The document discusses difficult abdominal wall closure, techniques for temporary abdominal closure, and definitive abdominal wall reconstruction. It provides details on: - Ideal suture materials that resist infection and provide strength for closure. - Indications for leaving the abdomen open such as damage control surgery or intra-abdominal hypertension. - Temporary abdominal closure techniques including negative pressure devices that control fluids and promote primary fascial closure in 70-80% of cases. - Factors to consider before definitive reconstruction such as optimizing patient status and using tension-free techniques like component separation with mesh reinforcement for a durable repair.

1. DIFFICULT ABDOMINAL WALL
BY: BIKASH C.SAH
1ST YEAR PG

2. • Difficult abdominal wall closure is a great
challenge, especially in patients with
abdominal compartment syndrome or
repetitive abdominal surgery.

3. SUTURE MATERIAL
Ideal suture material
for abdominal wall closure
1. Resists infection,
2. Provides adequate tensile strength to
prevent abdominal wall disruption,
3. Minimizes tissue damage, and
4. Absorbable

4. Polydioxanone (PDS; Ethicon, Johnson &
Johnson), which is frequently used as a double-
stranded suture to increase tensile strength
BECAUSE:
a) Longer strength retention profile
b) Absorption time is longer
c) Being a monofilament that may resist
infection to a greater degree than braided
suture

5. Closure technique
• Minimization of tissue damage is imperative,
and this may be done by limiting the
incorporation of the abdominal wall
musculature in the closure.
• Although recent evidence suggests that
smaller fascial bites may decrease the
incidence of dehiscence and ventral hernia,
likely a result of decreased tissue ischemia and
damage

6. Indications for Leaving the Abdomen Open
• Damage control Severe hemorrhage
i. Hypothermia,
ii. Coagulopathy,
iii. Acidosis
iv. Delayed definitive operation secondary to patient’s
physiologic state
• Intra-abdominal hypertension or compartment
syndrome
• Questionable visceral viability
• Planned acute reoperation
• Severe intra-abdominal sepsis
• Triage

7. 5 stages of damage control surgery
• Phase 1: Emergent laparotomy with control of
bleeding and contamination, abdominal packing of
medical bleeding, and abbreviated abdominal
wound closure
• Phase 2: Resuscitation: Correction of end points of
resuscitation—hypothermia, coagulopathy, and
acidosis
• Phase 3: Reexploration, staged abdominal repair,
and delayed primary fascial closure
• Phase 4: Planned ventral hernia
• Phase 5: Abdominal wall reconstruction

9. Initial Management
• Stabilize, resuscitate, and prepare the patient
for the next step toward closure of the
abdomen
• Return to the OR within 48 to 72 hours for re-
exploration and possible definitive closure
• If cannot be closed on the first trip back to the
OR, the same principles that dictated leaving
the patient open in the first place will apply

10. Subsequent Take-Backs to OR
Every 2-3 days return to OR for washouts
Each visit the fascia is brought together by
tension-free sutures
 By the 3rd-4thvisit, fascial approximation is
usually possible
Patients who remain open at day 8 are
unlikely to have a primary closure
Increased risk for serious complications,
including wound infections and fistulas

12. Temporary Abdominal Closure
Current options for TAC include
– Tension free atraumatic abdominal visceral
coverage and
– Dynamic techniques in which the fascial edges
are closed with serial plication

13. ADVANTAGE
Easily encompasses the bowel
Is expansible but also sturdy
Does not damage the fascia and prevents fascial
retraction
Contains and quantifies fluid loss
Prevents adhesion formation between viscera
and abdominal fascia
Promotes removal of infectious materials
Is quick to apply and remove
Has a good primary fascial closure rate.

14. DISADVANTAGE OF TAC
Fluid loss
Need to keep patients intubated/sedated
Systemic inflammatory response syndrome
Risk of infection, sepsis, and fistula formation

18. Negative-Pressure TACs (VAC)
• 03 layers TAC
1- Fenestrated polyvinyl sheet(inert, pliable material )- as inner
layer spread over viscera and tucked under fascia of
prevents from forming adhesions to the abdominal wall,
contains viscera, allows fluid movement
2- Middle layer of foam or towels- helps generate suction,
keeps the bowel moist, provides support.
3. Outer layer created by iodophore impregnated
polyester drape to create an airtight seal around the
entire apparatus and enable measurement of fluid loss
and generation of negative pressure through the
dressing.

22. Advantage
1. Applied quickly
2. Inexpensive and effective
3. Atraumatic,
4. Allows control of abdominal fluid

23. Outcomes of Vacuum-Based
Temporary Abdominal Closures
• Primary fascial closure rate 70-80%
• Mean closure time is 6-10 days
• 15% complication rate
1. Fistula formation 5-7%
2. Intra-abdominal abscess 4-6%
3. Delayed small bowel obstruction 4%

24. Recent advances
• Technique incorporating Dynamic serial
fascial closure in conjunction with
commercial available vacuum pack
demonstrated
 90% delayed primary fascial closure rate
 Extends beyond of the 08 days
 Highest closure rate
Lowest mortality rate

25. Abdominal reconstruction
Three main functions:
1. Reduction of contamination and control of
intra-abdominal sepsis,
2. Debridement of devitalized or contaminated
tissue, and
3. Reconstruction

26. ASSESSING READINESS FOR ABDOMINAL
CLOSURE
 Adequately resuscitated. The goal of resuscitation is
correction of hypothermia, coagulopathy, acidosis
 Clinical parameters such as renal dysfunction values,
Acute Physiology and Chronic Health Evaluation II
(APACHE II) score, and multiorgan dysfunction score
may be predictive of ongoing intra-abdominal sepsis
and can be used as indications for repeated
laparotomy
 Intra-abdominal hypertension (>20 mm Hg)
 Rise of peak inspiratory pressure of 10 cm H2O.

