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3.2 Etiopathogenesis
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with hemoglobin in the uptake and transport of
oxygen. It is recommended to continually remove
the smoke produced by tissue fulguration without
an increase in carboxyhemoglobin levels [89,
90]. Harmonic scissors produce vapor-free gas,
avoiding the potential effects of carbon monoxide [91]. Another negative effect of electrocautery is the potential for uterine irritation. The CO2
insufation into the amniotic cavity of anesthetized ewes produced severe fetal hypercapnia,
despite normal maternal CO2 pressure and pH
[92]. However, the possible adverse effect of CO2
pneumoamnion is most relevant to the future use
of fetal surgery and should not be extrapolated to
intraperitoneal surgery.
A cardiac output decrease may put the placental and fetal blood ow at risk. However, the
effect of increased IAP on venous return is
volume- dependent [93]. In relatively hypovolemic subjects, increased IAP decreases venous
return. This effect results from elevated venous
resistance greater than the concomitant increase
in mean systemic pressure. Conversely, in relatively hypervolemic subjects, increased IAP
causes minimal compression of the inferior vena
cava, and increased mean systemic pressure
“pumps” the blood into the inferior vena cava.
This effect causes increased venous return and
cardiac output resulting from the Starling mechanisms [93]. Therefore, pregnant women are
usually hypervolemic because pregnancy is associated with increased circulating blood volume.
The pneumoperitoneum should not lead to lower
cardiac output or decreased fetal ow. Moreover,
moderately increased IAP as in laparoscopy (12–
15mmHg) increases preload at the beginning of
pneumoperitoneum as a result of “milking”
pooled blood from the splanchnic veins to the
systemic circulation and forcing blood to the
intravascular compartment from the compressed
liver and spleen [94–96].
The anesthesiologist easily corrects maternal
respiratory acidosis, but the end-tidal CO2 may
not reect the fetus’s true pCO2 and acid-base
balance. Alterations in ventilator settings based
on maternal end-tidal CO2 resulted in late and
incomplete correction of respiratory acidosis.
Therefore, arterial blood gases should be fol-
lowed for accurate monitoring, especially
because the end-tidal CO2 signicantly underestimates maternal pCO2 by 15 mmHg and lags
behind it [70]. Fetal hypercarbia, acidosis, possibly tachycardia, and increased fetal arterial pressure are produced by a CO2 pneumoperitoneum
[70]. Again, adverse long-term effects of these
physiologic alterations on the fetus are not found
but should be avoided, if possible, by close monitoring of maternal indices.
An N2O pneumoperitoneum showed none of
the ‘acidotic’ changes of CO2 pneumoperitoneum, but it has not been used due to combustion
concerns [70].
The Postpartum Period
The postpartum patient can eliminate concerns
about the fetus. However, several unique characteristics apply to this group. The enlarged uterus
is a potential technical factor in the early postpartum period. After CS, the challenges of a recent
surgical incision must be considered.
Any conservative treatment course is hampered by these patients’ strong desire to minimize
the number of hospital days, recurrent symptoms,
and disability. Physiologically, postpartum
patients are still recovering from pregnancy and
childbirth. Also, separation from a newborn,
combined with varying degrees of labile emotions related to the postpartum state, accentuates
the usual psychological stresses of illness. If
early laparoscopy can be applied to this group,
the benets will be even greater than that reported
for the general population.
The enlarged uterus does not hamper exposure, even in the rst week. At the time of surgery, the uterine fundus is below the umbilicus.
This is consistent with technical success and
good exposure in pregnant patients undergoing
laparoscopy during the rst and second trimesters [97].
The nal unique consideration in the postpartum patient is the presence of a healing abdominal incision after CS. Adhesions are rarely
encountered after CS.It seems prudent to utilize
the minimal IAP of 10 mmHg in CS patients.
This may prevent undue mechanical strain on the
healing wound, which is necessary for adequate
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3 Increased Intra-abdominal Pressure
exposure in these patients. Although evidence
suggests a fascial separation, if present, occurs
early, it remains to be seen what long-term status
these incisions will achieve. The course of the
procedure and recovery is identical to the remainder of the patients. No hernia has developed in
these patients with a follow-up of 5.5years [98].
Combined or Consecutive Operations
During theSame Pregnancy
Different emergent procedures are performed during the same pregnancy. Maternal and fetal outcomes depend mostly on the severity of the
underlying disease, not the operation and anesthesia. Both open and laparoscopic approaches are
allowed. The cholecystectomy is performed rst
because it looks safer to conduct a cholecystectomy
in a stable patient before any signicant bleeding
potentially encountered with childbirth [99] unless
preoperative fetal distress is conrmed.
