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Management of the Open Abdomen Patient

  • Madhu Subramanian
  • Cheralyn Hendrix
  • Niels D. Martin
  • Babak SaraniEmail author
Chapter
  • 2 Downloads

Abstract

The concept of ‘abbreviated laparotomy’ and the practice of leaving the peritoneal cavity open was first described in trauma patients by Stone in 1983 and became an acceptable surgical strategy after a landmark paper in 1993 (Stone HH et al. Ann Surg. 1983;197(5):532–535; Rotondo MF, et al. J Trauma. 1993;35(3):383). The open abdomen strategy involves carrying out only life-saving procedures at the index operation, leaving the abdominal wall open, and covering the exposed viscera with a temporary abdominal dressing. Abbreviated laparotomy, also known as “staged” or “damage control” laparotomy, allows for immediate management of life-threatening conditions in patients who are too critically ill to otherwise withstand definitive operative repair. Definitive repair is then deferred to a time when physiologic homeostasis had been reestablished. In the last two decades, the indications for damage control laparotomy have expanded to also include emergency general surgery (Nagpal S, et al. J Trauma. 2009;67(5):152; Allardyce DB. Am J Surg. 1987;154(3):295–299; Soop M and Carlson GL. Br J Surg. 2017;104(2):e74; Wertheimer MD and Norris CS. Arch Surg. 1986;121(4):484–487). However, whereas damage control laparotomy is considered standard of care in trauma surgery, its role is more controversial and less well defined in emergency general surgery.

Keywords

Open abdomen Abdominal compartment syndrome Damage control surgery Negative pressure wound therapy 

Notes

Acknowledgment

No author has a conflict of interest or financial disclosure necessary.

