Ari Leppäniemi Managing the open abdomen

Managing the open abdomen
Ari Leppäniemi
Department t of Abdominal Surgery
Meilahti hospital
University of Helsinki
Finland

Frequency and causes of open abdomen
-in 23% (344/1531) after trauma laparotomies
- damage control 66%, ACS 33%
Miller 2005
Trauma Vascular General
Damage control 40% 9% 8%
Planned re-explor. 23% 32% 65%
Inability to close 19% 46% 13%
IAP increase 16% 14% 7%
Multifactorial 3% 0 8%
Barker 2007

Open abdomen at Meilahti
hospital 1997-2006
n
ACS
Severe pancreatitis 17 11 (65%)
Trauma/damage control 11 2
AAA 10 2
Abdominal sepsis 7 1
Bowel ischemia 4 1
Miscellaneous 8 4
Total 57 21 (37%)

Outcome after open abdomen in trauma
- n = 344, 68 (20%) died before wound closure
- complications after wound closure (69/276 = 25%)
- wound infection 16%, abscess 11%, fistula 12%
- 34 (12%) died after wound closure
- 7 (3%) from wound complication
Miller 2005
-n = 116, 10 (9%) died d before wound closure
- 106 survived to wound closure (DFC 63%, SSG 37%)
- abscess 5, fistula 4, evisceration 1, ACS 1, ileus 1
Barker 2007

Classification of open abdomen (OA)
1A Clean OA without adherence between bowel and
abdominal wall or fixity it (lateralization li ti of abd. wall)
1B Contaminated OA without adherence/fixity
2A
Clean OA developing adherence/fixity
2B Contaminated OA developing adherence/fixity
3 OA complicated by fistula formation
4 Frozen OA with adherent/fixed bowel, unable to
close surgically, with or without fistula
Björck et al. WJS 2009;33:1154

Short- and dlong term aims in open
abdomen
- short-term aims (temporary abdominal closure)
- close the “catabolic drain” of the open abdomen
- protect the viscera, prevent/manage fistulas
- prevent bowel and fascial adherence
- enable future fascial (and skin) closure
- long-term aims
- intact skin cover
- fascial closure at midline, if possible
- good functional outcome
- no pain, good cosmetic result

Temporary closure of the open abdomen -
what is the best method

Evolution of temporary abdominal
closure techniques
- first generation: abdominal coverage
- running skin suture, towel clip
- synthetic cover (plastic, mesh etc.)
- second generation: fluid control
- vacuum pack
- third generation: negative pressure therapy
- V.A.C.
- ABThera
De Waele and Leppäniemi 2011

Systematic ti review (3169 patients)
t Mort. DFC Fist. Absc. [%]
VAC 15 60 3 3
Vacuum pack 27 52 6 4
Wittmann patch 17 90 2 3
Mesh or sheet 26 23 6 2
Dynamic retention sutur. 23 85 nr nr
Bogota bag (silo) 41 29 0 6
Loose packing 39 11 28 nr
Skin only 39 43 nr nr
Zipper mesh/sheet 33 39 14 6
van Hensbroek et al. WJS 2009;33:199

Comparative studies I
- pre-patch (n=56) before 2004 (Bogota bag, vac pack, VAC,
mesh) vs. patch (n=103) (Wittmann) 2004 onwards
- early fascial closure 59% vs. 65% (p=ns)
- remaining:
pre-patch Patch p
Delayed fascial closure 30% 78%

Comparative studies II
- prospective randomized study, polyglactin mesh vs.
VACx3+mesh (90% trauma, n=51-3 early deaths)
VAC Mesh p
Delayed fascial closure 31% 26% ns
Abscess 44% 47% ns
Fistula 21%* 5%** ns
*all VAC fistulas related to feeding tubes and suture lines
- avoid feeding jejunostomy, prefer nasojejunal tube
**mesh fistula followed colon leak remote from the mesh
Bee et al. 2008

Temporary mesh (mesh-assisted
gradual closure)

Delayed primary fascial closure
(%)

When to accept the hernia
- re-explorations are no longer needed
- conditions favoring planned hernia strategy
- inability to reapproximate the retracted abdominal
wall edges
- sizeable tissue loss
-risk of tertiary ti ACS, if primary closure attempted
t - inadequate infection source control
-anterior enteric fistula
- poor nutritional status

Planned hernia
- fascial defect with original skin cover
- fascial replacement (mesh)
- fascial approximation
- combination
- fascial and skin defect
- component separation
- split-thickness skin graft
-granulation tissue and scar (VAC)

Mesh repair

Biological i l meshes
- partially remodeling prostheses
- porcine dermal collagen, human dermal
collagen, bovine pericardium collagen
- completely remodeling prostheses
- porcine intestinal mucosa
- different remodeling times
- resistance to mechanical stress (partially remodeling
meshes)
- low adhesiogenic power
- resistance to infection (contamination)

Components separation (Ramirez et al. 1990)

Planned hernia with early skin-grafting gat g

Abdominal wall reconstruction with
Tensor fascia lata (TFL) -flap
- myofascial or myofascial cutaneous flaps
- pedicled TFL (Wangensteen 1934)
- free vascularized TFL (Hill et al.1979)

Microvascular TFL-flap
- n = 20, mean age 52 (range 43-78) years
- mean follow up 5 (range 0.5-12) years
- perioperative mortality 0
- total flap necrosis 1
- distal tip necrosis 2
- postoperative p bleeding 1
- intra- abdominal infection 0
-deep surgical site infection 0
- hernia recurrence (after 3 months) 1
Tukiainen and Leppäniemi 2011

Management options (Leppäniemi & Tukiainen WJS 2011)
Defect Primary Addit/alternat.
Small hernia, intact skin
No contamination CS Mesh (M)
Contamination ti CS Biological i l mesh (Mb)
Small hernia, grafted skin
No contamination CS +M or flap
Contamination CS +Mb or flap
Large hernia, intact skin
No contamination CS + flap or M
Contamination CS + flap or Mb
Large hernia, grafted skin
No contamination Flap + CS + M
Contamination Flap + CS + Mb

Conclusions
- aim for delayed primary fascial closure
- mesh-assisted VAC promising
- if primary fascial closure not possible, planned hernia
with early skin-graft
- wait for the recovery of the patient and maturation of
the skin-graft
-choice of reconstruction ti method
- component separation, TFL, + mesh
- joint venture of abdominal and plastic surgeons !