When a laparoscopic approach is performed
with CS, CS should be performed rst due to the
remote intra-abdominal disease. There are several benets of such management. First, the fetus
has shorter exposure to the consequences of an
underlying maternal disease. Second, there is
more intra-abdominal space after CS, and the
pneumoperitoneum can be increased to
15 mmHg. Third, if the operation cannot be
completed by laparoscopy, a separate incision or
extension of median laparotomy enables combined procedures.
Gasless Laparoscopy
To overcome the potential adverse effects of pneumoperitoneum to the fetus, gasless laparoscopic
surgery (GLS) was developed during the 1990s
[100, 101]. GLS in pregnancy has comparable out-
comes to conventional CO2 laparoscopy, but it is
associated with some advantages. Hypercarbia
and increased intraperitoneal pressure due to CO2
insufation are avoided. Operations can be performed in epidural anesthesia [102].
There are two basic lift systems. The subcuta-
neous lift system [100, 102] has advantages over
the full-thickness wall lift [101]. First, the surgeon can avoid injury to the gravid uterus, thus
reducing the risk of abortion. Second, the subcutaneous lift system can be applied to all patients,
regardless of previous abdominal surgery or
unexpected adhesions. Another positive feature
of the subcutaneous lift system is eliminating
trauma to the peritoneum, which could cause
pain and result in adhesions.
Experience with gasless laparoscopy is limited to only 45 patients operated in pregnancy
[103–105]. More than 30 cases of non-emergent
GLS adnexal mass operations were performed
during pregnancy [102, 106–108]. Only six cases
of GLS cholecystectomy during pregnancy were
published [103, 109]. There is a case of GLS for
uterine myomectomy [110]. Three case reports of
GLS-treated adnexal torsion during pregnancy
were published. Two were successfully performed using the Laparofan (Origin, Menlo Park,
CA) [111, 112] and one with Mizuho Co [105].
Gasless laparoscopy is not widely accepted
in pregnant populations.
3.2.2.2 Burst Abdomen
Denition
A burst abdomen represents the partial or complete separation of an abdominal wall wound
with protrusion or evisceration of abdominal
contents. It should be distinguished from wound
dehiscence. Wound dehiscence and incisional
hernia are parts of the same wound failure process; timing and the healing of the overlying skin
distinguish the two. Wound dehiscence occurs
before cutaneous healing, while incisional hernias (see Sect. 19.4) lie under a well-healed skin
incision. Evisceration can occur after skin ischemia and subsequent skin dehiscence overlying
hernia due to increased IAP. This condition is
mostly seen with the (incarcerated) uterus in the
giant umbilical hernia (see Sect. 19.2).
Incidence andEtiopathogenesis
Burst abdomen during pregnancy develops after
incisional hernias (Fig.3.6) [113, 114], umbilical
hernias (Fig. 19.21) [115, 116], and surgical site
infections after laparotomy [117–119]. Intraabdominal sepsis in pregnancy is rare, and
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abdominal wall dehiscence following intraabdominal sepsis is even rarer. Respiratory insufciency, compensated by the additional use of
abdominal respiratory muscles, can cause wound
dehiscence [120]. The risk is higher if the underlying disease is causing respiratory insufciency.
For example, (1) silicosis can impair the prolif-
erative phase of wound healing through the
destruction of macrophages, which promote the
inammatory response and clear apoptotic cells
[120], and (2) corticosteroid therapy for silicosis
can additionally impair wound healing.
3.2.2.3 Acute Surgical Conditions
Acute Pancreatitis
A study of 17 pregnant women with acute pancreatitis in the third trimester (with 47% due to
hyperlipidemia) found a high prevalence of IAH,
with a mean IAP of 16.7 mmHg [121]. Two
(12%) developed ACS, with organ dysfunction
and a mean IAP of 21.7mmHg.
Intestinal Obstruction
See Chap. 18.
Acute Appendicitis
Acute appendicitis is the most common acute
abdominal surgical condition during pregnancy.
Therefore, although rare, the complications, such
as diffuse peritonitis and subsequent IAH, are
proportionally high [122, 123].
Spontaneous Hepatic Rupture
Spontaneous hepatic rupture in pregnancy with
hemoperitoneum causes IAP. The condition is
most commonly the result of preeclampsia, which
is a cause of increased IAP [124]. The third factor
Fig. 3.6 Protrusion of a 28–30-week pregnant uterus
through a large, 10-year unrepaired incisional hernia site.
