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Current techniques in managing open abdomen, 2015

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Current techniques in managing open abdomen, 2015

  1. 1. Current Techniques in managing Open Abdomen BY Hosam Mohamad Hamza, MSc Assistant Lecturer of General Surgery Laparo-endoscopy Minia Fcaulty Of Medicine Minia Egypt 2015
  2. 2. Items to be discussed: Introduction Pathophysiology of the abdomen What is the “open abdomen” (OA)..? Rationale to Leave Abdominal Cavity Open Complications of the OA Temporary Abdominal Closure (TAC) Management of Patients with TAC Definitive Closure Techniques
  3. 3. Introduction • Historically, failing to close the abdomen was anathema. • Death was an inevitable consequence of heat and fluid loss, secondary infection and intestinal fistulation. • However, an increased awareness of the pathophysiology of intra- abdominal hypertension and a change of focus in trauma surgery towards damage control laparotomy have resulted in an increase in the planned use of open abdominal management in critically ill patients. Taylor I, Johnson C and Carlson G. Indications for and management of the open abdomen. Rec Adv in surgery 36 (2014) 96–105
  4. 4. • Despite these developments, the abdomen should only be left open when conventional closed management is not possible because with OPEN ABDOMEN: 1. Mortality and complication rates remain high. 2. Abdominal wall / gut reconstruction after a period of open management, may be extremely technically challenging (esp. in the setting of an intestinal fistula) and is best undertaken in specialist centres. • Little good quality clinical data exist and considerably more evidence is needed for future practice. Taylor I, Johnson C and Carlson G. Indications for and management of the open abdomen. Rec Adv in surgery 36 (2014) 96–105
  5. 5. • Intestine is a highly vascularized structure with a rich network of arteries, veins, capillaries and lymphatics. • In pathologic states, decreased fluid clearance from the extracellular space can result in swelling of intestinal wall several times the normal diameter, potentially interfering with bowel perfusion. • Furthermore, peritoneal surface is highly vascularized and possess inflammatory cells. The net result is excretion of pro-inflammatory substances that increase the local inflammatory response as well as systemic absorption leading to a systemic inflammatory response syndrome (SIRS) and may progress to a multi-organ dysfunction syndrome (MODS). • Premature closure of the abdomen can exacerbate the inflammatory response and potentially accelerate the syndrome. Pathophysiology
  6. 6. • The open abdomen (OA) treatmentThe open abdomen (OA) treatment can be defined as leaving the fascial edges of the abdominal wall intentionally unapproximated. • Aliases include: Laparostomy Temporary Abdominal Closure (TAC) Eteppenlavage • Nowadays, the OA procedure has been widely applied and improved clinical outcomes since it was first popularized in the mid 1990s. What is the “ Open Abdomen” ..?
  7. 7. Indications to leave the abdomen open 1-Major abdominal trauma 1- Death ∆(D.C.S.) 2- Massive bowel oedema 3- Need for multiple 4- Extensive abd wall defects re-explorations. 2-Intra-abdominal hypertension )IAH) Abdominal Compartment Syndrome (ACS( prevention / TTT 3-Severe abdominal sepsis: as in =secondary peritonitis. =unsatisfactory source control • Theoretically, OA is assumed to improve drainage and ↑ bacterial killing (improved oxygenation). • Very little evidence is there to support this technique in treating intra-abdominal infections depending on the degree of peritoneal contamination per se. • The only 2 sufficient indications for OA management are: 1. Intestinal oedema from sepsis or resuscitation that may precipitate ACS if abdomen is closed. 2. Planned reoperation. Robeldo FE, Luque E, Suarez R, et al. Open versus closed management of the abdomen in the surgical treatment of secondary peritonitis: a randomized clinical trial. Surg Infect (Larchmt). 2007;8(1):63-72
  8. 8. • Intra-abdominal pressure (IAP) is a function of all of the following: 1. volume of intra-abdominal contents. 2. distensibility of the abdominal wall. 3. state of contraction of the abdominal wall musculature and diaphragm. 4. Normal IAP is said to be 0-5 mmHg (atmospheric or subatmospheric). It varies with position, activity and BMI. 5. Intraabdominal hypertension (IAH) is defined as a sustained elevation of IAP greater than 12 mmHg. 6. Abdominal compartment syndrome (ACS) is a syndrome of the adverse physiologic consequences occurring as a result of raised IAP greater than 25 mmHg and can be only resolved by abdominal decompression.
