Optimum Methods for Keeping the Abdomen Open
Purpose of Review
Damage control laparotomy, also known as an “open abdomen,” is a life-saving maneuver frequently used to treat severely injured and emergency general surgery patients.
Several techniques exist to keep the abdomen open; temporary abdominal closure methods have evolved over time from inexpensive, simple techniques to more advanced methods utilizing commercially available products with improving results.
In this review, we describe the techniques of open abdomen management along with their advantages and drawbacks as well as advanced management of patients with open abdomens.
KeywordsOpen abdomen Temporary abdominal closure Damage control laparotomy
Damage control laparotomy (DCL), also known as “open abdomen, OA,” refers to the surgical technique where the abdominal cavity is entered and left open deliberately at the completion of an abdominal exploration . Most commonly described in trauma patients, DCL is a life-saving maneuver in which the surgeon accepts that portions of the procedure will not be completed . This technique ensures hemorrhage and sepsis source control has been obtained to the best of the surgeon’s ability. Once the abdominal domain has been maintained, albeit temporarily, the patient is rapidly transferred to the intensive care unit (ICU) for ongoing resuscitation [3, 4]. Re-exploration and definitive treatment of injuries are usually undertaken within 24–72 h of the index operation.
The use of packing to manage hepatic hemorrhage was originally described by Pringle and Halsted in their respective landmark papers in 1908 and 1913 [5, 6]. Their technique was widely adopted through World War II when primary repair re-emerged as standard of care due to emerging improvements in surgical technique and resources . The late 1970s and early 1980s saw resurgence in the use of DCL [5, 6]. OA in the setting of emergency general surgery (EGS), specifically for acute suppurative peritonitis, was described by Steinberg in 1979 . Following his publication, several reports described management of infected pancreatic necrosis with open abdomen management [9, 10].
Furthermore, in a prospective evaluation to treat liver injuries, Lucas and Ledgerwood reported acceptable outcomes for treating major hepatic injuries using similar techniques . In the modern era, the concept of damage control resuscitation and utilization of open abdomen in trauma was popularized by Rotondo and Moore in the early 1990s [12, 13]. After dissemination of their source control methods coupled with early resuscitation in the ICU, DCL gained widespread acceptance. As a result of this popularity, multiple techniques to facilitate re-exploration have been developed. To this date, there is absence of Level I evidence data about optimal management of patients with open abdomen. This has led to multi-institutional and worldwide collaborations to help us better understand and improve care for this patient population . It is the aim of this chapter to describe the techniques of open abdomen management along with their advantages and drawbacks.
Risks Associated with the Open Abdomen
When the decision is made to abbreviate the procedure and keep the abdomen open, the surgeon must start thinking about timing and method of achieving closure, as there are many risks associated with OA. Fluid loss from open abdomen is estimated to be 1 cc/kg per hour . Each liter removed contains 2 g of protein, leading to a significant nutritional loss in the critically ill patient . Hypothermia is another major complication which may aggravate acidosis and coagulopathy. Coverage of the viscera prevents heat loss due to evaporation and radiation, and is associated with improved outcomes [17, 18]. Loss of domain, which can lead to failure of fascial closure and development of ventral hernia, is another major risk of OA. Failure of primary fascial closure can result in surgical site infection and enterocutaneous fistulae formation, leading to significant morbidity [19, 20, 21].
Several techniques exist to keep the abdomen open. Ideally, these temporary abdominal closure (TAC) techniques should provide several features: (1) rapid access to the peritoneal cavity for re-exploration, (2) tension-free fascial closure to the prevent rise in intra-abdominal pressure, (3) facilitate fascial closure at the appropriate time, and (4) serve as a barrier to the external environment while safely covering the abdominal viscera and preventing fluid losses [22, 23]. TAC methods have evolved over time from inexpensive, simple techniques to more advanced methods utilizing commercially available products. While there is a lot of literature reported for types of TAC, there are relatively few studies which directly compare techniques. In fact, there are limited Level I recommendations in this field with only limited number of randomized trials comparing various TAC techniques [24••, 25••, 26•, 27, 28, 29••, 30•]. In a multi-institutional, randomized trial, we evaluated the effect of chemically induced paralysis of the lateral abdominal wall on primary fascial closure rates. Patients were randomized to ultrasound-guided injections of their abdominal wall muscles with either Botox or placebo. Primary fascial closure rates were high in both groups: 96 % for Botox and 93 % for placebo [31, 32••].
