hematoma; free blood around liver and spleen.

• Aortography: no active bleeding


CTdownstatesurgery.org

Hospital Course

• 10/3 – Initial exploration

• 10/12 – IVC filter placement

• 10/14 – Tracheostomy

• 10/23 – IR Coil

• 11/18 – STSG

• 12/13 – Discharge


Presenter

Presentation Notes

ARDS Pneumonia ARI Hypertension

Patientdownstatesurgery.org

Pathways to Open Abdomen

Open Abdomen

Damage Control

/ Trauma

Septic Dehiscence

Compartment Syndrome

Necrotizing fascitis

Unresolved Intra-

abdominal Processes


Presenter

Presentation Notes

Second look

Surgical Issues

• Fluid losses

• Logistical burden

• Fistula formation

• Infection


Ideal Barrier Characteristics

• Contain and protect viscera

• Atraumatic

• Simple

• Easy application

• Inexpensive


Temporary Closure Techniquedownstatesurgery.org

Presenter

Presentation Notes

Gauze packing


Presenter

Presentation Notes

Towel clips


Presenter

Presentation Notes

Bogata bag

Open Abdomen as a Healing Wound

• Primary intention– Fascial reapproximation without tension

• Secondary intention– “Frozen abdomen”

– Loss of peritoneal space 10-14 days

• Delayed primary closure– Accommodate the conditions for closure by

secondary intention


Planned Ventral Hernia

Stage IProsthetic insertion

• 14-21 days

Stage IIProsthetic removal

• 2 days

Stage IIIPlanned

ventral hernia

• 6-12 Months

Stage IVDefinitive

reconstruction


Planned Ventral Herniadownstatesurgery.org

Component Separationdownstatesurgery.org

Presenter

Presentation Notes

Separation of Subcutaneous fat from external oblique and rectus Deconstruction of Rectus Sheath Relaxing incisions lateral to rectus

Component Separationdownstatesurgery.org

Mesh

• Absorbable– Inexpensive

– Decreased incidence of infection

– Decreased incidence of fistula formation

• Biologic– Immunologically inert

– Suitable for infected wounds

– One stage closure


Presenter

Presentation Notes

Alloderm – acellular human dermis Permacol

Preservation of Peritoneal Spacedownstatesurgery.org

Convergence of 3 Concepts

Negative Pressure Wound

Therapy

Physiology of Open Abdomen

Progressive Wound Closure

Fluid Management/Logistics


Negative Pressure Wound Therapydownstatesurgery.org

Negative Pressure Wound Therapy

• Garner, et. al., 2001 – 13/14, 92%

• Miller, et. al., 2002 – 59/83, 71%

• Stonebrook, et. al., 2003 – 10/15, 67%

• Sulibrook, et. al., 2003 – 25/29, 86%


Adverse Outcomes

• Rao M, et. al. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9(3):266-268.

• 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.


FDA Public Health Notification

• “Serious Complications Associated with Negative Pressure Wound Therapy Systems”

• Date: November 13, 2009


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


Presenter

Presentation Notes

patients at high risk for bleeding and hemorrhage patients on anticoagulants or platelet aggregation inhibitors patients requiring: MRI Hyperbaric chamber Defibrillation patient size and weight use near vagus nerve (bradycardia) circumferential dressing application mode of therapy- intermittent versus continuous negative pressure patients with: friable vessels and infected blood vessels vascular anastomosis infected wounds osteomyelitis exposed organs, vessels, nerves, tendon, and ligaments sharp edges in the wound (i.e. bone fragments) spinal cord injury (stimulation of sympathetic nervous system) enteric fistulas

Take-aways

• Consideration of the open abdomen as a healing wound

• Evolution of open abdominal wound closure

• Risks and benefits associated with NPWT


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):586-596.

• 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):843-849.

• Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg. 1994;219(6):643-653.

• 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):89-95.

• 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):731-738; 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):266-268.

• 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):201-206; discussion 206-207

• 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.


delayed closure of the open abdomen · septic dehiscence compartment ... temporary closure...

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