Abdominal decompression lowers IAH 24.2 ± 9.3 to 14.1 ± 5.5 mm Hg and results in the improvement in lung dynamic compliance from 24.1 ± 7.9 to 27.6 ± 9.4 mL/cm H2O.11 Abdominal decompression may also be of benefit in the setting of increased intracranial pressure.12 By using the definition of ACS (the development of significant respiratory compromise, including elevated inspiratory pressure >35 mbar, renal dysfunction [urine <30 mL/hr], hemodynamic instability requiring catecholamines, and a rigid or tense abdomen), it has been found that in these patients, emergency abdominal decompression resulted in a significant increase in the cardiac index, tidal volume, and urine output, with a resultant decrease in bladder pressure, heart rate, central venous pressure, pulmonary artery occlusion pressure, peak airway pressure, partial pressure arterial carbon dioxide, and lactate.2 Bladder pressures >25 mm Hg have been suggested to indicate ACS.12 Several studies have demonstrated that ACS may cause a critical increase in the intracranial pressure, which markedly improves after the release of the abdominal tension and aiding in the management of intracranial pressure for patients with traumatic brain injury.11,13
One early study looked at 35 patients who underwent packing for control of intra-abdominal hemorrhage. The design looked more at packing as a technique, but did some analysis of management of the abdominal wall.13 Five of 12 patients (42%) closed primarily developed wound infection, compared with 1 of 10 (10%) closed with mesh. Also noted were better peak airway pressures in mesh patients, although these findings were not statistically significant.30 This preliminary experience supports packing to control coagulopathic bleeding, use of TAC, and further intensive care unit (ICU) resuscitation with a planned second laparotomy for definitive management of GI injuries.31 These patients with severe nonhepatic injuries shared a constellation of findings including acidosis, hypothermia, and coagulopathy. Protocols to pursue DC should take into account the development of acidosis, hypothermia, and massive transfusion or resuscitation.32 One suggested protocol established pH of 7.2 or less, temperature 34°C or less, serum bicarbonate level of 15 mEq per liter or less, transfusion volumes of 4000 mL or more of PRBCs, total blood replacement of 5000 mL or more if both PRBCs and whole blood are used, and total operating room fluid replacement of 12,000 mL or more. Groups were compared in a sequential time study before and after protocol. Although mortality was similar between these two groups, the postprotocol group was found to have decreased operative time, transfusions, length of stay, blood loss, infectious complications, and visceral edema.32
Early recognition and delayed abdominal closure has been shown to improve the outcomes in rAAA patients with ACS.17 The main features of ACS after rAAA were increased central venous pressure (CVP), and mean airway pressure, and low urine output (UOP).45 The results suggested a decrease in early mortality among patients undergoing delayed abdominal closure. Late mortality because of MOF may also be reduced with delayed abdominal closure.17 Improved late outcome seems plausible, given the findings of decreased pulmonary damage (improved P/F ratio) and improved tissue oxygenation (SvO2) that was present after early postoperative resuscitation.15 As in massively resuscitated trauma victims,16,17,21,29 delayed laparotomy closure in rAAA patients may confer a physiologic and survival benefit. Greater intraoperative blood loss, longer cross clamp times, and longer operative time were risk factors for IAH, which often resulted in colonic ischemia. Earlier decompression and treatment of colonic ischemia may improve mortality.46 rAAA patients with IAH >21 have a better overall mortality when undergoing abdominal decompression.15,45
As surgeons began managing patients with open abdomens, many techniques were used for TACs (Table 4). The options for TAC are many and include the “Bogotá bag,” fashioned from a large intravenous fluid bag, a ready-to-use transparent “bowel bag,” VP Technique, synthetic mesh (absorbable or non-absorbable), or a Velcro-type sheath as advocated by Wittmann et al.48 Many have since been abandoned or supplanted by newer techniques. Today, the most common techniques for TAC include the Bogotá Bag, VP, and Wittmann Patch (WP). These methods of closure have wide support in the literature and are considered safe. All allow ready access for relaparotomy procedures and provide a tension-free closure, obviating IAH.