The Silo Closure (aka “Bogota Bag”)
Wittmann-Patch® (NovoMedicus, Germany)
This technique achieves TAC by suturing two patches to each side of the fascia with a non-absorbable suture. The two sheets adhere to each other with a Velcro-like mechanism as one sheet consists of micro-mushrooms (i.e., hooks) and the second is made up of multiple slings which catch and hold the micro-mushrooms . This provides easy access for re-exploration. A primary advantage of this technique is that it allows for serial re-approximation of the fascia by tightening the patch and cutting off the excess material. Eventually, the fascia will be mobilized sufficiently to the midline to allow for primary fascial closure. These serial tightening procedures can even be performed in the patient’s bed in intensive care unit . In a retrospective review, the technique was associated with an improved delayed primary fascial closure rate by 48 % over other various TAC techniques (i.e., silo, vac-pack, absorbable mesh) [45••]. Primary fascial closure rate has even been reported to be as high as 94 % . One of the disadvantages of this method is tissue injury due to excessive tension on the fascial edges. As a result, fascial inflammation and necrosis may ensue, which may hinder the healing process, and increase rates of ventral herniae [24••, 46]. Long-term data on hernia rates after primary fascial closure using the Wittmann-Patch is lacking.
Negative Pressure TAC
Negative pressure therapy is done using a vacuum device. There are both commercial and non-commercial options created out of items commonly available in the operating room. First described by Barker and colleagues, the vacuum pack is constructed in layers: a porous 1010 3 M™ Steri-Drape™ sheet is placed underneath the peritoneum to cover the viscera, a surgical towel or KERLIX™ gauze over the sheet, Jackson-Pratt (JP) drains, an adhesive drape 3 M™ Ioban™ to cover the entire wound . The JP drains are connected to a wall suction outlet which provided continuous negative pressure. This method is relatively cheap, easily applied, and easy to make if commercial devices are not readily available. The main drawback of this technique is decreased primary fascial closure rates and unequal distribution of suction throughout the abdominal cavity, leading to intra-abdominal fluid accumulation. In a single-institution retrospective review, the primary fascial closure rate using this method was 52 % .
Dynamic Retention Sutures
Several methods of retention sutures have been described, often used in conjunction with negative pressure TAC. Trans-fascial sutures are placed to provide continuous medial tension on the abdominal wall, thus preventing lateral retraction. This can be achieved using vessel loops or heavy non-absorbable suture material. Studies have shown an increased rate of fascial closure. In a report of 100 consecutive patients treated with vacuum-assisted closure and no. 1-polydioxanone (PDS) sutures, primary fascial closure was achieved in all patients [61••]. In another retrospective review, delayed primary fascial closure rate was 87 % with low infection (4 %) and enterocutaneous rates (3 %) . Additionally, a retrospective study of 16 OA patients treated with continuous retention sutures showed complete fascial closure in 82 % of patients . Given these encouraging results and low complication rates, retention sutures are routinely placed in our practice.
Clinical Management of Patients with Open Abdomen
Intra-abdominal hypertension and acute abdominal compartment syndrome are very common in trauma and critically ill patients. If left untreated, mortality from this condition is high [64, 65]. In a prospective study, 33 patients with abdominal compartment syndrome were treated with decompressive laparotomy. Having the abdomen open resulted in immediate reduction in intra-abdominal pressure and significant improvement in end organ perfusion and function . When acute compartment syndrome is suspected, the diagnosis can be confirmed with measurement of bladder pressure .
The ultimate goal of TAC is to improve the odds of mortality for emergency surgical and trauma patients by abbreviated laparotomy and rapid reversal of acidosis, hypothermia, and coagulopathy using damage control resuscitation. A major secondary goal of this process, however, is to ensure delayed primary fascial closure. The techniques outlined above all will facilitate these goals to varying degrees. While these techniques are necessary, they are not sufficient. There are adjuncts to these techniques which may increase the rates of primary fascial closure to the greatest rate possible.