27. TIMING OF REOPERATION
• When open abdomen managed with skin graft
typically requires when the graft releases
from the underlying viscera and the graft is
able to pass the so-called pinch test i.e. 6 to12
months before consideration of abdominal
reconstruction (Ideal timing)

28. • If there is ostomy has been made
Longer time between ostomy creation and reversal has been associated with
fewer complications, and adhesions appeared to diminish at about 15 weeks and
beyond.
Typical delays of 6 months or more should be
expected before ostomy reversal.

29. ALTERNATIVE CLOSURE TECHNIQUE

30. Mesh

34. SYNTHETIC MESH
• Surgical treatment of choice for repair of
ventral incisional hernias
• Long-lasting repair with low recurrence rate
• Ease of use, and
• Relatively low cost compared with biologic
mesh
• Use: most commonly used prosthetic for
reinforcement for initial incisional and
recurrent hernia repairs

35. Biologic Mesh
Promotes tissue regeneration and
revascularization
Can be used in a contaminated field, but not in
heavily infected fields (matrix disintegrates)
Has a tendency to develop significant laxity
Overlying skin wound should be closed to
promote incorporation of the mesh
Hernia rate with Allodermis ~17%
Few complications are reported

36. Absorbable Mesh
• If the wound is infected
• If the fascial defect is extremely large

37. Repair of Hernia after an Open
Abdomen
Place tissue expanders prior to surgery if
necessary
 Excise the skin graft and completely remove
mesh
 Perform lysis of adhesions to release viscera
from overlying fascia
 Re-approximate fascia
Place onlay mesh on top of the fascia for
reinforcement
Place drains under skin flaps

38. Challenges in Ventral Hernia Repair in
a Contaminated Field
Multiple previous attempts at hernia repair
Significant disruption of tissue planes
Enterocutaneous fistulas must be resected
Accompanying prosthetic material must be
removed
Large fascial defect replacing with permanent
prosthetic mesh is relatively contraindicated in
the acute phase
Protein-calorie malnutrition
 Primary repair has high rate of failure

39. Definitive reconstruction
• Goal
1. First to optimize the patient’s condition and
2. Then to restore the structure and functional
continuity of the musculofascial system and
3. Provide stable and durable wound coverage
to minimize additional complications

40. PREPARATION FOR ABDOMINAL WALL
RECONSTRUCTION
Mesh infection is better prevented than treated.
• Preoperative risk factors must be carefully evaluated and optimized before
an elective complex abdominal wall reconstruction is performed.
 Control diabetes
 Maximize protein-calorie repletion and
 Maximize cardiopulmonary status.
 Mandatory cigarette smoking cessation is required for at least 4 to 6
weeks.
 Previous methicillin-resistant Staphylococcus aureus (MRSA) infection, ----
Decolonizing the patient or suppressing MRSA carriers preoperatively and
using Vancomycin prophylaxis preoperatively.
Preoperative computed tomography scan of the abdominal wall
is necessary before any consideration of major reconstruction

41. Contd.
Intraoperative measures
Iodine-impregnated polyurethane films
Avoidance of wrinkles and redundant mesh
Soaking of synthetic mesh in antibiotic
solution
 Avoidance of contacting the mesh with the
skin
Judicious use of drains

42. Definitive Closure of the Abdomen
 1stchoice – primary closure
Optional retention sutures
Avoid closure under tension
Currently, a tension-free fascia to fascia closure
using component separation techniques
combined with mesh reinforcement is
considered the ideal method for abdominal wall
reconstruction.

44. Methods use
Rives Stoppa repair and Transversus abdominis
release repair
Gold standard.
Use a Retromuscular sublay of mesh
Preserve neurovascular space in posterior
component separation,
Posterior compartment is highly vascular

46. MODIFIED RIVES-STOPPA AND TRANSVERSUS
ABDOMINIS RELEASE TECHNIQUES
The posterior rectus sheath is incised
approximately 0.5 cm from the fascial edge of
the defect. The retromuscular plane is then
developed to the lateral extent of the dissection:
the linea semilunar.

47. If this dissection is insufficient to close the posterior
rectus fascia, an
Extension of this technique is the transversus abdominis
release.
In this technique, the transversus abdominis muscle is
divided, which then permits entrance into the space
between the transversalis fascia and the lateral edge of
this divided transversus abdominis muscle.
This allows the creation of a wide lateral dissection
plane with substantial posterior and anterior fascial
advancement.

49. Ramirez technique:
Classically described for component
Separation requires large subcutaneous flaps
for access to be gained to the lateral
abdominal wall to release the external oblique
fascia.
 This technique has high wound morbidity
and is in general no longer recommended for
high-risk patients.

53. • World J Surg.2009Feb;33(2):199-207.Temporary
closure of the open abdomen: a systematic review on
delayed primary fascial closure in patients with an
open abdomen.
Boele van HensbroekP, Wind J, DiikgraafMG, et al.
Literature review of 154 abstracts of TAC techniques
vacuum-assisted closure
vacuum pack
artificial burr
Mesh/sheet
silo
skin closure
dynamic retention sutures (DRS)

54. • Highest Fascial closure rates and lowest
mortality rates
Artificial burr -- 90% & 17%
DRS -- 85% & 23%
VAC -- 60% & 18%

55. Thank you.