Purpose
To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).

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Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Twenty years ago, the idea of electively leaving the abdomen of a surgical patient open after laparotomy was an abhorrent one to most surgeons. In the intervening years, the development of the concept of the damage control laparotomy and the understanding of the abdominal compartment syndrome has markedly changed this idea. It is now recognized that the combination of acidosis, coagulopathy, and hypothermia represent a potentially lethal combination in the injured patient, and prolonged operation in such a case will only worsen the problem. In this situation, abbreviated laparotomy aimed at stopping surgical bleeding and limiting contamination is usually preformed. This frequently leaves the abdomen in such a state that the patient requires at least one if not several reoperations to restore intestinal and/or vascular continuity.

We also now know that visceral or retroperitoneal edema due to shock and reperfusion may increase intraabdominal pressure to dangerous levels, leading to organ dysfunction. Patients with this constellation of symptoms must have their abdomens left open temporarily to allow for visceral and renal perfusion as well as adequate pulmonary function.

With recognition of optimal management of these 2 patient populations, the care of the injured patient has been greatly improved. With the solution to one problem, however, another has been created. A method for temporary coverage of the open abdomen is now required. Surgeons have responded with several alternatives, many of which are effective in protecting the viscera and allowing serial access to the peritoneum.1–5 The reported eventual fascial closure rate varies from 50% to 70%, depending on the technique. All of these methods have in common the problem of the inability to obtain primary fascial closure beyond 7 to 10 days. After this, the viscera have adhered to the anterior abdominal wall and the fascia has retracted. This situation requires the creation of a planned ventral hernia and eventual abdominal wall reconstruction in the ensuing months.5

A recent report from our institution outlined the development of a technique of vacuum-assisted fascial closure (VAFC) in which a primary fascial closure rate of 69% was reported with the technique.6 More importantly, VAFC allowed for the fascial closure of 22 of these patients at large intervals after the original laparotomy (mean, 21 days; range, 9 to 49 days). The ability to close the abdomen at such an interval was felt to be a significant improvement over earlier techniques, and a protocol for management of the open abdomen incorporating this technique was implemented. The authors speculated on the basis of these results that more aggressive employment of VAFC under such a protocol would lead to higher rates of abdominal closure overall and further decrease need for future abdominal wall reconstruction.

The aim of this study is to examine the use of VAFC under this protocol and its effect on abdominal outcome.

Prospective Evaluation of Vacuum-Assisted Fascial Closure After Open Abdomen: Planned Ventral Hernia Rate Is Substantially Reduced

Background: We reviewed our experience with the open abdomen and hypothesized that the known high wound complication rates were related to the timing and method of wound closure. Methods: All trauma admissions from 1995 through 2002 requiring an open abdomen and temporary abdominal coverage were included. The study group was then classified by three wound closure methods used in survivors: 1) primary (primary fascial closure); 2) temporizing (skin only, spit thickness skin graft and/or absorbable mesh), and 3) prosthetic (fascial repair using nonabsorbable prosthetic mesh). Results: In all, 344 patients required an open abdomen and temporary abdominal coverage either as part of a planned staged damage-control celiotomy (66%) or the development of the abdominal compartment syndrome (33%). Of these, 276 patients survived to wound closure. Sixty-nine of the 276 (25%) suffered wound complications (wound infection, abscess, and/or fistula). Thirty-four (12%) died after wound closure; seven of the deaths as a direct result of the wound complication. Complications increased significantly after 8 days (p < 0.0001) from the initial operative intervention to fascial closure. Primary fascial closure was achieved in 180 of 276 (65%) patients. Although there was no difference in the mean Injury Severity Score between the three groups, the primary group had significantly fewer mean transfusion requirements, shorter mean time to fascial closure, and a lower complication rate as compared with either the temporizing or prosthetic groups. The primary group thus incurred significantly less mean initial hospitalization charges. Conclusion: Morbidity associated with wound complications from the open abdomen remains high (25%). Morbidity is associated with the timing and method of wound closure and transfusion volume, but independent on injury severity. Also, delayed primary fascial closure before 8 days is associated with the best outcomes with the least charges.

Complications after 344 damage-control open celiotomies.

Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted closure provides a new paradigm that can be used in concert with a wide variety of standard existing plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations. The ease of technique and a high rate of success have encouraged its adaptation by thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discusses multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems. This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.

Vacuum-assisted closure: state of clinic art.

Fluid resuscitation from hemorrhagic and septic shock results in significant soft tissue edema. The bowel is not spared, and this visceral edema often precludes abdominal wall closure after celiotomy because the fascia cannot be approximated without excessive tension. Closure under tension often leads to fascial necrosis or abdominal compartment syndrome. Recognition of those complications has led to a widespread application of leaving the abdominal cavity open after either primary surgery or after decompressive laparotomy for established compartment syndrome. A wide variety of techniques have been applied for management of the resulting acute defect, whereas a paucity of information has been reported concerning definitive management of the large ventral hernias, which result when the abdomen has been managed in an open fashion after a catastrophic shock insult.

Polypropylene mesh has been used for temporary closure but has been associated with infection, mesh extrusion, and fistula. Intestinal fistulization remains the most morbid complication associated with the acute management of the open abdomen. Fistula rates of 12-50% have been reported when prostheses are used for acute management.1-3 Other methods of maintaining the viscera in the abdominal cavity during the initial phase have included acute coverage with intravenous solution bags, closure with zipper or Velcro-type devices sewn to the fascial edges, and vacuum dressing approaches.4-7 We reported an initial experience with a staged approach to management of these defects a decade ago after experiences with acute coverage using most of the aforementioned materials.1 Over time, we began to steadily adopt absorbable mesh for acute management, which ultimately became our acute prosthesis of choice.

When prosthetic materials are subsequently used for definitive abdominal wall reconstruction, the most important complications are prosthetic infection and recurrent hernia. Although gram-positive infections occasionally occur in association with permanent mesh used for reconstruction, many infections result when mesh is inserted in the face of intestinal contamination from either associated ostomy closure or fistula excision, which are commonly associated with management of the initial insult. Recurrent hernia rates of 15-50% have been reported with the use of polypropylene mesh for definitive reconstruction of large abdominal wall defects.1,8 We reported a small number of definitive reconstructions using local tissue transfer without permanent prostheses to avoid the complication of infected foreign body, and in attempt to reduce recurrent hernia rates.1 Since that time, we have added modifications to the acute management of the open abdominal wall defects and have also developed a sizable experience with definitive reconstruction using a modified components separation reconstruction technique. That technique uses local myofascial tissue transfer and usually avoids the need for permanent prosthetic material for hernia repair. The present study was performed to analyze results of both acute and long-term management including definitive reconstruction with this staged approach.

Staged Management of Giant Abdominal Wall Defects: Acute and Long-Term Results

Background: The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients. Methods: The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure ≥ 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC. Results: From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99). Conclusion: VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided

Byron J Faler

Papers

Late fascial closure in lieu of ventral hernia: the next step in open abdomen management.