Working Towards Delayed Primary Closure.

Once the decision is made to leave an abdominal wound open, in addition to all the other
clinical challenges that require addressing, one goal should remain in the forefront of the
clinicians thinking and that is ultimate closure. It is essential that there is regular evaluation
and re-evaluation of the abdominal contents and the wound environment to ultimately
facilitate primary fascial closure or functional abdominal closure.

Many patients will progress to sutured primary fascial closure without difficulty. There will
however be many patients who end up with more complex wounds including wide fascial
defects with lateralisation of the muscle wall and loss of tissue domain or associated with
enteric fistulae. By definition these latter wounds are contaminated and therefore use of
mesh to assist closure can be fraught with potential septic complications.

In this complex group many clinicians will opt for a staged approach to abdominal wall
reconstruction. This involves a combination of component separation and fascial closure (or
at least partial closure) with the addition of an absorbable mesh either as an onlay or ‘bridge’.
The trade off with this approach is avoiding infection in a permanent mesh set against the
almost inevitable ventral herniation at a later date. The patient will then often require another
major operation to close the hernia with permanent mesh at a later date. Clearly re-operating
on these patients is difficult and again fraught with the danger of significant complication
including of course further intestinal fistulation.

To date there has been no alternative to this staged approach. That is until the arrival of a
regenerative biological mesh STRATTICE. This mesh has been designed or processed in a way
that it has lost its antigenicity but retains the ability to support revascularisation and cellular
repopulation along with white cell migration. This allows it to be used in the presence of local
contamination such as that found in these complex open wounds. 

Banwell, P.E., Téot, L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Wound Care 2003;12:1, 22-28.

Sugrue M, D’Amours SK, Joshipura M. Damage control surgery and the abdomen. Int J Care Injured 2004; 35; 642-48.

Swan MC, Banwell PE. The open abdomen: aetiology, classification and current
management strategies. J Wound Care 2005;14:7-11.

World Society of The Abdominal Compartment Syndrome (WSACS). Part 1. Defintions.Results from the international
conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. Intensive Care Med 2006; 32(11):1722-1732.

World Society of The Abdominal Compartment Syndrome (WSACS). Part 2. Recommendations. Results from the
international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. Intensive Care Med 2007; 33(6): 951-62.

Requirements Of An Optimal Device For Temporary Abdominal Closure

Temporary abdominal closure (TAC) has been demonstrated to be an effective method for the
prevention of intra-abdominal hypertension (IAH) and treatment of abdominal compartment
syndrome (ACS). A variety of TAC devices have been described including plastic silos (the
so-called “Bogota bag”), prosthetic meshes, Velcro™ burrs (the Wittmann™ patch), the
home-made “vacuum-pack” dressing, the KCI vacuum-assisted closure (V.A.C.) Abdominal
Dressing, and the recently introduced ABThera Open Abdomen Dressing. The optimal
requirements for a TAC device include: 1) abdominal content control, 2) active removal and
quantification of peritoneal fluid / exudate, 3) prevention of visceral adherence, 4) prevention
of fascial retraction, 5) infection control, 6) inflammatory response reduction, 7) enteric fistula
prevention / control, and 8) facilitation of functional abdominal closure. Each of the devices
listed above possesses a variable ability to modulate these characteristics.

TAC represents an important tool in what may be termed “active total abdominal
management”, which emphasizes the goals of decreased intra-abdominal pressure, active
removal of pro-inflammatory cytokines, decreased organ dysfunction and failure, decreased
fistulization, and increased same-admission definitive abdominal closure. This comprehensive
open abdomen management strategy is associated with improved patient survival, reduced
length of stay, and increased definitive abdominal closure among patients who require an
open abdomen. Such a management strategy, however, must begin at the time of initial
decompression to fully realize these benefits.

Development of a Comprehensive Guideline To Improve Outcomes In High-Risk Trauma Patients With Open Abdomens

^{Kaplan, M., Md, Liebman, J, Md, Wheel, K Md, Bones, K, Rn, Hooper, A, Rn, Servas, P, Rn, And Simms, H Md}

Objective: To evaluate a comprehensive multidisciplinary guideline developed to standardize the management of patents with an open abdomen (OA) to improve outcomes.

Methods: Retrospective study on the effectiveness a guideline that was developed at a Level I trauma center to standardize the management trauma patents with OA. Guideline development included: re-definition of the indications for an OA, fluid and blood transfusion guidelines, revised damage control guidelines, expanded use of advanced closure techniques, and expanded use of Vacuum Assisted Closure (VAC). Consensus panel recommendations from two panels were used as well as the definitions of ACS from the WSACS.Two cohorts were evaluated pre and post guideline implementation: Group I (PGL) pre-guideline from 2001-2004; Group II (GL) guideline implementation 2004-2008. Groups were compared for rates of mortality, closure, fistula, multiple organ dysfunction syndrome, intra-abdominal hypertension (IAH), and abdominal compartment syndrome (ACS).

Results: In the study period 456 trauma patents required laparotomy; 27 of 221 laparotomies (12.7%) were in PGL with and of the 236 laparotomies in GL 57 (24.1%) were opened post procedure. Indications to keep the abdomen open were meet in 85% of PGL and 100% in GLgroup. Average ISS was 27 in PGL compared to 24.4 in GL. Closure rates were 70% in PGL with a mean closure time of 23 days and 94% in GL with mean closure time of 6.4 days. Mean IAH for PGL was 29mmHg compared to 16 mmHg in GL (p<. 05). GL group had no reported incidences of ACS compared PGL with 12 patients (45%). PGL had 7 patients (50%) with fistulas compared to 2 (4%) in GL. PGL had VAC therapy in 20% and GL had VAC therapy 100%. There was a 50% incidence of organ failure in the PGL group compared to 4% in GL group. Mortality rates were decreased from 27% in PGL to 17% in GL group (p> .05).

Conclusion: The development of a comprehensive guideline based on established physiologic and contemporary concepts known will enhance and improve the management of trauma patients with an OA improved. Guidelines implementation is effective and had a significant impact in decreasing complications with improved closure rates and decrease in significant complications associated with an open abdomen. Mortality rates decreased but did not meet statistical significance.

Rationale for consensus on clinical guidelines. Classification, an important step to improve the management of patients with an open abdomen.

The patient may reach the situation of needing to be treated with an open abdomen (OA)
through different clinical pathways:
1) The septic contaminated abdomen that cannot be closed for infectious reasons and/or
where a second-look laparotomy is mandatory;
2) The patient with a tense abdomen after massive resuscitation or a prolonged major
surgical procedure, who is at risk of developing ACS;
3) A ‘damage control’ situation where the patient remains inadequately resuscitated and
who needs a period of intensive care therapy prior to a definitive surgical procedure;
4) The patient with primary or secondary ACS, who needs a life-saving decompressive
laparotomy.

A consensus group with experts in the field of treating patients with OA met twice in
Amsterdam, 2007 and 2009. We concluded that a classification system for patients with OA
could be an important step forward allowing:
1) A description of the patient’s clinical course;
2) Standardised clinical guidelines improving OA management; 3) Improved reporting of OA
status, facilitating comparisons between studies and heterogeneous patient populations. The
following grading is suggested:
Grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of
the abdominal wall (lateralisation); Grade 1B, contaminated OA without adherence/fixity;
Grade 2A, clean OA developing adherence/fixity; Grade 2B, contaminated OA developing
adherence/fixity; Grade 3, OA complicated by fistula formation; Grade 4, frozen OA with
adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this
classification system will facilitate communication, clarify OA management, and potentially
improve patient care.