PPE mesh sewn to the fascia to form a fascial bridge was one of the earliest attempts to create a tension-free TAC. Chan and Esufali reported on 21 patients who had PPE placed as a TAC. Ten of the 15 survivors had the mesh removed and were able to undergo primary fascial closure. The five remaining patients had the mesh removed and a split-thickness skin graft applied. No complications resulted from mesh placement.53 In 1997, Schwartz et al.54 reported on using PPE with the technical modification of suturing the mesh to the fascia to reduce fascial necrosis. No descriptions of complications were reported. Purported benefits of PPE were its porous nature allowing the egress of fluids as well as low cost. Concerns over a high rate intestinal fistula (7%),55 17% to 33%,56 and 75%,57 and infection limited general adoption of PPE as a TAC.
Borraez developed the Bogotá bag in 1984. The technique involves sewing a sterile plastic 3-L urologic irrigation bag to the fascia to form a fascial bridge. This technique is simple and inexpensive.58 It does have the potential for fascial trauma, as it requires sewing to the fascia. It has been used extensively for trauma indications50 and for abdominal sepsis.59 Besides intravenous bags, silastic sheeting has been used in a similar manner to the Bogotá bag by a number of authors to achieve a tension-free TAC.15,17,60–62 This technique is safe and has low incidence of bowel injury and adhesion formation. Eventual fascial closure after this technique, however, is fairly low in most series (28%),59 and the negative pressure TAC (VP) seems to improve on this.
Gortex (W. L. Gore & Associates, Flagstaff, AZ) mesh has also been used as a fascial bridge for TAC. Nagy et al.57 reported its use in TAC with no fistula formation. Ciresi63 reported use of Gortex in patients having laparotomy for trauma and ruptured AAA. The study noted a low rate of reactivity to the Gortex, making re-exploration uncomplicated because of minimal adhesions. The subsequent closure rate was high and fistula rate was very low. The high cost of Gortex, lack of fluid egress, and the potential fascial trauma from suturing the TAC in place have limited the use of Gortex as a TAC.64
Use of the WP (Starsurgical, Burlington, WI) was first reported in 1990 for use with serial abdominal washout for severe peritonitis.48,51 One hundred seventeen patients with abdominal sepsis were prospectively studied. There were no enterocutaneous fistulas reported and no cases of fascial necrosis with the WP when compared with zipper closure or closure with retention sutures. Aprahamian et al.51 studied the device in 20 consecutive trauma laparotomies. Fifteen of the 16 survivors underwent primary fascial closure at subsequent operation. In one patient, the device was removed due to fascial infection requiring surgical debridement. In a small series of patients developing ACS, WP was associated with no complications, and all survivors were able to undergo primary fascial closure.65
The WP consists of two sheets of hook-and-burr material (similar to Velcro) that is sewn to the fascial edges after a plastic drape is placed over the viscera. The hook-and-burr are then overlapped with limited tension to provide a secure TAC. Gauze is used to pack the subcutaneous tissue.48 Pulling the Velcro-like material apart easily allows for re-exploration of the abdomen. At the completion of the subsequent operations, the patch can be tightened to keep fascial tension. Repeated tightening of the patch allows for a gradual sequential closure of the fascia.
The VP technique uses a three-layer TAC. First, a fenestrated polyvinyl sheet (ISO 1010 Drape, Microtek Medical, Columbus, MS) is draped over the exposed viscera and tucked under the fascial edges. Next, a surgical towel is placed under the fascia followed by two silicone drains (Jackson-Pratt Drain, Allegiance, McGaw Park, IL), which are placed on top of the towel. An adhesive, iodophor-impregnated polyester drape (Ioban 2, 3 mol/L Healthcare, St. Paul, MN) is placed over the skin laterally to the anterior axillary lines to seal the wound. The surgical drains are connected to a Y-connector, and wall suction is applied. This dressing has gained wide acceptance because it is fast to apply, inexpensive, atraumatic and allows for excellent control of abdominal fluids. It is also cost effective at approximately $50 per application.68,70 VP remains the most popular TAC used today for trauma and emergent general surgery. It is the current standard of care for TAC.