All institutions which have the possibility of performing damage control surgery must have a protocol in place outlining the steps needed to facilitate the original TAC. This protocol must extend into the immediate post-operative period by outlining the timing and technique of abdominal re-exploration. With this type of an approach, rates nearing 100 % primary fascial closure are possible when the protocol is adhered to [61••]. A large portion of this success may be attributable to planned serial re-exploration at every 48 h. When this was not done, rates of primary fascial closure plummeted to 55 %. In the largest prospective, multi-institutional trial to date of trauma patients undergoing TAC, every hour delay in re-exploration decreased the risk of primary fascial closure by 1.1 % [68••]. Moreover, leaving the abdomen open for a longer period increases the risk of microbial colonization of the wound. But this has not been shown to increase wound complications or enterocutaneous fistula formation .
Excessive fluid administration can lessen rates of primary fascial closure. Out of 181 non-trauma patients undergoing TAC management, patients who did not achieve primary fascial closure had a greater cumulative fluid balance through post-operative day 10 . This excessive rate of fluid administration was linked temporally to the development of sepsis and other infectious complications including intra-abdominal abscess and enterocutaneous fistula formation. Avoiding these complications may lower fluid requirements thereby increasing primary fascial closure rates. Previously thought of an anathema enteral feeding in the setting of TAC has been shown to be safe and associated with lower rates of infectious complications including pneumonia [71•]. While the mechanism for this benefit of feeding remains unknown, it is theorized that enteral feeding provides trophic factors critical in maintaining tight junctions of the gastrointestinal mucosa .
There are many methods surgeons can use to keep the abdomen open. While the primary goal of these TAC techniques is to improve mortality for critically ill surgical patients by facilitating damage control resuscitation, obtaining primary fascial closure once the critical illness has been successfully treated remains paramount. Not only is the correct utilization of TAC techniques necessary to ensure the highest rates of primary fascial closure, but also the continued involvement of the surgeon via protocols and avoidance of complications is critical.
Compliance with Ethical Standards
Conflict of Interest
Drs. Khasawneh and Zielinski declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 6.Halsted SW. Ligature and suture material: the employment of fine silk in preference to catgut and the advantages of transfixing tissues and vessels in controlling hemorrhage-also an account of the introduction of gloves, gutta-percha tissue and silver foil. JAMA 1913; 60:1119−1126.Google Scholar
- 24.••Diaz JJ, Jr., Cullinane DC, Dutton WD, et al. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma 2010;68:1425–38. This is a review article that included prospective and retrospective studies about managing patients with an open abdomen. The authors concluded that every institution should have a protocol to manage patients with an open abdomen. Google Scholar
- 25.••Henteleff HJ, Parry NG, Burlew CC. What is the comparative efficacy of negative-pressure wound therapy vs alternate temporary abdominal closure techniques in open abdominal wounds? J Am Coll Surg. 2014;218:1251–3. Review article that included 2 randomized controlled trials (RCT) and 9 cohort studies. Negative pressure closure device was compared to other methods of temporary abdominal closure. The authors concluded that negative pressure closure devices are associated with better outcomes, mainly in primary fascial closure rates.Google Scholar
- 26.•Pliakos I, Papavramidis TS, Mihalopoulos N, et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery 2010;148:947–53. Randomized controlled trial that compared vacuum-assisted closure (VAC) technique to VAC with retention sutures. Patients who had retention sutures in addition to VAC closure had better outcomes; greater primary fascial closure rates, and shorter hospital stay. Google Scholar
- 27.Long KL, Hamilton DA, Davenport DL, Bernard AC, Kearney PA, Chang PK. A prospective, controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared with VAC alone in the management of an open abdomen. Am Surg. 2014;80:567–71.PubMedGoogle Scholar
