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Vacuum Pack Technique of Temporary Abdominal Closure: A 7-Year Experience with 112 Patients

Barker, Donald E. MD; Kaufman, Henry J. MD; Smith, Lisa A. MD; Ciraulo, David L. DO, MPH; Richart, Charles L. MD; Burns, R. Phillip MD

The Journal of Trauma: Injury, Infection, and Critical Care: February 2000 - Volume 48 - Issue 2 - p 201-207
Annual Meeting Articles
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Background: Temporary abdominal wound closure after celiotomy for trauma is often desirable. The ideal method of temporary closure should allow rapid closure, easy maintenance, and allow reexploration and wound repair with minimal tissue damage. Over the past 7 years, we have successfully used a vacuum closure system (the vacuum pack) for temporary management of the open abdomen.

Methods: Medical records of trauma patients undergoing exploratory celiotomy from April of 1992 to February of 1999 were reviewed. Demographic data as well as indications for open-abdominal management and complications of open-abdominal management were collected.

Results: Two hundred sixteen vacuum packs were performed in 112 trauma patients. Of the 216 vacuum packs placed, 2.8% were placed for increased intra-abdominal pressure, 5.3% for inability to achieve tension-free fascial closure, 20% for damage control, 55% for reexploration, and 16.7% for a combination of factors. Sixty-two patients (55.4%) went on to primary closure and 25 patients (22.3%) underwent polyglactin mesh repair of the defect followed by wound granulation and eventual skin grafting. Twenty-two patients (19.6%) died before abdominal closure was attempted. Five patients (4.5%) developed enterocutaneous fistulae. Five patients (4.5%) developed intra-abdominal abscesses. There were no eviscerations. Three patients (2.7%) required further explorations after abdominal closure. Overall mortality rate was 25.9%, none related to the vacuum pack.

Conclusions: The vacuum pack is the temporary abdominal wound closure of choice in patients undergoing open abdominal management at our institution. Primary closure is achieved in the majority of patients with a low rate of complication. The technique is simple and easily mastered. Technical complications are rare and easily repaired.

From the Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee.

Address for reprints: Donald E. Barker, MD, University of Tennessee College of Medicine, Chattanooga Unit, Department of Surgery, 979 E. Third Street, Suite 401, Chattanooga, TN 37403.

Submitted for publication September 25, 1999.

Accepted for publication November 15, 1999.

Presented at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.

Temporary abdominal wound closure after celiotomy for trauma is desirable when tension-free primary approximation of the abdominal wall tissues is impractical or when reexploration is planned. Attempts at abdominal closure in patients with marked visceral edema, retroperitoneal hematoma, or packing of the peritoneal cavity may result in increased intra-abdominal pressure and abdominal compartment syndrome (ACS), with subsequent detrimental effects on pulmonary, cardiac, and renal function. When reexploration is planned for control of intra-abdominal contamination, inspection for visceral viability or after damage control procedures, temporary closure facilitates access to the peritoneal cavity.

The ideal temporary abdominal wound closure should provide containment of the intra-abdominal viscera, protect the viscera from mechanical injury, prevent bowel dessication, minimize abdominal wall tissue damage, prevent contamination of the peritoneal cavity, control egress of peritoneal fluid, be rapidly applied, lend itself to multiple applications, and be relatively inexpensive. We have developed a temporary abdominal wound closure technique that we believe meets these criteria for temporary abdominal wound closure and have used it in the management of the open abdomen in the trauma patient. 1,2

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MATERIALS AND METHODS

Technique

After the completion of abdominal exploration, a polyethylene sheet is perforated multiple times with a scalpel blade (Fig. 1). It is then placed over the peritoneal viscera and beneath the peritoneum of the abdominal wall (Fig. 2). Next, a moist sterile surgical towel(s) is folded to fit the abdominal wall defect and is placed over the polyethylene sheet (Fig. 3). The edges of the towel are positioned below the skin edges. Placement of the towel edges below the peritoneum is helpful if viscera is protruding through the abdominal wall defect. Two 10-French flat silicone drains are placed on top of the towel. The tubing from the drains is tunneled beneath the skin to exit 3 to 5 cm away from the superior pole of the wound (Fig. 4). The exit sites can be buttressed with gauze sponges to prevent pressure necrosis of the skin from the drain tubing. The adjacent skin is sponged dry and painted with tincture of benzoin. The benzoin-painted skin is kept dry until covered with a plastic polyester drape backed with iodophor-impregnated adhesive.

