Local wound care can be extremely problematic in the patient with an open abdomen and an entero-cutaneus fistula. In an attempt to mitigate the inflammatory state preventing resolution of the entero-atmospheric fistula, Jamshidi and Schecter59 treated seven patients with direct application of a biological dressing (HADM and/or cadaveric split thickness skin graft). Five of this series of seven closed with only two requiring further operative management. Physiologically similar, the application of skin graft to the granulated wound bed can have good results with as much as 93% graft take at 1 week.60 The use of an innovative negative pressure dressings or the KCI V.A.C. therapy to collect the draining succus entericus to keep the open abdomen clean can be a daily wound management issue. An innovative option for improving wound care is the creation of the “floating stoma.” Recent case studies have described techniques for “floating stoma” with or without KCI V.A.C. therapy of the wound bed in attempts to simplify treatment before and after definitive repair.61
The restoration of gastrointestinal continuity at the time of the abdominal wall reconstruction is safe and the preferred treatment for entero-atmospheric fistula.62 Success depends on the achievement of the goals set out in the management phase; the eradication of sepsis, optimizing nutrition status (albumin >3.25 g/dL), and delaying operative repair a minimum of 3 months to 12 months to allow for the development of a “neo-peritoneal cavity.”63 An essential management priority is to stage the “elective” gastrointestinal reconstruction when the patient's sepsis has resolved. After the inflammatory process within the abdominal cavity has resolved, the intra-abdominal adhesions will progress through the various stages of inflammation to vascularize and loosen fibrous adhesions resulting in a safer operative procedure.64 Even in the most optimized patient, entero-atmospheric fistulas remain among the most challenging problems, a surgeon will face.
Once it has been determined that the abdominal fascia will not come together because of massive visceral edema, loss of domain, and/or loss of abdominal wall tissue, the only option left is a planned ventral hernia or fascial bridge with biological mesh or absorbable mesh.68,69 The initial goal of a planned ventral hernia is to keep the viscera within the abdominal cavity. This is accomplished by using absorbable mesh (Vicryl [Ethicon] or Dexon [Covidien]) to prevent evisceration. This allows time for the viscera to adhere together. This occurs during the course of 2 weeks to 3 weeks. Once the base of the open wound has granulated, a skin graft can be performed to cover the viscera. If the fascial defect is not large, another option is to elevate skin flaps and perform a skin only closure.70 Caution must be exercised when elevating skin flaps in the setting of continued intra-abdominal sepsis, lack of source control, and massive visceral edema; because this setting has a high risk of skin flap infarction and flap loss. In this setting, allowing the wound base to progress to a good granulated base and proceeding to skin graft tissue coverage may be the safest option. Regardless of the technique used, visceral coverage is essential to decrease metabolic burden and prevent the formation of entero-atmospheric fistulae as a result of trauma from exposure or dressing changes.
Temporary abdominal closure with silicone sheets or Gortex has also been used to keep the abdominal contents from eviscerating.11,71 This is done until the viscera have adhered together. The prosthetic mesh is removed and the granulation bed is skin grafted. Others have used bilateral bipedal flaps to cover the granulation bed with skin. The goal is to decrease the incidence of intestinal fistula formation.37,72
The introduction of biological mesh has been used in an attempt to do single stage repairs of ventral hernias.16,38 The data to date suggests that the majority of patients repaired with biological mesh may develop laxity of the repair resulting in a hernia 6 months to 12 months later.45 The role of biological mesh in the healing process has not been completely elucidated.
The final stage of damage control is an “elective” abdominal wall reconstruction.71,73 Because of the complexity of this topic, the EAST Open Abdomen Committee is in the process of developing a set of guidelines for abdominal wall reconstruction after the open abdomen. Questions regarding the preoperative evaluation, operative approach, and postoperative management and follow-up will be addressed (Table 5).
Damage control laparotomy in severe trauma, emergency general, and vascular surgery, in the setting of an abbreviated laparotomy as a result of physiologic exhaustion, has become the standard of care. The open abdomen technique has become an essential component of the procedure.
The management and closure of the open abdomen has developed into a separate surgical entity and remains a challenging problem to the surgeon. Several techniques have been developed to close the open abdomen. The majority of open abdomens can undergo early abdominal fascial closure during the initial re-laparotomy. If three or more laparotomies are required, DAFC can be achieved in the majority of cases using three surgical techniques (Wound Vac, Wittmann device, dynamic/suture closure with or without the use of a wound vacuum device). When the midline fascia cannot be approximated, two other techniques to consider are bridge closure with absorbable mesh or acute component separation.
The development of the entero-atmospheric fistula is a major clinical complication of the open abdomen. The development of the “floating stoma” and skin graft of the open abdomen becomes paramount in achieving control of enteric contents and wound sepsis. Finally, when DAFC cannot be achieved, one may proceed to plan ventral hernia, with the hope of accomplishing abdominal wall reconstruction in the future.
The management of the open abdomen remains a very heterogeneous area of study. This is due to various issues such as the etiologies of the open abdomen (trauma, emergency general, and vascular surgery) and the presence of intra-abdominal sepsis. In addition, there are no accepted classification systems for the open abdomen. Recently, a consensus meeting of experts was held in January 2009 to propose a classification system for the open abdomen.74 The classification is simple and can be applied to future studies. Currently, there is no sponsoring organization of the classification proposed and it has not been studied or validated. However, a standard classification system of the open abdomen is necessary, if a scientific approach is to be taken in regards to this vexing clinical problem (Table 6).
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