(Reproduced with permission from [113])
Fig. 3.7 Perihepatic packing as a temporary treatment of spontaneous liver rupture in pregnancy. (Reproduced with
permission from [124] under the CC BY 4.0 and Reproduced with permission from [125])
that increases IAP is perihepatic packing (Fig.3.7),
a commonly used measure for temporary bleeding
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3 Increased Intra-abdominal Pressure
control when a hepatobiliary surgeon is unavailable [124, 126]. Simultaneously with perihepatic
packing, CS is performed. Due to deranged coagulation, closure of the gravid uterus is commonly
completed with pelvic packing, which also
increases IAP [127]. In most published cases, IAP
was not measured or not mentioned. One of the
positive effects of lowering IAP is emergent CS.
3.3 Clinical Presentation
The diagnosis of peripartum ACS is challenging
due to the lack of well-established normative
pregnant values of IAP and the overlap of signs
and symptoms between ACS and severe preeclampsia, such as oliguria and nonspecic
abdominal pain [128]. Abdominal distension is
always present. Percussion reveals intraperitoneal uid or tympanism (drum-like distension)
characteristic of bowel obstruction or paralytic
ileus. BP differentiates between preeclampsia/
eclampsia (elevated) and septic or hemorrhagic
shock. BP should be checked every several hours
or when the clinical condition deteriorates.
Patients with elevated BP with HELLP syndrome
can develop hepatic rupture with the hemoperitoneum resulting in a fall in BP [54].
A burst abdomen is easy to detect clinically as
a possible consequence of IAH/ACS in pregnancy. The condition may manifest following
straining or removal of the skin sutures. Patients
often note a ‘ripping sensation’ or a feeling that
‘something has given way’. Impeding abdominal
wall dehiscence is often preceded by the appearance of a salmon-pink serous discharge from the
wound. Late presentation of the burst abdomen
could result from the increased IAP and compression on the weakened abdominal wall from
the inside, sometimes with surgical site infection.
Large gravid uterus can be the only organ [113,
129] of evisceration (Fig.3.6).
3.4 Diagnosis
Diagnostic workup should include the detection
of IAP, IAH, and ACS and the underlying pathophysiologic process that leads to increased
IAP.Nonoperative (see Sect. 2.2.1) and operative
conditions (see Sect. 2.2.2) should be searched.
ACS is widely unrecognized because the routine
measurement of IAP generally has not been
accepted.
3.4.1 Intra-abdominal Pressure
Measurement
IAP measurement in obstetric patients who
receive ≥100mL/kg total resuscitation vol-
ume within 24h is recommended [27].
While the clinical examination is inaccurate for detecting raised IAP, IAH, and ACS,
the diagnosis should rely upon accurate serial
or continuous IAP measurements [130]. Serial
IAP measurements should occur every 4–6h
in patients at risk of IAH [27]. There is an
increasing number of IAP measurement
techniques.
Trans-bladder measurement at end-
expiration through a Foley catheter is the
method of choice due to its simplicity and
low cost. The level of the transducer
should be placed at the mid-axillary line
at the level of the iliac crest to obtain
accurate measurements. (World Society
of Abdominal Compartment Syndrome
[28])
Abdominal compartmentalization leads to
signicantly different IAP values depending on
the measurement location. For example, in
OHSS, after multiple abdominal operations and
adhesions, there is a signicant discrepancy
with IAP measurements through the bladder
and stomach [131]. The pelvic compartment
syndrome is a part of the pathophysiology that
includes the origin of IAP from the
retroperitoneum.
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3.4.2 Laboratory Findings
Hematocrit, hemoglobin, platelets, bilirubin,
aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase are diagnostic
for HELLP syndrome [128]. Three times over
normal upper levels, serum amylase and lipase
levels indicate acute pancreatitis (see Chap. 17).
For example, after transvaginal oocyte retrieval,
the underlying intraperitoneal infection can result
in an abscess, primary or secondary peritonitis
[132]. Raised C-reactive protein levels and leukocytosis indicate an underlying infection. Newonset proteinuria indicates preeclampsia/
eclampsia. Blood urea nitrogen and creatinine
levels determine the severity of the acute renal
failure.
Thromboelastography helps in the accurate
correction of deranged coagulation [127].