References

  1. 1.
    Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197(5):532–5.CrossRefGoogle Scholar
  2. 2.
    Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):383. Accessed Aug 14, 2018CrossRefGoogle Scholar
  3. 3.
    Nagpal S, Halpern CH, Sims C, et al. Decompressive laparotomy to treat intractable cerebral hypoxia. J Trauma. 2009;67(5):152. Accessed Aug 22, 2018CrossRefGoogle Scholar
  4. 4.
    Allardyce DB. Incidence of necrotizing pancreatitis and factors related to mortality. Am J Surg. 1987;154(3):295–9. Accessed Aug 22, 2018CrossRefGoogle Scholar
  5. 5.
    Soop M, Carlson GL. Recent developments in the surgical management of complex intra-abdominal infection. Br J Surg. 2017;104(2):e74. Accessed Aug 16, 2018.  https://doi.org/10.1002/bjs.10437.CrossRefGoogle Scholar
  6. 6.
    Wertheimer MD, Norris CS. Surgical management of necrotizing pancreatitis. Arch Surg. 1986;121(4):484–7. Accessed Aug 22, 2018CrossRefGoogle Scholar
  7. 7.
    Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med. 2001;22(2):211–26. Accessed Oct 27, 2018.  https://doi.org/10.1055/s-2001-13834.CrossRefPubMedGoogle Scholar
  8. 8.
    Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the berlin definition. JAMA. 2012;307(23):2526–33. Accessed Oct 27, 2018.  https://doi.org/10.1001/jama.2012.5669.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Feliciano DV, Pachter HL. Hepatic trauma revisited. Curr Probl Surg. 1989;26(7):453–524. doi: https://doi.org/0011-3840(89)90014-2 [pii].
  10. 10.
    Diaz JJ, 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(6):1425–38. Accessed Aug 22, 2018CrossRefGoogle Scholar
  11. 11.
    Fietsam R, Villalba M, Glover JL, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. Am Surg. 1989;55(6):396–402.PubMedGoogle Scholar
  12. 12.
    Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg. 1984;199(1):28–30.CrossRefGoogle Scholar
  13. 13.
    Bleszynski MS, Chan T, Buczkowski AK. Open abdomen with negative pressure device vs primary abdominal closure for the management of surgical abdominal sepsis: a retrospective review. Am J Surg. 2016;211(5):926–32. Accessed Aug 22, 2018.  https://doi.org/10.1016/j.amjsurg.2016.01.012.CrossRefPubMedGoogle Scholar
  14. 14.
    Kim JJ, Liang MK, Subramanian A, Balentine CJ, Sansgiry S, Awad SS. Predictors of relaparotomy after nontrauma emergency general surgery with initial fascial closure. Am J Surg. 2011;202(5):549–52.  https://doi.org/10.1016/j.amjsurg.2011.06.023.CrossRefPubMedGoogle Scholar
  15. 15.
    Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma--a unified approach. J Trauma. 1982;22(8):672–9. Accessed Oct 29, 2018CrossRefGoogle Scholar
  16. 16.
    Roberts DJ, Ball CG, Feliciano DV, et al. History of the innovation of damage control for management of trauma patients: 1902-2016. Ann Surg. 2017;265(5):1034–44.  https://doi.org/10.1097/SLA.0000000000001803.CrossRefPubMedGoogle Scholar
  17. 17.
    Moore EE. Thomas G. Orr memorial lecture. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg. 1996;172(5):405–10. Accessed Aug 14, 2018CrossRefGoogle Scholar
  18. 18.
    Kirkpatrick AW, Coccolini F, Ansaloni L, et al. Closed or open after source control laparotomy for severe complicated intra-abdominal sepsis (the COOL trial): Study protocol for a randomized controlled trial. World J Emerg Surg. 2018;13:4. eCollection 2018.  https://doi.org/10.1186/s13017-018-0183-4.CrossRefGoogle Scholar
  19. 19.
    Tremblay LN, Feliciano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg. 2001;182(6):670–5. Accessed Aug 22, 2018CrossRefGoogle Scholar
  20. 20.
    Cirocchi R, Birindelli A, Biffl WL, et al. What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis. J Trauma Acute Care Surg. 2016;81(3):575–84. Accessed Aug 14, 2018.  https://doi.org/10.1097/TA.0000000000001126. CrossRefPubMedGoogle Scholar
  21. 21.
    Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39(4):912–25.  https://doi.org/10.1007/s00268-014-2883-6.CrossRefPubMedGoogle Scholar
  22. 22.
    Brock WB, Barker DE, Burns RP. Temporary closure of open abdominal wounds: the vacuum pack. Am Surg. 1995;61(1):30–5. Accessed Aug 22, 2018PubMedGoogle Scholar
  23. 23.
    Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma. 2000;48(2):207. Accessed Aug 22, 2018CrossRefGoogle Scholar
  24. 24.
    Cheatham ML, Demetriades D, Fabian TC, et al. Prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique. World J Surg. 2013;37(9):2018–30. Accessed Aug 22, 2018CrossRefGoogle Scholar
  25. 25.
    Weinberg JA, George RL, Griffin RL, et al. Closing the open abdomen: improved success with Wittmann patch staged abdominal closure. J Trauma. 2008;65(2):345–8.  https://doi.org/10.1097/TA.0b013e31817fa489.CrossRefPubMedGoogle Scholar
  26. 26.
    Keramati M, Srivastava A, Sakabu S, et al. The Wittmann patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn. Burns. 2008;34(4):493–7. Accessed Aug 22, 2018CrossRefGoogle Scholar
