Abdomen Pak

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Modern Management of the Open

Abdomen

“A Cautionary Tale”

Grand Rounds

December 16, 2010SUNY, Downstate

downstatesurgery.org



Case

• HPI: 41 yo M BIBA; stabbed in left back while

walking out of a shopping center.

• PMH/PSH: GSW to head.

• PE revealed 1-2 cm deep left paraspinal stab

wound ~2 cm in length.




Imaging

• CT: L2 transverse process fracture; left

perinephric stranding.

• CT Angio: expanding hematoma; free blood

around liver and spleen.

• Aortography: no active bleeding




CTdownstatesurgery.org



Hospital Course

• 10/3 – Initial exploration

• 10/12 – IVC filter placement

•

10/14 – Tracheostomy• 10/23 – IR Coil

• 11/18 – STSG

• 12/13 – Discharge




Patient




Patientdownstatesurgery.org



Pathways to Open Abdomen

OpenAbdomen

DamageControl

/ Trauma

Septic

Dehiscence

CompartmentSyndrome

Necrotizing

fascitis

UnresolvedIntra-

abdominalProcesses




Surgical Issues

• Fluid losses

• Logistical burden

•

Fistula formation• Infection




Ideal Barrier Characteristics

• Contain and protect viscera

• Atraumatic

•

Simple• Easy application

• Inexpensive




Temporary Closure Techniquedownstatesurgery.org

d




d t t



Open Abdomen as a Healing Wound

• Primary intention

– Fascial reapproximation without tension

• Secondary intention

– “Frozen abdomen”

– Loss of peritoneal space 10-14 days

• Delayed primary closure

– Accommodate the conditions for closure by

secondary intention


d t t



Planned Ventral Hernia

Stage IProstheticinsertion

• 14-21days

Stage II

Prostheticremoval

• 2 days

Stage IIIPlanned

ventral hernia

• 6-12Months

Stage IVDefinitive

reconstruction


d t t



Planned Ventral Herniadownstatesurgery.org

d t t



Component Separationdownstatesurgery.org

d t t




d t t



Mesh

• Absorbable

– Inexpensive

– Decreased incidence of infection

– Decreased incidence of fistula formation

• Biologic

– Immunologically inert

– Suitable for infected wounds

– One stage closure


do nstates rger org



Preservation of Peritoneal Spacedownstatesurgery.org

downstatesurgery org



Convergence of 3 Concepts

NegativePressure Wound

Therapy

Physiology of OpenAbdomen

ProgressiveWound Closure

FluidManagement/Logistics





Negative Pressure Wound Therapydownstatesurgery.org




Negative Pressure Wound Therapy

• Garner, et. al., 2001 – 13/14, 92%

• Miller, et. al., 2002 – 59/83, 71%

•

Stonebrook, et. al., 2003 – 10/15, 67%• Sulibrook, et. al., 2003 – 25/29, 86%





Adverse Outcomes

• Rao M, et. al. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis.2007;9(3):266-268.

• Starr-Marshall K. Vacuum-assisted closure of abdominal

wounds and entero-cutaneous fistulae; the St Marksexperience. Colorectal Dis. 2007;9(6):573.

• Fischer JE. A cautionary note: the use of vacuum-assistedclosure systems in the treatment of gastrointestinalcutaneous fistula may be associated with higher mortality

from subsequent fistula development. The American Journal of Surgery . 2008;196(1):1-2.





FDA Public Health Notification

• “Serious Complications Associated with

Negative Pressure Wound Therapy Systems”

• Date: November 13, 2009





FDA NPWT Contraindications

• necrotic tissue with eschar present

• untreated osteomyelitis

• non-enteric and unexplored fistulas

• malignancy in the wound

• exposed vasculature

• exposed nerves

• exposed anastomotic site

• exposed organs





Take-aways

• Consideration of the open abdomen as a

healing wound

• Evolution of open abdominal wound closure

• Risks and benefits associated with NPWT





References

• Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous

fistula may be associated with higher mortality from subsequent fistula development. The American Journal of Surgery .

2008;196(1):1-2.

• Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP. Complex Abdominal Wall Reconstruction: A Comparison of

Flap and Mesh Closure. Ann Surg. 2000;232(4):586-596.

• Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen: a quiet revolution. Scand J Surg.

2005;94(1):9-14.

• Miller PR, Thompson JT, Faler BJ, Meredith JW, Chang MC. Late fascial closure in lieu of ventral hernia: the next step in open

abdomen management. J Trauma. 2002;53(5):843-849.

• Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann

Surg. 1994;219(6):643-653.

• Koss W, Ho HC, Yu M, et al. Preventing Loss of Domain: A Management Strategy for Closure of the “Open Abdomen” During

the Initial Hospitalization. Journal of Surgical Education. 66(2):89-95.

• Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive

midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast. Reconstr. Surg.

2000;105(2):731-738; quiz 739.

• Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal

Dis. 2007;9(3):266-268.

• Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of temporary abdominal closure: a 7-year experience with

112 patients. J Trauma. 2000;48(2):201-206; discussion 206-207

• Starr-Marshall K. Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae; the St Marks experience.

Colorectal Dis. 2007;9(6):573.

• Sailes FC, Walls J, Guelig D, et al. Ventral Hernia Repairs: 10-Year Single-Institution Review at Thomas Jefferson University

Hospital. Journal of the American College of Surgeons.


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