  9. 9. Complications of OA management Ileus EA fistula Bleeding Hernia Heat/Fluid loss Infection Defective ventilation Defective ventilation Fascial retraction Fascial retraction
  10. 10. Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg. 2013;257(6):1154-9
  11. 11. 1) Psychological disturbances: relatively neglected but likely to be substantial. 2) Heat loss (decreased central temperature): • One of the most devastating problems of OA. • Causes of heat loss: 1- Exposed moist bowel with large evaporative water losses. 2- Fluid loss (see below). 3- Wound discharge with the patient left in a ‘ wet bed ‘. • FATAL: 1) heat loss contributes to a significant coagulopathy. 2) the need for ↑ heat production by the body (to maintain normothermia) will magnify catabolic stress. • This is to be anticipated and avoided by nursing the patient in warm environment as with burned patients. Complications of OA management Zarzaur BL, DiCocco JM, Shahan CP, et al. Late fascial closure in lieu of ventral hernia; the next step in open abdominal management. J Trauma. 2011;70(2):285-91
  12. 12. 4) Bleeding: •Abdominal viscera have a rich blood supply and leaving the abdomen open undoubtedly increases the risk of hge. •Sources may include: a. wound edges b. omentum c. dilated fragile veins of granulation tissue in the healing wound. •Some patients were reported to require further intervention just to control bleeding after OA management. Complications of OA , Contd; Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg. 2013;257(6):1154-9 3) Fluid loss (3rd Spacing): •The primary insult leading to the necessity of an OA management usually requires aggressive fluid resuscitation. •The downside to crystalloid resuscitation is the sequestration of the fluid in the bowel wall and mesentery leading to further IAH
  13. 13. 5) Hernia formation: - due to: 1.Damage to the abdominal fascia. 2.Closure of the skin, muscle, and/or peritoneum. 3.Planned hernia: intestines allowed to granulate then covered with skin graft. 4.Contributing factors: 5.abdominal distention. 6.abdominal wall tension. 7.the underlying medical status of the patient. 8.fistula formation. -Closure of planned hernias is complex and staged for complete fascial closure. -Hernias that form as a result of an OA generally have little risk of strangulation of the bowel but cause considerable deformity and discomfort.. Complications of OA , Contd; Losanoff JE, Richman BW, Jones JW. Temporary abdominal coverage and reclosure of the open abdomen: frequently asked questions. J Am Coll Surg. 2002;195(1):105–115
  14. 14. 6) Intestinal fistulation (enteroatmospheric fistula, EAF): •Incidence: controversial (high with abd sepsis as bowel is oedematous). •Risk factors: 1.bowel exposure to air → drying & desiccation of serosa. 2.exposed suture lines / anastomosis. 3.injury caused by wound dressings. 4.shearing forces if the small bowel is fixed to abd wall or mesh. 5.Negative Pressure Wound Therapy (NPWT; the only RCT comparing –ve P with mesh showed a high EAF rate in the –ve P group). Bee et al; 2008 •Drawbacks: 1.fistulae within an OA virtually never close spontaneously. 2.delayed primary abdominal closure becomes impossible. 3.mortality rates of approximately 50% (sepsis, electrolyte imbalance) 7) Infection: 1.Although the abdomen may be left open to teat abdominal infection, OA itself may expose the patient to additional risk of infection either from fistulas or from exposure to the environment. 2.Carrying out dressing changes is to be done in the OR rather than on ICU to reduce the chances of contamination. Complications of OA , Contd;
  15. 15. Intestinal fistulation (enteroatmospheric fistula, EAF) Complications of OA , Contd;
  16. 16. 8) Ileus: •inevitable at the early postoperative period. •PN may be required for some weeks until gut function returns. 9) Facial retraction: •Patients with OA following midline incision have unopposed forces of the oblique muscles that tend to pull the abdominal wall in a lateral direction. •During the 1st week, natural elasticity of the abdominal wall results in significant retraction of the wound edges: Increases the risk of serosal tear and fistula Increases the size of the defect Loss of abdominal domain= loss of the space into which the oedematous viscera must return after the oedema subsides Complications of OA , Contd;
  17. 17. 10) Defective ventilation: •An intact abdominal wall is a prerequisite to effective breathing and coughing. •Patients with an OA will require a period of mechanical ventilation. •After a couple of weeks the intrinsic strength of the abdominal wound is sufficient to allow for weaning •The use of TAC techniques may support earlier weaning. Complications of OA , Contd;
  18. 18. These complications can be minimized by: 1.Understanding of the pathophysiology found in the OA . 2.Using materials that minimize trauma to the abdominal contents. 3.Prevention of severe intra-abdominal sepsis. 4.Facilitation of multiple re-explorations; if needed. 5.Prevention of abdominal wall loss. 6.Tension-free fascial closure. Complications of OA , Contd;
  19. 19. Management of the patient with OA
  20. 20. Management of OA General management Wound management IV Fluids Heat loss control Analgesia & sedation Nutrition Temporary abd closure (T.A.C.) Dressing Definitive closure
