Negative Pressure Wound Therapy of Open Abdomen and Definitive Closure Techniques After Decompressive Laparotomy

A Single-Center Observational Prospective Study

Mircea Muresan, MD, PhD; Simona Muresan, MD, PhD; Klara Brinzaniuc, MD, PhD; Daniela Sala, MD, PhD; Radu Neagoe, MD, PhD

Disclosures

Wounds. 2018;30(10):310-316. 

In This Article

Materials and Methods

This article contains 2 observational studies, 1 prospective and the other retrospective.

Prospective Study Design

This was a longitudinal, observational prospective study. Prior to approval by the ethics committees of the Clinical Emergency County Hospital of Târgu Mureș (Târgu Mureș, Romania) and the University of Medicine and Pharmacy of Târgu Mureș (Târgu Mureș, Romania), it was registered as study No. 118/22 in January 2016. Informed consent was obtained from each patient; for comatose patients, consent was given by relatives, according to Romanian state legislation.

The study took place between January 2016 and September 2016 and included 19 patients who underwent DL, taken from a total of 66 patients monitored after developing ACS (Figure 1). Inclusion criteria consisted of those with primary and secondary ACS and a lack of response to the specific conservative treatment (in accordance with the WSACS guidelines) within 24 hours. Exclusion criteria included those with ACS with good response to medical treatment as well as those with isolated intra-abdominal pressure (IAP).

Figure 1.

The abdominal diseases that led to the development of abdominal compartment syndrome and required decompressive laparotomy.

Decompressive Laparotomy and Open Abdomen Management

Decompressive laparotomy was performed within the first 24 hours by a midline incision above and below the umbilical orifice, with enough to release the loops and epiploon from the peritoneal cavity. From the start, the subsequent TAC management was dictated using a negative pressure continuous suction system with 2 roles: aspiration of collections and reduction of intra-abdominal tissue edema, thus avoiding musculoaponeurotic retraction of the wound edges and the induction of granulation tissue. To this end, the VivanoMed Abdominal Kit (HARTMANN, Heidenheim an der Brenz, Germany) was used; the entire system assembly consisted of the VivanoTec Unit (HARTMANN) and consumables. The single-use abdominal kit contains mesh to protect the viscera with a 65-cm diameter fitted with superior pockets to facilitate insertion, 2 polyurethane foam dressings of 38 cm × 25 cm × 1.6 cm, 1 suction port, and hydrofilm strips for sealing.

Immediately after DL, the intestines and epiploon were protected by inserting the mesh from the kit described above into the upper interhepatophrenic spaces, laterally into the flaps towards the right and left parietocolic grooves, and into the posterior plane behind the urinary bladder. On top of the mesh, polyurethane foam was mounted in 2 or 3 layers by adjusting the dimensions of the dressings to the incision. After installing sealing strips over the entire wound without creating tension, the suction port connected to the collection tank was secured. The device was originally set to a gentle pressure of -105 mm Hg in order to avoid possible intra-abdominal bleeding or bleeding at the wound edges. The dressings were changed every 2 to 3 days using the abdominal kit if the patient's condition was critical with maintained ACS.

After a third change of the abdominal kit, due to the appearance of the granulation tissue covering the omentum, bowels, and wound margins, the pressure was reduced to -135 mm Hg (as per manufacturer's recommendation) and the process continued in the same manner until final closure.

Subsequently, given favorable developments, the reconstruction of the abdominal wall was performed by primary myofascial closure or using a substitute dual mesh (polyester and dimethyl siloxane; Intramesh; Cousin Biotech, Wervicq-Sud, France) sutured on the musculoaponeurotic edges with Prolene 3.0 (Ethicon Inc, a Johnson & Johnson company, Bridgewater, NJ) continuous threads secured via 10 separate suture points (Figure 2).

Figure 2.

Intraoperative aspect of negative pressure wound therapy (NPWT): (A) decompressive laparotomy with bowel protecting temporary mesh; (B) foam adapted to the wound dimensions; (C) wound post NPWT and foam application; (D) granulated tissue after 10 days; (E) polyester dual mesh; and (F) final aspect after skin closure.

From the ACS diagnosis up to the final closure, the IAP was monitored by an indirect transvesical measurement using a dedicated kit (AbViser AutoValve Intra-Abdominal Pressure Monitoring Device 331; ConvaTec, Bridgewater, NJ). All procedures (temporary closure, the initiation of NPWT, dressing changes, and definitive closures) were performed in the operating room.

In all cases, after a proper lateral mobilization of the skin, the definitive closure required no skin grafts. In 1 case, following the appearance of a small area of skin necrosis, excision and secondary suture were necessary.

Patient follow-up took place during the 6 months after discharge, and, in months 1, 3, and 6, included clinical and imaging checks (use both the abdominal cavity and wall ultrasound and computed tomography scan) for intra-abdominal collections and the integrity of the abdominal wall.

Retrospective Observational Study Design

In order to increase the impact of the study, the investigators performed a simultaneous retrospective study by collecting data from patients who had undergone open abdomen management before the introduction of NPWT. Therefore, 21 files from the previous 2 years were analyzed in relation to patients who had been admitted to the same clinic and who required open abdomen for the same primary diseases: peritonitis caused by enteral fistulas (8 cases), infected necrotizing pancreatitis (10 cases), trauma (2 cases), and frozen abdomen (1 case). The TAC was performed using plastic film over the open abdomen.

Wound care was performed in the operating room, with 11 patients receiving intravenous anesthesia and 10 patients receiving local lidocaine wound instillation. Primary suture was possible in the 2 cases with abdominal suture without meshes after abdominal trauma. In 5 cases (2 cases of enteral fistula and 3 cases of acute pancreatitis), definitive closure was performed using substitutive polipropilene mesh over the great omentum and attached to the muscular wound margins. Due to wound edge lateral retraction and continuous wound secretions, it was impossible to achieve the definitive abdominal closure in 6 cases (3 enteral fistulas and 3 acute pancreatitis) using just the skin flaps; those patients developed a conducted incisional hernia. Local wound complications were encountered in 16 of the 21 patients (76.19%), with a mortality rate of 47.61%.

All statistical calculations were performed using GraphPad software (GraphPad; San Diego, CA). The investigators tested the normal distribution for a continuous variable using the Kolmogorov-Smirnov test. They characterized the distributions using the mean and standard deviation (SD) for variables with a normal distribution, or the median and range for variables with a non-normal distribution. According to data distribution, adequate statistical tests were chosen. Differences in mean age by gender were determined using Student's t test. The statistical analyses of IAP, mortality, and DL results were performed using the analysis of variance (associated with the Bonferroni multiple comparison test).

In a box-and-whisker plot, the central box represents the values from the lower to the upper quartile (25th to 75th percentile); the middle line represents the median. A line extends from the minimum to the maximum value. All tests were interpreted relative to the significance threshold of P = .05, and the results were considered to be statistically significant for P < .05.

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