FIG 1

FIG 1

FIG 2

FIG 2

FIG 3

FIG 3

FIG 4

FIG 4

Each drain tube is connected to a bulb suction. Each bulb suction is connected to a limb of a Y-adapter (Fig. 5). The Y-adapter is connected to a suction source at 100 to 150 mm Hg continuous negative pressure. A distinctive high-pitched sound is created by air flow through the drains. This sound is present anytime the negative pressure seal is broken. While suction is applied to the drains, the plastic polyester adhesive drape is placed over the wound and adjacent abdominal wall skin. Air and liquid is sucked from the surgical towel between the two plastic sheets, and the dressing becomes semirigid (Fig. 6). Just before transport, the tubing is clamped between the suction source and the Y-adapter. Suction is then disconnected. Suction is reconnected to the drains once transport is complete and maintained until reexploration is required.

FIG 5

FIG 5

FIG 6

FIG 6

The materials necessary for the vacuum pack are readily available from standard stock in most operating rooms (Table 1). Cost of materials for each vacuum pack at our institution is $47.64.

Table 1

Table 1

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Patients

The medical records of trauma patients undergoing open abdominal management by using the vacuum pack technique at a designated Level I trauma center from April of 1992 to February of 1999 were reviewed. Demographic data including age, sex, mechanism of injury, Injury Severity Score, intra-abdominal injury, and reason for open abdominal management were identified. Data regarding the use of the vacuum pack and any associated complications were collected. ACS was diagnosed clinically per physician progress notes, and peak ventilatory pressures, bladder pressures, and/or oliguria were noted if obtained. Postvacuum pack wound management data were also noted. Hospital mortality data were collected, and causes of death were noted.

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RESULTS

The vacuum pack technique was used 216 times in 112 trauma patients requiring open abdominal management during the review period. The initial indications for open abdominal management are listed in Table 2. The indications for each vacuum pack placement are listed in Table 3.

Table 2

Table 2

Table 3

Table 3

Patient ages ranged from 5 years to 80 years (mean, 38.9 ± 16.85 years). There were 27 (24.1%) female and 85 (75.9%) male patients. Mechanisms of injury were blunt in 77 patients (68.8%) and penetrating in 35 patients (31.2%) and are shown in Table 4. Mean Injury Severity Score was 27.5 (range, 5 to 75 ± 14.09). Twenty-nine patients died for an overall hospital mortality of 25.9%.

Table 4

Table 4

Fifty-six patients (50.0%) had a single vacuum pack application, which remained in place from 1 to 6 days (mean, 1.9 days ± 1.10). Excluding patients who died after a single vacuum pack placement, mean time to closure was 2.2 ± 1.12 days (range, 1 to 6 days). Fifty-six patients (50.0%) had multiple applications over 1 to 34 days (mean, 7.1 ± 6.19 days). Individual vacuum packs in this group remained in place from 1 to 11 days (mean, 2.5 ± 1.53 days). For patients with multiple vacuum packs, the mean number of vacuum packs was 2.9 ± 1.58 (range, 2–10).

Eleven patients (9.8%) developed abdominal complications after vacuum pack placement during hospitalization. Five patients developed enterocutaneous fistulas. There were three small bowel fistulas, one pancreatic fistula, and one gastric fistula. Fistula formation was not directly related to the vacuum pack. Intra-abdominal abscesses were diagnosed in five patients. One patient developed ACS.

Eighty-eight patients underwent eventual abdominal wound closure (Table 5). Twenty-two patients (19.6%) died before abdominal wound closure. Seven patients (6.3%) died after closure. Sixty-two patients (70.5%) underwent fascial wound closure. Patients closed primarily had a mean time to closure of 3.1 ± 1.79 days (range, 1–9 days). One patient (1.1%) had skin closure alone. Twenty-seven patients (30.0%) underwent split-thickness skin graft after a granulation bed had been achieved. Of these 27 patients, 25 patients (27.8%) had polyglactin mesh placed at the fascial level at the time of removal of last vacuum pack and before wound granulation. Mean time to split-thickness skin graft was 32.5 ± 25.3 days (range, 12–141 days) and 27.3 ± 10.28 days (range, 12–52 days) excluding the single outlier.

