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Modern Management of the Open

Abdomen
“A Cautionary Tale”
Grand Rounds
December 16, 2010
SUNY, Downstate
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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.
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Imaging
• CT: L2 transverse process fracture; left
perinephric stranding.
• CT Angio: expanding hematoma; free blood
around liver and spleen.
• Aortography: no active bleeding
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CT
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CT
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Hospital Course
• 10/3 – Initial exploration
• 10/12 – IVC filter placement
• 10/14 – Tracheostomy
• 10/23 – IR Coil
• 11/18 – STSG
• 12/13 – Discharge
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Patient
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Patient
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Pathways to Open Abdomen

Compartment
Syndrome
Septic Necrotizing
Dehiscence fascitis

Unresolved
Damage
Open Intra-
Control
/ Trauma Abdomen abdominal
Processes
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Surgical Issues
• Fluid losses
• Logistical burden
• Fistula formation
• Infection
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Ideal Barrier Characteristics
• Contain and protect viscera
• Atraumatic
• Simple
• Easy application
• Inexpensive
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Temporary Closure Technique
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Temporary Closure Technique
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Temporary Closure Technique
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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
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Planned Ventral Hernia
Stage I
• 14-21
Prosthetic
days
insertion

Stage II
Prosthetic • 2 days
removal

Stage III
• 6-12
Planned
Months
ventral hernia

Stage IV
Definitive
reconstruction
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Planned Ventral Hernia
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Planned Ventral Hernia
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Component Separation
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Component Separation
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Component Separation
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Mesh
• Absorbable
– Inexpensive
– Decreased incidence of infection
– Decreased incidence of fistula formation
• Biologic
– Immunologically inert
– Suitable for infected wounds
– One stage closure
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Preservation of Peritoneal Space
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Preservation of Peritoneal Space
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Preservation of Peritoneal Space
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Convergence of 3 Concepts

Physiology of Open
Abdomen

Negative
Pressure Wound
Therapy

Fluid Progressive
Management/Logistics Wound Closure
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Negative Pressure Wound Therapy
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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%
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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.
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FDA Public Health Notification
• “Serious Complications Associated with
Negative Pressure Wound Therapy Systems”
• Date: November 13, 2009
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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
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Take-aways
• Consideration of the open abdomen as a
healing wound
• Evolution of open abdominal wound closure
• Risks and benefits associated with NPWT
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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.