  27. 27.
    Nagy KK, Fildes JJ, Mahr C, et al. Experience with three prosthetic materials in temporary abdominal wall closure. Am Surg. 1996;62(5):331–5. Accessed Aug 22, 2018PubMedGoogle Scholar
  28. 28.
    Robin-Lersundi A, Vega Ruiz V, López-Monclús J, et al. Temporary abdominal closure with polytetrafluoroethylene prosthetic mesh in critically ill non-trauma patients. Hernia. 2015;19(2):329–37. Accessed Aug 22, 2018CrossRefGoogle Scholar
  29. 29.
    Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39(4):912–25. Accessed Aug 22, 2018CrossRefGoogle Scholar
  30. 30.
    Gracias VH, Braslow B, Johnson J, et al. Abdominal compartment syndrome in the open abdomen. Arch Surg. 2002;137(11):1298–300. Accessed Oct 27, 2018CrossRefGoogle Scholar
  31. 31.
    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(2):431–8.  https://doi.org/10.1016/j.surg.2014.04.019.CrossRefPubMedGoogle Scholar
  32. 32.
    Miller RS, Morris JA, Diaz JJ, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma. 2005;59(6):1374. Accessed Aug 22, 2018CrossRefGoogle Scholar
  33. 33.
    Crafts TD, Hunsberger EB, Jensen AR, Rescorla FJ, Yoder MC, Markel TA. Direct peritoneal resuscitation improves survival and decreases inflammation after intestinal ischemia and reperfusion injury. J Surg Res. 2015;199(2):428–34. Accessed Oct 27, 2018.  https://doi.org/10.1016/j.jss.2015.06.031. CrossRefPubMedGoogle Scholar
  34. 34.
    Weaver JL, Smith JW. Direct peritoneal resuscitation: A review. Int J Surg. 2016;33(Pt B):237–41. Accessed Oct 27, 2018.  https://doi.org/10.1016/j.ijsu.2015.09.037.CrossRefPubMedGoogle Scholar
  35. 35.
    Weaver JL, Matheson PJ, Hurt RT, et al. Direct peritoneal resuscitation alters hepatic miRNA expression after hemorrhagic shock. J Am Coll Surg. 2016;223(1):68–75. Accessed Oct 27, 2018.  https://doi.org/10.1016/j.jamcollsurg.2016.03.024.CrossRefPubMedGoogle Scholar
  36. 36.
    Weaver JL, Matheson PJ, Matheson A, et al. Direct peritoneal resuscitation reduces intestinal permeability after brain death. J Trauma Acute Care Surg. 2018;84(2):265–72. Accessed Oct 27, 2018.  https://doi.org/10.1097/TA.0000000000001742.CrossRefPubMedGoogle Scholar
  37. 37.
    McKenzie J, Quinones PM, Mentzer CJ, Kruse EJ. Direct peritoneal resuscitation in the setting of hemorrhagic pancreatitis. Am Surg. 2017;83(11):441. Accessed Oct 27, 2018Google Scholar
  38. 38.
    Ghneim MH, Regner JL, Jupiter DC, et al. Goal directed fluid resuscitation decreases time for lactate clearance and facilitates early fascial closure in damage control surgery. Am J Surg. 2013;206(6):1000.  https://doi.org/10.1016/j.amjsurg.2013.07.021.CrossRefGoogle Scholar
  39. 39.
    Oda J, Ueyama M, Yamashita K, et al. Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients. J Trauma. 2006;60(1):64–71.  https://doi.org/10.1097/01.ta.0000199431.66938.99.CrossRefPubMedGoogle Scholar
  40. 40.
    Harvin JA, Mims MM, Duchesne JC, et al. Chasing 100%: The use of hypertonic saline to improve early, primary fascial closure after damage control laparotomy. J Trauma Acute Care Surg. 2013;74(2):432. Accessed Oct 27, 2018.  https://doi.org/10.1097/TA.0b013e31827e2a96.CrossRefGoogle Scholar
  41. 41.
    Sagraves SG, Toschlog EA, Rotondo MF. Damage control surgery--the intensivist’s role. J Intensive Care Med. 2006;21(1):5–16. doi: https://doi.org/21/1/5 [pii].
  42. 42.
    Cheatham ML, Safcsak K, Block EF, Nelson LD. Preload assessment in patients with an open abdomen. J Trauma. 1999;46(1):16–22. Accessed Aug 14, 2018CrossRefGoogle Scholar
  43. 43.
    Ghneim MH, Regner JL, Jupiter DC, et al. Goal directed fluid resuscitation decreases time for lactate clearance and facilitates early fascial closure in damage control surgery. Am J Surg. 2013;206(6):1000.  https://doi.org/10.1016/j.amjsurg.2013.07.021.CrossRefGoogle Scholar
  44. 44.
    Cheatham ML, Safcsak K, Block EF, Nelson LD. Preload assessment in patients with an open abdomen. J Trauma. 1999;46(1):16–22.CrossRefGoogle Scholar
  45. 45.
    Ghneim MH, Regner JL, Jupiter DC, et al. Goal directed fluid resuscitation decreases time for lactate clearance and facilitates early fascial closure in damage control surgery. Am J Surg. 2013;206(6):1000.  https://doi.org/10.1016/j.amjsurg.2013.07.021.CrossRefGoogle Scholar
  46. 46.
    McKibbin B, Cresci G, Hawkins M. Nutrition support for the patient with an open abdomen after major abdominal trauma. Nutrition. 2003;19(6):563–6. doi: https://doi.org/S089990070201105X [pii].
  47. 47.
    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(5):690–7.  https://doi.org/10.1016/j.jamcollsurg.2008.06.332.CrossRefPubMedGoogle Scholar
  48. 48.
    Byrnes MC, Reicks P, Irwin E. Early enteral nutrition can be successfully implemented in trauma patients with an "open abdomen". Am J Surg. 2010;199(3):62; discussion 363.  https://doi.org/10.1016/j.amjsurg.2009.08.033
  49. 49.
