The zipper-mesh method for treating delayed generalized peritonitis

The role of open abdomen in non-trauma patient: WSES Consensus Paper

The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients

BACKGROUND

Several challenging clinical situations in patients with peritonitis can result in an open abdomen (OA) and subsequent temporary abdominal closure (TAC). Indications and treatment choices differ among surgeons. The risk of fistula development and the possibility to achieve delayed fascial closure differ between techniques. The aim of this study was to review the literature on the OA and TAC in peritonitis patients, to analyze indications and to assess delayed fascial closure, enteroatmospheric fistula and mortality rate, overall and per TAC technique.

METHODS

Electronic databases were searched for studies describing the OA in patients of whom 50% or more had peritonitis of a non-traumatic origin.

RESULTS

The search identified 74 studies describing 78 patient series, comprising 4,358 patients of which 3,461 (79%) had peritonitis. The overall quality of the included studies was low and the indications for open abdominal management differed considerably. Negative pressure wound therapy (NPWT) was the most frequent described TAC technique (38 of 78 series). The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction (6 series, 463 patients: 73.1%, 95% confidence interval 63.3-81.0%) and dynamic retention sutures (5 series, 77 patients: 73.6%, 51.1-88.1%). Weighted rates of fistula varied from 5.7% after NPWT with fascial traction (2.2-14.1%), 14.6% (12.1-17.6%) for NPWT only, and 17.2% after mesh inlay (17.2-29.5%).

CONCLUSION

Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.

Temporary abdominal closure with zipper-mesh device for management of intra-abdominal sepsis

OBJECTIVE: to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

Strategies for modulating the inflammatory response after decompression from abdominal compartment syndrome

BACKGROUND

Management of the open abdomen is an increasingly common part of surgical practice. The purpose of this review is to examine the scientific background for the use of temporary abdominal closure (TAC) in the open abdomen as a way to modulate the local and systemic inflammatory response, with an emphasis on decompression after abdominal compartment syndrome (ACS).

METHODS

A review of the relevant English language literature was conducted. Priority was placed on articles published within the last 5 years.

RESULTS/CONCLUSION

Recent data from our group and others have begun to lay the foundation for the concept of TAC as a method to modulate the local and/or systemic inflammatory response in patients with an open abdomen resulting from ACS.

Critical care issues in managing complex open abdominal wound

Over the past 30 years, surgical specialties have introduced and expanded the role of open abdominal management in complicated operative cases, necessitating an intensivist's understanding of the indications and unique intensive care unit (ICU) issues related to the open abdomen. When presented with the open abdomen, resuscitation to correct shock is of primary concern. This is accomplished by correction of hypothermia, acidosis, and coagulopathy in trauma and adequate resolution of intra-abdominal hypertension or source control in general surgery. These patients typically require deep sedation and often paralysis and benefit from low-volume ventilatory strategies to prevent and treat acute lung injury. Antibiotics must be tailored to the clinical situation, but in most cases, 24 hours of perioperative treatment is all that is required. In cases of gross contamination and peritonitis, a 5- to 7-day course of broad-spectrum antibiotics may be of benefit.Adequate source control has been demonstrated to have the greatest impact on outcome and when the patient's clinical milieu dictates, bedside washouts. Enteral nutrition should be instituted as early as possible after intestinal continuity has been reestablished. Additional protein is required to account for losses from the open abdomen. Reconstruction may require staging, but in general, should proceed following resolution of shock and control of sepsis. Elevated multiorgan dysfunction score, Acute Physiology And Chronic Health Evaluation II (APACHE II), and a rise in peak inspiratory pressure portend poor source control and could result in failure of fascial closure. If unable to proceed to fascial closure, then considerations should be made for planned ventral hernia and subsequent abdominal wall reconstruction.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control

BACKGROUND

The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the world's literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen.

METHODS

A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence.

RESULTS

There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy.

CONCLUSION

The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Palisade dorsoventral lavage for neglected peritonitis

A modification of the procedure of laparostomy with palisade dorsoventral lavage for treating neglected peritonitis is described. It consists of adding a polyethylene foil to cover the intestines and thus avoiding the direct contact between them from one side, and the suction drains and the palisade laparostomy screen from the other. Between 1988 and 1995, 19 patients with neglected peritonitis (APACHE II scores from 12 to 42; mean 22.3) were managed using this modified technique. A total of 81 reexplorations were done (average, 4.3 reexplorations per patient). The technique proved effective (21% mortality, n = 4). No intestinal perforations, fistulas, or residual pus collections occurred among survivors or among those who died. Primary fascial closure was achieved in all survivors and during an 18-months followup, no incisional hernia occurred. Based on these results, we believe this technique is extremely useful when both laparostomy and continuous peritoneal irrigations are considered in patients with neglected peritonitis.