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

Discussion

Open abdomen indications are diverse, and many are related to traumatic injuries (Table 3 [12–14]). Decompressive laparotomy is of particular importance in ACS, reducing the mortality caused by the disease by between 16% and 37%.[8–11]

Various solutions for open abdomen have developed along with the evolution of this new therapeutic concept of TAC. Among the many surgical variants for TAC, only a few have been incorporated into standard medical practice.[6] The simplest and cheapest is merely closing the skin over the viscera using clip clamps, allowing quick and easy access to the peritoneal cavity whenever needed. The disadvantages of this process are that the affronted skin may cause pressure on the gutted organs, and it does not prevent lateral musculoaponeurotic retraction.[15] The Bogota method, or plastic-bag closure, consists of covering the intestinal loops in a plastic film made on the spot, depending on the size of the wound, from saline-solution bags or urine-collection bags. These are fixed by both the musculoaponeurotic edges and the skin.[16] The Wittmann technique consists of mounting 2 overlapping sheets of Velcro (London, UK), sutured on the musculoaponeurotic edges, on both sides. After each inspection of the abdominal cavity, the position of the foils will be readapted to return them towards the midline of the aponeurotic edges.[17] The method of wound aspiration by creating negative pressure has been proven to have the best results,[12] accomplishing several of the goals of TAC management: suctioning secretions, isolating the wound, and musculoaponeurotic closure with wound orientation towards myofascial primary closure. After the procedure performed by Brock et al in 1995, the development of dedicated NPWT kits was initiated.[18,19] The TAC approach using NPWT technique also has been in the WSACS recommendation since the 2013 consensus.[1] Nowadays, it has a 1B grade indication for open abdomen management.[14] In the cases presented herein, the chosen solution was a negative pressure continuous suction system (eFigure 4).

eFigure 4.

Abdominal kit and the negative pressure unit device.

Initially appearing as a separate method, the use of meshes to prevent lateral retraction was subsequently combined with NPWT techniques, eg, polydioxanone mesh plus NPWT,[20] polypropylene plus NPWT,[21] or the ABRA Abdominal (Southmedic, Barrie, Ontario, Canada) system, the combination of transfascial elastomeric fibers tensed with buttons placed on the skin, with NPWT.[22] All these techniques have significantly increased the percentage of late myofascial closure by up to 100%, according to research.[23]

The final closure of the abdominal wall should be done without tension. Depending on the TAC technique used, primary fascial closure varies. In this reported study, it could be carried out in 4 of the 19 cases. Closure without tension can be achieved using meshes.[24] If visceral protection with epiploon can be performed, or if the granulation tissue is sufficiently well developed after NPWT, polypropylene meshes can be used.[25] Safe alternatives are dual meshes made from polypropylene, polyester, or expanded polytetrafluoroethylene, which can be sutured to the aponeurotic edges and applied safely over the viscera.[26] Biological materials offer a possible solution, but they are laborious and can give rise to postoperative complications due to graft necrosis (Table 3[12–14]).[27,28] Modern cross-linked and noncross-linked meshes manufactured in the laboratory are currently very expensive, thus, they should only be used in reserved cases.[29] In the present study, the investigators had very good results with fewer complications using polyester-dimethyl siloxane dual mesh.

After introducing the concept of open abdomen management in 2009, Björck and Wanhainen presented a classification system, later revised in 2013, that takes into consideration the origin of the open abdomen and the therapeutic attitude (Table 4,[6,30–33]Table 5[34]). The application of this classification in the investigators' study could be correlated with the patients' prognosis, local complications, and mortality rate.

The open abdomen in ACS is a particular entity, as both the pathophysiological cascade of ACS and the disease that caused it must be treated, even if it seems a desperate and difficult solution to manage later, both in terms of the temporary and the permanent closure. Decompressive laparotomy is today part of the ACS treatment algorithm established by WSACS.[1] As conservative treatment shows good results in a proportion of patients developing ACS, DL is rarely performed. Cheatham and Safcsak[35] conducted a study on 265 patients with ACS, in which only 31 patients needed DL.

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