  21. 21. Management of OA 1- I.V. fluid administration: •The 1st 24 hrs in ICU after returning from OR frequently require large fluid infusions to optimise preload. •It can be challenging to balance this need with the restrictive resuscitation that minimises visceral oedema. •Literature favours early aggressive fluid resuscitation guided by goal-directed fluid therapy followed by the use of vasopressors to maintain physiological parameters. Taylor I, Johnson C and Carlson G. Indications for and management of the open abdomen. Rec Adv in surgery 36 (2014) 96–105
  22. 22. Management of OA 1- I.V. fluid administration: •There has been some work on direct peritoneal fluid administration in patients with bowel oedema, but at present this remains a research area rather than standard clinical practice. Smith JW, Garrison RN, Mantheson PJ, et al. Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery. J Am Coll Surg. 2010;210(5):658-67
  23. 23. Management of OA 2- Heat loss control: •On arrival in ICU, patients are frequently cold. •The OA will furtherly increase heat loss. •Active and passive methods of rewarming may be required: Taylor I, Johnson C and Carlson G. Indications for and management of the open abdomen. Rec Adv in surgery 36 (2014) 96–105
  24. 24. Management of OA 3- Analgesia and sedation: •Need for analgesia is, perhaps surprisingly, not significantly different to that after major surgery in which abdomen is closed. •Pain control will go hand in hand with management of agitation and stress of the striking sight of OA esp. if associated with EAF. •Established protocols involve the use of fentanyl and midazolam in combination, with expert and sympathetic psychological support. Dutton WD, Diaz JJ, Miller RS. Critical care issues in managing complex open abdominal wound. J Intensive Care Med. 2012;27(3):161-71
  25. 25. Management of OA 4- Nutrition: •OA may represent a source of protein/nitrogen loss (patients are inevitably severely insulin resistant and profoundly catabolic). •Intestinal failure develops in at least 15% of these patients. •Enteral nutrition (EN) should be employed whenever possible ( ↓ septic complications and ↓ time before closure). •Patients with EAF usually require parenteral nutrition (PN), but may also be satisfactorily fed by "fistuloclycis". •Nutritional support can be optimised by consultation of specialist dieticians. Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg. 2013;257(6):1154-9
  26. 26. Management of OA 5- Temporary abdominal closure (T. A. C.) : •OA is maintained by a TAC device. •TAC was first described by Ogilvie using a piece of canvas (1940). •Many techniques exist, the ideal technique should fulfill the following goals: •Easy re-access to the abdominal cavity (patients with OA require multiple trips to the operating room. ie, every 24–48 hrs for as long as 2 or 3 weeks using staged abdominal explorations). •Protection of the abdominal contents. •Prevention of (or better lowering) bacterial contamination and infection. •Prevention of evisceration (selective tamponade). •Preservation of fascia. •Prevention of fascial retraction and loss of domain. •Quantification of 3rd space losses. •keeping the patient dry. •Providing abdominal support for ventilation. •Prevention IAH (high-risk patients can rapidly develop high abdominal pressures secondary to bleeding, pack placement, and rapid accumulation of third space fluid) 1.
  27. 27. Management of OA 5- T. A. C. :
  28. 28. Vacuum Pack Technique “ Vacuum Assisted Closure “ or “ Negative Pressure Wound Therapy “ •A simple 3 layer system using negative pressure for abdominal support: 1. Fenestrated polyurethane sheet wrap around the bowels (prevents bowel adherence to the ant abd wall and facilitate fluid drainage ). 2. Sponge (granular foam dressing). 3. Adhesive plastic sheet (applied over the sponge) •A uniform suction (100 to 150 mmHg or lower if haemostasis is crucial) is applied to the sponge layer using sophisticated software giving specific alarms when NPWT is impaired or interrupted. Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg. 2013;257(6):1154-9
  29. 29. General indications of NPWT: 1- Chronic wounds (e.g. MRSA) 2- Open Abdomen 3- Partial thickness burns. 4- Indulent ulcers (DM, bed sores, venous,….) Mechanism of action: •Continuous negative preesure applied to the wound surface helps wound healing by evoking 2 wound responses: A- Physical response (macrostrain)= * approximation of wound edges. * removal of excess fluids. * reduction of tissue oedema. B- Biological response (microstrain)= = removal of exudates that may contain inhibitors of healing. = reduction of oedema with better tissue perfusion. = cell-surface strain (microdeformation) by negative pressure induces cellular stretch → cells become more metabolically active → ++ fibroblast migration ++ cell proliferation ++ extracellular matrix deposition •With repeated dressing, the GT gradually fills the gap allowing subsequent 2ry closure . granulation tissue formation }
  30. 30. • Commercially available devices such as VAC,KCI = $500 / dressing. • Alternatives include bogota bag or 2 plastic sheet stuck together with perforations. • Sponges with 2 JP drains through the skin to suction. • Adherent plastic sheet over the sponges on the abdominal wall • $ 50 Poor Man’s VAC
  31. 31. Management of OA 6- Dressing : after the decision has been made to leave the abdomen open, dressing should be: •Available in the theatre. •Easy to apply. •Protecting the skin and viscera to ↓ fistulation. •Easy to remove for redressing.