Table 5

Table 5

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DISCUSSION

Open abdominal management is reserved for those patients in whom abdominal closure would result in excessive intra-abdominal pressure or who require early return to the operating room for reexploration. Several techniques for temporary abdominal wound closure have been proposed, including skin closure alone or use of various biosynthetic materials sutured to the skin or fascia. Placement of polypropylene mesh in temporary closure of the abdomen has been well documented. 3–9 It has been used with and without a zipper mechanism to allow for sequential abdominal reexplorations. 10–16 Underlying viscera may adhere to the mesh and become injured during subsequent reexploration. 16 The mesh, if left long enough, may erode into the bowel. 17 Repetitive suturing of biosynthetic material to fascial edges damages the fascia and may be a causative factor in development of fascial necrosis. 9

Several techniques have been described for temporary closure of the abdominal wall. These include the use of expanded polytetrafluoroethylene, Silastic sheets, and zipper fasteners. 16–20 Although these materials are less adherent to underlying viscera, their use requires suturing of the prosthetic material to the abdominal wall tissues. Management of peritoneal fluid is still a problem unless a drainage system is incorporated. Closure of the skin only can result in leaks of peritoneal fluid, which saturates dressings and potentially allows contamination of the peritoneal cavity.

The vacuum pack is a sutureless closure that avoids mechanical trauma to the tissues of the abdominal wall. Placement of the polyethylene drape beneath the peritoneum helps contain the viscera and prevents adherence to peritoneum adjacent to the abdominal wound and to the other vacuum pack layers. This method lessens the chance of bowel injury at the time of reexploration. Slits cut in the drape before placement allow removal of excess peritoneal fluid. Peritoneal fluid losses can be quantified and replaced as needed. The surgical towel(s) placed over the polyethylene drape provides support to the vacuum pack once suction is applied. It prevents direct application of suction to the underlying bowel and absorbs fluid, which can then be removed through the suction drains. Suction applied through the drains collapses the layers of the vacuum pack making it semirigid. Application of the adhesive-backed drape stabilizes the dressing in place and seals the wound edges, preventing passage of fluid in or out of the wound. The surrounding skin is protected and skin soilage is minimized. If the vacuum seal is broken, the suction drains create a characteristic sound, which should prompt a search for the leak.

The vacuum pack can be modified for use in both pediatric and adult trauma patients. Materials are cut to fit the size of the wound. The youngest patient in our series was 5 years of age and the oldest was 80 years old.

Indications for open abdominal management included increased volume of intra-abdominal contents, need for a second look to determine bowel viability or after damage control procedures, and presence of gross contamination. Closure of the abdominal wound under tension can result in abdominal wall tissue necrosis with subsequent infection. In the face of dehiscence, wound-related mortality may reach 90%. 6,21,22 Wound infection and tissue necrosis was not observed in patients with vacuum packs in place.

Increased intra-abdominal pressure causes ACS, resulting in cardiac, respiratory, and renal deterioration. 23–30 Intraoperatively, there are no immediate increases in peak airway pressures or decreases in blood pressure after application of the vacuum pack. 1 In the postoperative period, clinically apparent ACS was rare, occurring only in one patient. When additional space is needed within the peritoneal cavity, the outer polyester drape can be incised vertically in the midline, allowing expansion of the abdominal cavity. The incised area is then covered with adhesive-backed plastic polyester. This technique was used in the one patient with clinically apparent ACS. The low incidence of ACS in this series of patients may be attributed in part to the surgeons’ willingness to accept open abdominal management.

Damage control celiotomy is widely accepted for trauma patients who require temporizing surgery until physiologic stability is achieved. 31,32 In these patients, the vacuum pack provides a quick means of closure. Reexploration of the abdomen is facilitated by the ease of vacuum pack removal and reapplication.