A commercial version of the VP has been performed using the VAC Abdominal Dressing System from KCI (San Antonio, TX). There have been a number of previous reports that have highlighted the advantages of VAC therapy as TAC. In a series of 112 patients, 11 (9.8%) developed abdominal complications, of whom five (4.5%) developed a fistula: three from the small bowel, one pancreatic, and one gastric. Two of the small bowel fistulae and the gastric fistula occurred in patients who had an intestinal resection and anastomosis at their primary operation.70 Miller and coworkers72 reported the use of VAC in 45 patients with minimal complications and a 48% primary fascial closure rate. One series, with 29 emergent general surgical patients requiring bowel resection, reported a very high incidence (20%) of enterocutaneous fistulas.73
The ideal TAC would fulfill the following criteria: easy to apply, tension free, atraumatic, inexpensive, and allow for a high rate of definitive fascial closure when the device is no longer needed. Currently, the most popular techniques of TAC are the VP, WP, and the Bogotá bag. All these techniques are safe and allow ready access for relaparotomy. They are also tension free, thus avoiding the added complication of IAH and ACS. VP has the added advantage of not needing to be sutured to the fascia, saving time, and potential tissue destruction. There does not seem to be a single TAC that is superior to the others commonly in use. It is largely a matter of surgeon preference, and without direct comparison of the commonly used techniques a single method cannot be recommended.
Relaparotomy and STAR serves three main functions: washout to reduce contamination and control intra-abdominal sepsis, resection or debridement of devitalized or contaminated tissue, and reconstruction of the GI tract (Table 5). Relaparotomy and STAR should be performed when the patient has been adequately resuscitated as demonstrated by correction of hypothermia, acidosis, and coagulopathy.74 This can usually be accomplished within 36 hours.74 This technique has been shown to improve the outcomes in severely injured trauma patients.75
In the patient with sepsis, the clinical parameters such as renal dysfunction, APACHE II score, and MODS score were predictive of on going intra-abdominal sepsis6,7,83 and were the indications for relaparotomy.43,72,76,77,80 Those patients with continued intra-abdominal sepsis who underwent repeat laparotomy had reduced mortality.43 In patients with high ventilatory demands, bedside relaparotomy has provided a safe adjunct with risks similar to those performed in the operative theater.72
A clear benefit for planned relaparotomy versus on demand has not been demonstrated.84 Van Ruler et al. in a randomized controlled trial of 116 on-demand and 116 planned relaparotomies in the setting of peritonitis demonstrated no significant difference in primary end point (57% on-demand [n = 64] vs. 65% planned [n = 73], p = 0.25) or in mortality or morbidity alone (29% on-demand [n = 32] vs. 36% planned [n = 41], p = 0.22) (40% on-demand [n = 32] vs. 44% planned [n = 32], p = 0.58), respectively. A total of 42% of the on-demand patients had a relaparotomy versus 94% of the planned relaparotomy group. Thirty-one percent of first relaparotomies were negative in the on-demand group versus 66% in the planned group (p = 0.001). Patients in the on-demand group had shorter median ICU stays (7 vs. 11 days, p = 0.001) and shorter median hospital stays (27 vs. 35 days, p = 0.008). Direct medical costs per patient were reduced by 23% using the on-demand strategy. On-demand relaparotomy did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, healthcare utilization, and medical costs.84
Early nutritional support is well described in surgical literature. Evidence that it is safe, well tolerated, decreases hospital length of stay, and may reduce infectious complications is clear. However, the idea of early enteral nutrition in the management of the open abdomen is relatively poorly investigated (Table 6). We can infer from a relatively recent study that the OA represents a significant source of protein or nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a negative effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.85
Furthermore, early enteral nutrition (<4 days) is well tolerated, and in comparison with delayed enteral nutrition may result in higher primary fascial closure (74% vs. 49%; p = 0.02), lower fistula rate (9% vs. 26%; p = 0.05) and lower total hospital charges.86 Early enteral nutrition instituted in less than 48 hours is well tolerated in open abdomens for trauma and reduces nosocomial infections (most notably pneumonia) with no significant difference in multiorgan dysfunction syndrome, length of ventilator days, ICU days, hospital days, or mortality.87 Although these results are encouraging, in the absence of a larger body of literature, any recommendation must be made with caution, and further study is necessary to make significant inferences.