- 29.••Kirkpatrick AW, Roberts DJ, Faris PD, et al. Active negative pressure peritoneal therapy after abbreviated laparotomy: the intraperitoneal vacuum randomized controlled trial. Ann Surg. 2015;262:38–46. A single-center randomized controlled trial that included 54 patients treated with either ABThera or Baker’s vacuum pack. The primary endpoint was the difference in the plasma concentration of inflammatory markers after temporary abdominal closure application. A survival difference was detected between patients randomized to the ABThera versus Barker’s vacuum pack. However, that did not seem to be mediated by an improvement in peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation.Google Scholar
- 30.•Bee TK, Croce MA, Magnotti LJ, et al. Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma. 2008;65:337–42; discussion 42–4. A prospective randomized trial that included 51 patients. Patients were randomized to either vacuum-assisted closure or polyglactin mesh closure after damage control laparotomy. There were no differences between delayed primary fascial closure rates in both groups. Google Scholar
- 32.••Zielinski MD, Kuntz M, Zhang X, et al. Botulinum toxin A-induced paralysis of the lateral abdominal wall after damage-control laparotomy: a multi-institutional, prospective, randomized, placebo-controlled pilot study. J Trauma Acute Care Surg. 2016;80:237–42. A multi-institutional, prospective, randomized, placebo-controlled pilot study. The study included 46 patients that were randomized to either to receive ultrasound-guided injections of their external oblique, internal oblique, and transversus abdominus muscles with either Botox (150 mL, 2 U/mL) or placebo (150-mL 0.9 % NaCl). The use of Botox after open abdomen was safe but did not seem to affect primary fascial closure, hospital length of stay, or pain modulation.CrossRefPubMedGoogle Scholar
- 33.Feliciano DV, Burch JM. Towel clips, silos and heroic forms of wound closure. Advances in Trauma and Critical Care. St Louis: Mosby-YearBook; 1991;6:235–50.Google Scholar
- 45.••Weinberg JA, George RL, Griffin RL, et al. Closing the open abdomen: improved success with Wittmann Patch staged abdominal closure. J Trauma. 2008;65:345–8. A retrospective cohort study that compared outcomes of patients treated with Wittmann Patch closure. The authors concluded that Wittmann Patch contributed to an increased incidence of delayed fascial closure. Patch closure didn’t affect complication rates. Google Scholar
- 51.•Sutton PA, Evans JP, Uzair S, Varghese JV. The use of Gore Bio-A in the management of the open abdomen. BMJ Case Rep. 2013;2013. Article reporting the use of Gore Bio-A mesh in the setting of hollow viscus perforation and intra-abdominal contamination. The authors reported that use of Gore Bio-A is a safe, feasible and cost effective alternative to traditional biologics for the closure of an open abdomen.Google Scholar
- 60.Delgado A, Sammons A. In vitro pressure manifolding distribution evaluation of ABTheraTM Active Abdominal Therapy System, V.A.C.® Abdominal Dressing System, and Barker’s vacuum packing technique conducted under dynamic conditions. SAGE Open Med. 2016;4:2050312115624988.Google Scholar
- 61.••Burlew CC, Moore EE, Biffl WL, Bensard DD, Johnson JL, Barnett CC. One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma Acute Care Surg. 2012;72:235–41. Retrospective review of 100 consecutive patients treated with sequential closure technique. In this technique, temporary abdominal closure is achieved by placing negative pressure device in addition to placing retention sutures. The authors reported 100% fascial closure rates. This approach reduced morbidity of the open abdomen. Google Scholar
- 63.Gaddnas F, Saarnio J, Ala-Kokko T, Laurila J, Koivukangas V. Continuous retention suture for the management of open abdomen: a high rate of delayed fascial closure. Scand J Surg SJS Off Organ FinnSurg Soc Scand Surg Soc. 2007;96:301–7.Google Scholar
- 66.De Waele JJ, Kimball E, Malbrain M, et al. Decompressive laparotomy for abdominal compartment syndrome. Br J Surg. 2016.Google Scholar
- 68.••Pommerening MJ, DuBose JJ, Zielinski MD, et al. Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy. Surgery 2014;156:431–8. Multicenter prospective study that included 499 patients who underwent damage control laparotomy. Primary closure rates were 65.5%. Delays in returning to the operating room after damage control laparotomy was associated with reduction in primary fascial closure rate.Google Scholar
- 71.•Dissanaike S, Pham T, Shalhub S, et al. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg. 2008;207:690–7. Multicenter prospective cohort study that aimed to determine the safety and effect of immediate enteral nutrition in patients with open abdomen. Immediate enteral nutrition after damage control was safe. There was a reduction in pneumonia rates in patients who had immediate enteral nutrition. Google Scholar