Fistulas are common when the bowel is exposed. 21,33,34 None of the five fistulas reported in this series were directly caused by placement of the vacuum pack. The pancreatic fistula occurred in a patient with pancreatic injury. The gastric fistula occurred as a result of disruption of a previous gastrojejunostomy. The small bowel fistulas occurred in a patient with a high-velocity gunshot wound requiring multiple small bowel resections, in a patient with blunt duodenal injury, and in a patient with a previous fistula with attempted resection.

Technical problems with the vacuum pack were rare. Peritoneal fluid leaks were repaired at the bedside by application of additional adhesive drape over the leak site. Skin excoriation from peritoneal fluid was minimized. The adhesive-backed plastic polyester drape proved durable, and no structural failures were noted.

Fifteen patients had enterostomas in place on the anterior abdominal wall at the time of vacuum pack closure. The wounds remained protected from intestinal effluent.

Permanent closure of the abdominal wound was the goal for all patients. After fascial closure, there were six major wound complications. Wound dehiscence occurred in four of these patients. One patient had skin necrosis, and one patient had fat necrosis. There were no serious wound complications in patients closed with split-thickness skin grafts.

Absorbable polyglactin mesh was used to contain the abdominal viscera when access to the peritoneal cavity was no longer needed. Granulating wounds were dressed with petroleum gauze and moist gauze dressings until adequate granulation tissue was present to support a split-thickness skin graft. Care was taken during dressing changes to prevent damage to the underlying viscera. Skin grafts were taken from the dorsolateral thigh in all patients except one, for whom they were taken from the lateral abdominal wall. A modified vacuum pack dressing was used to keep the skin graft in place. Its application provides pressure to all areas of the skin graft and is particularly useful when the granulation bed is uneven. The dressing is removed on postgraft day 5. Skin graft take was judged adequate in all cases.

The major long-term morbidity in patients requiring skin grafting is the resultant abdominal wall hernia (Fig. 7). Hernias are repaired once the patient has recovered from their injuries and the skin graft can be easily separated from the underlying tissue. Repair is usually performed 3 to 6 months after injury.

FIG 7

FIG 7

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CONCLUSION

The vacuum pack seems to be a reliable method of temporary closure of the open abdomen in trauma patients. There were no major acute complications directly associated with its use. The major long-term complication is the large ventral hernia, which is created in those patients who cannot undergo primary fascial closure.

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Acknowledgments

Thanks to Patricia L. Lewis, RN, and Michael D. Biderman, PhD, for their assistance with this manuscript.

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REFERENCES

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DISCUSSION

Dr. Ronald M. Stewart (San Antonio, Texas): Dr. Barker and colleagues have presented a simple, interesting, and relatively novel technique for early management of the open abdomen. In the manuscript, they nicely summarize their results along with their complication rates in detail.

The technique and management plan that they use, I do believe, was associated with the low complication rate and is reasonably economical. The potential advantages are decreased blood and bodily fluid exposure and an improved ability to measure excess fluid losses. We currently do not use this technique and, compared to how we manage these patients, I do believe those two factors are real.

The authors, in their conclusions in the abstract, allude to a high rate of primary closure as an advance to the technique. And on this point I am considerably more skeptical. The authors were able to achieve a relatively high closure rate of 55.4% in their patients.

If you look at the indication for the technique, need for reexploration accounted for 55% of all the vacuum packs. Damage control was 20%. Inability to achieve a tension-free closure was 5%. And an increase in intra-abdominal pressure was 3%. I would hypothesize that the need for reexploration group had a significantly higher closure rate than the other, what I would consider more traditional, indications.

So, I really have a couple of straight-forward questions for the authors. What are your primary closure rates stratified by indication? And, it is a nice technique. But, do you feel that perhaps you might be overusing the technique with respect to particularly that need for reexploration group? And the third question would be, have you compared this technique to any other of the more commonly used techniques in the early management of the open abdomen? I would like to thank the Association for the privilege. Thank you.

Dr. Harvey J. Sugerman (Richmond, Virginia): I guess what I do not see is the advantage of this over just doing what we do, which is take a nonsticky hydrate polyvinyl sheet and staple it with a skin stapler to the skin. I am confused as to the advantage of this vacuum pack. And perhaps it needs to be a comparative study of some sort.

