A method for primary closure of large contaminated abdominal wall defects

Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications

The acute replacement of full-thickness abdominal wall has been facilitated by polypropylene mesh (Marlex) (PPM), allowing debridement of nonviable tissue and restoration of abdominal wall integrity without tension. However, no substantial long-term follow-up has been reported on the definitive wound coverage after the use of PPM in open wounds. Since 1976, we have placed PPM in 31 patients; 25 for infectious complication, three for massive bowel distension preventing abdominal closure, and three for shotgun wounds with extensive tissue loss. In 29 of 31 patients, the mesh was placed in heavily contaminated wounds; extensive fasciitis was present in 23 patients and 21 had intra-abdominal abscesses. Following mesh placement, 23 reoperations were required for continuing complications. No patients eviscerated, despite these multiple procedures. Polypropylene mesh was highly effective in restoring abdominal wall continuity. Despite advantages when PPM was used, significant long-term problems developed. Seven patients died from their primary illness in the postoperative period. Nine wounds were closed by granulation and subsequent split-thickness skin grafts. All nine developed mesh extrusion and/or enteric fistulae. Nine wounds healed by secondary intention, six developed enteric fistulae or continuing mesh extrusion. Full-thickness flap coverage after granulation provided the best means of wound closure. Polypropylene mesh had significant early advantages for providing abdominal wall integrity even in the presence of severe infection. However, long-term problems were common when wounds were closed to skin grafts or secondary intention. If the mesh cannot be completely removed, strong consideration should be given to myocutaneous flaps for coverage after the primary illness has resolved.

Management of acute full-thickness losses of the abdominal wall

Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.