  32. 32. Management of OA 7- Definitive Closure at a 2nd look laparotomy “ Delayed primary closure “ •Plan a strategy for closing the abdomen at almost the same time as the decision to leave it open. •Timing: oIn general, delayed 1ry closure will be possible within several days, once haemodynamic stability and visceral oedema subside (IAH is avoided). oWhen abdomen is left open for long periods, fascial retraction with loss of domain ensues. oIf it is not possible to close abdomen by day 10, it may not be possible at all. •Delayed 1ry closure is more likely to be possible after DCS for surgery, or haemorrhage (e.g. ruptured AAA) than for treatment of abdominal sepsis or ACS. Boele van Hensbroek P, Wind J, Dijkgraaf MG, et al. Temporary closure of the open abdomen: systematic review on delayed 1ry closure. World J Surg. 2009;33(2):199-207
  33. 33. When Primary Closure is not possible Fascial closure rates of 60% at a 2nd look laparotomy have been reported although the rate of incisional hernia may be as high as 30%. If so, available options may include: 1.Planned Ventral Hernia 2.Skin graft 3.Component Separation 4.Canica ABRA closure system
  34. 34. Planned Ventral Hernia • Collagenization of the wound converts granulation tissue into scar. • Absorbable mesh may be used to provide some stability to the abdominal wall. • Wound contraction will occur over 3-6 months. • Over the succeeding months to a year, the collagen is slowly removed and a hernia will become apparent.
  35. 35. Ventral Megahernia Surgical correction carries extensive risks with at least a 30% complication rate including: •Skin necrosis •Bowel ischaemia •Abdominal compartment syndrome •Prolonged intubation •Wound infection •Recurrence •Death
  36. 36. Skin Grafting • Easier wound care. • ?? less EAF rates. • viscera are left to granulate and a skin graft is undertaken. • giant ventral hernia is inevitable but can be repaired after an interval of at least 6-12 months)
  37. 37. Component separation technique 1. Abdominal wall flap is mobilized from the underlying fascia, this is done until lateral to the linea semilunaris. 2. Be careful to maintain the abdominal wall muscle perforators to avoid devascularization of the skin. 3. A small incision is then made in the external oblique just lateral to the linea semilunaris. 4. By the aid of a haemostat, the incision is taken cephalad till the lower ribs and caudad to the pubis using cautery. 5. Medial traction of rectus muscle by the assistant helps to accomplish the procedure. 6. This is done bilaterally. 7. Upto 14 cm can be gained in the abd wall per side. 8. Midline closure
  38. 38. Component separation technique
  39. 39. • In rare circumstances, adequate skin cover is not possible despite application of the previously described techniques. • Complex myocutaneous flaps have been successfully used to close such defects. • Success with anterolat. Thigh and rectus abdominis flaps have been described. Complex Fascial Flaps Lambe G, Russell C, West C, et al. Autologous reconstruction of massive EAF with a pedicled subtotal lateral thigh flap. Br J Surg. 2012;99(7):964-72
  40. 40. • Gore-Tex Dual Mesh in initial stage. • Subsequent stages involve serial excision-towel clamping of the mesh or resuturing of the mesh every 72 hrs to 2 weeks. • VAC may be placed over the mesh • Mesh is then excised and the fascia is reapproximated with component separation and bioprosthetic reinforcement. • Allows for primary closure in ~90% without planned ventral hernia. • Average time to definitive closure 46 days. • No reports of EAF in 37 patients. Rasilainen SK, Mentula PJ, Leppaniemi AK. Vacuum and mesh mediated fascial traction for primary closure for primary closure of the open abdomen , Br J Surg. 2012;99(12):1725-32 Serial abdominal closure
  41. 41. • ABRA closure system restores the primary closure option for full-thickness abdominal defects, by approximating the skin and fascial margins for low- tension primary closure. • It acts by turning the ‘ flat abdomen ’ with eviscerating contents to a ‘ rounded abdomen ‘ with a more voluminous abdominal cavity. • All necrotic tissues, adhesions or unhealthy granulation tissues are excised to achieve clean mobile wound margins. • Any pre-existing abdominal closure device should be removed prior to ABRA application. ABRA Dynamic Closure System
  42. 42. Thank you hosam_hamza@ymail.com

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