    Jacobs DG, Jacobs DO, Kudsk KA, et al. Practice management guidelines for nutritional support of the trauma patient. J Trauma. 2004;57(3):78. discussion 679. doi: https://doi.org/00005373–200409000-00036 [pii].
  50. 50.
    ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1 Suppl):138SA.Google Scholar
  51. 51.
    Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen balance, protein loss, and the open abdomen. Crit Care Med. 2007;35(1):127–31. Accessed Aug 14, 2018.  https://doi.org/10.1097/01.CCM.0000250390.49380.94.CrossRefPubMedGoogle Scholar
  52. 52.
    McKibbin B, Cresci G, Hawkins M. Nutrition support for the patient with an open abdomen after major abdominal trauma. Nutrition. 2003;19(6):563–6. doi: https://doi.org/S089990070201105X [pii].
  53. 53.
    Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215(5):3.CrossRefGoogle Scholar
  54. 54.
    Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma--reduced septic morbidity. J Trauma. 1989;29(7):3.CrossRefGoogle Scholar
  55. 55.
    Moore SM, Burlew CC. Nutrition support in the open abdomen. Nutr Clin Pract. 2016;31(1):9–13. Accessed Aug 14, 2018.  https://doi.org/10.1177/0884533615620420. CrossRefPubMedGoogle Scholar
  56. 56.
    Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian critical care clinical practice guidelines committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355–73.  https://doi.org/10.1177/0148607103027005355.CrossRefGoogle Scholar
  57. 57.
    Burlew CC, Moore EE, Cuschieri J, et al. Who should we feed? Western trauma association multi-institutional study of enteral nutrition in the open abdomen after injury. J Trauma Acute Care Surg. 2012;73(6):8.  https://doi.org/10.1097/TA.0b013e318259924c.CrossRefGoogle Scholar
  58. 58.
    Collier B, Guillamondegui O, Cotton B, et al. Feeding the open abdomen. JPEN J Parenter Enteral Nutr. 2007;31(5):410–5. Accessed Oct 29, 2018.  https://doi.org/10.1177/0148607107031005410.CrossRefPubMedGoogle Scholar
  59. 59.
    Bansal V, Coimbra R. Nutritional support in patients following damage control laparotomy with an open abdomen. Eur J Trauma Emerg Surg. 2013;39(3):243–8. Accessed Oct 18, 2018.  https://doi.org/10.1007/s00068-013-0287-1.CrossRefPubMedGoogle Scholar
  60. 60.
    Park PK, Cannon JW, Ye W, et al. Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):238.  https://doi.org/10.1097/TA.0b013e31829a8c71.CrossRefGoogle Scholar
  61. 61.
    Zielinski MD, Jenkins D, Cotton BA, et al. Adult respiratory distress syndrome risk factors for injured patients undergoing damage-control laparotomy: AAST multicenter post hoc analysis. J Trauma Acute Care Surg. 2014;77(6):886–91.  https://doi.org/10.1097/TA.0000000000000421.CrossRefPubMedGoogle Scholar
  62. 62.
    Fan E, Del Sorbo L, Goligher EC, et al. American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–1263.  https://doi.org/10.1164/rccm.201703-0548ST. Erratum in: Am J Respir Crit Care Med. 2017 Jun 1;195(11):1540.
  63. 63.
    Sujka JA, Safcsak K, Cheatham ML, Ibrahim JA. Trauma patients with an open abdomen following damage control laparotomy can be extubated prior to abdominal closure. World J Surg. 2018;42(10):3210–4.  https://doi.org/10.1007/s00268-018-4610-1.CrossRefPubMedGoogle Scholar
  64. 64.
    Stawicki SP, Green JM, Martin ND, et al. Results of a prospective, randomized, controlled study of the use of carboxymethylcellulose sodium hyaluronate adhesion barrier in trauma open abdomens. Surgery. 2014;156(2):419–30. Accessed Oct 18, 2018.  https://doi.org/10.1016/j.surg.2014.03.007.CrossRefPubMedGoogle Scholar
  65. 65.
    Miller RS, Morris JA, Diaz JJ, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma. 2005;59(6):1374. Accessed Aug 14, 2018CrossRefGoogle Scholar
  66. 66.
    Vogel TR, Diaz JJ, Miller RS, et al. The open abdomen in trauma: do infectious complications affect primary abdominal closure? Surg Infect. 2006;7(5):433–41. Accessed Oct 29, 2018.  https://doi.org/10.1089/sur.2006.7.433.CrossRefGoogle Scholar
  67. 67.
    Rasilainen SK, Juhani MP, Kalevi LA. Microbial colonization of open abdomen in critically ill surgical patients. World J Emerg Surg. 2015;10:5. eCollection 2015.  https://doi.org/10.1186/s13017-015-0018-5.CrossRefGoogle Scholar
  68. 68.
    Goldberg SR, Henning J, Wolfe LG, Duane TM. Practice patterns for the use of antibiotic agents in damage control laparotomy and its impact on outcomes. Surg Infect. 2017;18(3):282–6.CrossRefGoogle Scholar
  69. 69.
    Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133–64. Accessed Oct 29, 2018.  https://doi.org/10.1086/649554. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Madhu Subramanian
    • 1
  • Cheralyn Hendrix
    • 2
  • Niels D. Martin
    • 1
  • Babak Sarani
    • 2
    Email author
  1. 1.Department of SurgeryPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of SurgeryGeorge Washington UniversityWashington, DCUSA

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