A special note should be made of the extremely rare occurrence of nonocclusive bowel ischemia because of early and aggressive enteral feeding.88 Tube feedings should be discontinued immediately, and total parenteral nutrition (TPN) should be started in patients with abdominal pain, distension, increased nasogastric drainage, and signs of intestinal ileus.89 Laparotomy should be considered in patients who manifest an acute surgical abdomen.
Through its various evolutions, the techniques of OA management have demonstrated usefulness in surgery. From life-saving decompression of ACS in vascular surgery and DC to providing ready and repeated access for source control in abdominal sepsis, the last 30 years have provided a substantial body of clinical experience to guide our endeavor to decrease morbidity and mortality. There remains a great degree of heterogeneity in the patient populations and the surgical techniques described. We hope these recommendations provide a means to guide the indications, use, and early management of open abdomen in both trauma and nontrauma surgery.
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: a non-traumatic experience. Annals of the Royal College of Surgeons of England
102. Torrie J, Hill AA, Streat S. Staged abdominal repair in critical illness. Anaesthesia & Intensive Care
Diaz et al.1 have done a superb job of analyzing the complex, heterogenous literature on damage control. These practice management guidelines (PMG) measure up to the high standards of others created by the Eastern Association for the Surgery of Trauma (EAST).
The EAST Primer of 2000 on PMG development2 has become the beacon that directs us to advance recommendations at levels I to III, based on evidence as classes I to III. However, it is clear from a review of the various PMG of EAST that class I evidence (prospective, randomized trials) exists for few clinical problems. Their solutions must necessarily be based on class II or even class III evidence. The current PMG are no exception. Only one report of the 95 relevant articles reviewed, on burn resuscitation with colloids versus crystalloids, had the strength of a class I evidence but was not strong enough to warrant a level I recommendation.
There was only one level I recommendation in the current PMG, relating to emergent/urgent decompressive laparotomy for abdominal compartment syndrome, as defined by consensus opinion of the World Congress of Abdominal Compartment Syndrome. Expert opinion and consensus panel discussions have not been given much eminence by the EAST primer. Nevertheless, the authors to their credit recognized their value and included them in their analysis to form many level II and a few level III recommendations on intraabdominal hypertension and abdominal compartment syndrome. They proved to be prescient: in a report too recent to be included in this analysis, Cheatham and Safcsak3 documented improved survival, reduced resource utilization, and increased fascial closure by management protocols refined by algorithms and definitions of the World Society of Abdominal Compartment Syndrome. The accompanying editorial4 applauded: “the waiting is over: the first clinical outcome study of the treatment of intra-abdominal hypertension has arrived.”
Consensus opinion that is a product of rigorous analysis and discussion, in concert with even lowly class III data, may lead to strong level II recommendations as shown by these PMG. The importance of this process cannot be overstated: first, they emphasize the benefits of temporary abdominal closure and open abdomen management. Second, they collate current refinements in our management of these critically injured or ill patients and the role of prevention, monitoring, and prompt treatment of intraabdominal hypertension. Third, they serve to promulgate the current knowledge about these preventable complications and help rectify the obstinate “never” and “do-not-believe-in-it” attitudes of clinicians still prevalent in different countries, specialties of critical care, and even specialties of surgery.5 In the interest of full disclosure, this writer is a member and an officer of the executive committee of World Society of Abdominal Compartment Syndrome.
Rao R. Ivatury, MD
Department of Surgery
Medical College of Virginia Hospitals
1. Diaz JJ, Cullinanae DC, Dutton WD, et al. Open abdomen
and emergency general surgery
: part 1 “damage control
.” J Trauma
2. Eastern Association for the Surgery of Trauma
. Utilizing evidence based outcome measures to develop practice management guidelines: a primer. Eastern Association for the Surgery of Trauma
(EAST) Ad Hoc Committee on Practice Management Guideline Development. 2000. Available at: www.EAST.org
. Accessed February 2, 2010.
3. Cheatham ML, Safcsak K. Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? Crit Care Med
4. Sriram K, Mizock BA. The waiting is over: the first clinical outcome study of the treatment of intraabdominal hypertension has arrived. Crit Care Med
5. Ivatury RR. Abdominal compartment syndrome: a century later, isn't it time to accept and promulgate? Crit Care Med