Dr. John Sherck (San Jose, California): I would like to commend the authors and Dr. Barker for popularizing and refining this very excellent technique.

We have used a very similar approach for over 10 years at our institution and also found it to be reliable, fast, cheap, and helpful.

Sometimes we have had leak of fluid from around the sticky-seal, even though we have a drain in place. Have you had that problem? And how do you deal with it?

Dr. Ronald J. Simon (Bronx, New York): Just two quick questions. Eleven days with a gauze in the abdomen. We all know that after 3 or 4 days they get very, very funky. Is it possible that your longer packs have the higher incidence of infectious complications?

We just go right to a Vicryl mesh, and you seem to go to a Vicryl mesh in a delayed fashion. What is your indication for switching from this vacuum pack to a Vicryl mesh? Thank you.

Dr. Scott B. Frame (Cincinnati, Ohio): We use this in our practice. You lose a lot of fluid that gets sucked out during this. Do you have any feel for how much protein loss there is and what adverse effects that may have on the patient insofar as wound healing and overall catabolic response?

Dr. Kimberly K. Nagy (Chicago, Illinois): Frequently, we use this in patients who are too sick for various reasons and you cannot close their abdomen. I am wondering, what do you do in cases when you cannot get the patient back to the operating room in a timely fashion because of pulmonary or hemodynamic instability? How long are you willing to leave this in place?

Dr. Donald E. Barker (closing): I appreciate Dr. Stewart’s questions and comments as well as those from the floor.

Dr. Stewart, to answer your first question about stratifying primary closure rates by indication, I think the more important thing affecting closure rates is not necessarily indication for open abdomen management, but is the length of time that the abdominal wound is managed in an open fashion. If a patient goes over 6 days, the probability of being able to do a primary fascial closure is markedly reduced. In fact, I think we’ve only had one patient at 7 days and one patient at 9 days that we were able to primarily close.

We frequently question the issue of overuse, because the technique is so simple to use. And as you saw, not all the patients that this technique is used in are trauma patients. It is used in a lot of general surgery patients. It is the sort of thing that caught on because it was very simple. We actually do attempt to close the fascia in a lot of our patients, but we do not close under extreme tension or if we plan reexploration. We hope we do not overuse this, but I think it is so easy to use that there is a tendency for that to happen and we need to guard against that.

We have not compared this to other techniques because it has been so simple for folks to use that they have all adopted it very readily and use it regularly. But, I think that would be an interesting thing to do.

Dr. Sugerman, the advantage over just a simple stapled piece of plastic on the skin, I think, would be that we are able to control any sort of fluid leaks we have. We feel like this maintains itself as a sterile barrier for the complete time that it is in place.

Dr. Sherck, pertaining to fluid leaks and how we repair those, generally, if you develop a fluid leak or a leak in the seal, either the grenade that they are connected to will expand and it is no longer collapsed or you will develop this very annoying sound and I guarantee you the nurses will let you know because they cannot stand to hear it. We generally just take another piece of adhesive-backed plastic and place that along the edge of the dressing and that generally takes care of the problem for us.

Dr. Simon, regarding whether our infection rate is increased if we leave the dressings on for a long period of time, we watch these dressings very, very closely for any signs of infection. We monitor the fluid and make sure that we are not really getting anything purulent out of there. We do not like to leave the dressings on for long periods of time, but in patients that are hemodynamically unstable, patients that are still fighting to keep alive, and are still requiring resuscitation for long periods of time, we’re forced to leave those dressings on.

Dr. Frame, regarding protein loss from the wound, it would be difficult to determine what contribution the vacuum pack suction and the draining of the peritoneal fluid impacts on protein loss because a lot of these patients, again, are requiring a lot of fluid; they are severely injured. And I think the serum protein levels and albumin levels are depressed anyhow.

Dr. Nagy, if we have to change the vacuum pack, we can actually change this at the bedside in the patient that is ventilated. We can use a short-acting neuromuscular blocker and add pain medication to provide them with some anesthetic.

I appreciate the questions. I thank the Association, again, for the privilege of the floor.

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