3.4.3 Plain Chest X-Ray
Chest X-ray can reveal pulmonary edema or
pleural effusion due to intra-abdominal pathology with IAH.
3.4.4 Abdominal Ultrasound
Transabdominal ultrasound can reveal a large
quantity of free intraperitoneal uid. It detects
underlying pathologies, such as large polycystic
ovaries in OHSS and acute pancreatitis (see
Chap. 17). Transvaginal ultrasound better denes
gynecologic causes of IAP.
3.5 Treatment
Prevention of IAH is the best way to avoid endorgan dysfunction and the associated sequelae of
ACS.The treatment goal for ACS is to decrease
IAP through medical or surgical targeting of the
forces affecting IAP.Management strategies have
ve categories: a decrease in intraluminal contents, a decrease in abdominal space-occupying
lesions, improvement of abdominal compliance,
avoidance of uid overload, and physiological
support of organs [28]. Medical management is
achieved with bowel decompression, uid collection drainage, sedation/analgesia, neuromuscular
blockade, limiting uid administration, and
diuresis/dialysis. However, the only denitive
treatment for ACS is surgical decompression of
the abdomen. Surgical decompression should
proceed without delay if indicated, as medical
interventions are often insufcient to treat ACS
adequately [133]. When ACS is encountered in
an obstetric patient, assessment of fetal viability
adds additional management considerations.
Urgent “therapeutic” delivery may become necessary if the condition of the mother or fetus
acutely worsens.
The proposed management algorithm for peripartum IAH and ACS is presented in Fig.3.8.
3.5.1 Nonoperative Treatment
3.5.1.1 Nutrition
Nutrition is a key component in the recovery of
patients following severe injury or abdominal
sepsis. The open abdomen results in signicant
protein and nitrogen loss (up to 2g/day) in the
general population [134]. Failure to account for
this may lead to malnutrition and poor outcomes.
This is more pronounced in pregnancy due to the
additional nutritional requirements of the fetus.
Protein deciencies are also a risk factor for
abdominal wall dehiscence.
Enteral feeding does not increase the risk of
ACS [135], and it is safe within 36h (or within
hemodynamic stabilization) of damage control
laparotomy [136–138] in the general population.
This concept has demonstrated increased fascial
closure rates and decreased infectious complications with early enteral nutrition. This could be
3.5.1.2 Medical Treatment
Enteral Decompression
Enteral decompression is recommended with the
liberal use of nasogastric or rectal tubes when the
stomach or colon is dilated in IAH.Promotility
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3 Increased Intra-abdominal Pressure
Fig. 3.8 Proposed
management algorithm
for peripartum IAH and
ACS. ACS abdominal
compartment syndrome,
IAH intra-abdominal
hypertension, IAP
intra-abdominal
pressure. (Reproduced
with permission from
[27])
Evaluate for obstetric IAH/ACS risk
factors; Measure IAP at iliac crest,
mid-axillary line
Patient has IAH, if:
Pre-delivery
IAP >14 mm Hg
Initiate treatment to reduce IAP
Avoid excessive fluid resuscitation
Optimize organ perfusion
New organ dysfunction
Pre-delivery Postpartum
IAP >25 mm Hg IAP >20 mm Hg
Intra-abdominal hypertension (IAH)
and
YES
Likely
ACS
Identify and treat ACS etiology
Postpartum
IAP >12 mm Hg
NO
Determine fetal
viability; Continually
assess benefits of
delivery vs. risks of
pregancy
Initiate continuous fetal
monitoring for viable fetus and
monitor IAP with serial
measurements every 4 hours
while patient is critically ill
Continue serial IAP
measurement and
fetal monitoring while
Patient is critically ill
NO
IAP is consistently:
Pre-delivery Postpartum
<14 mm Hg <12 mm Hg
YES
IAH has likely resolved
Discontinue IAP measurements
and monitor patient for clinical
deterioration
Does
patient have
primary
ACS?
YES
Perform/revise abdominal
decompression with
temporary abdominal closure
to reduce IAP
Abdominal compartment syndrome (ACS)
YES
Organ failure
Pre-delivery
IAP >25 mm Hg IAP >20 mm Hg
and
Serial IAP
measurement and
fetal monitoring
If
Postpartum
Patient has
NO
IAP >25 mm Hg
YES
Continue medical treatment to reduce IAP
Measure IAP at least every 4 hours while patient is critically ill
Perform balanced resuscitation, targeting
preload, contractility and afterload using
crystalloid/colloid/vasoactive medication
AVOID EXCESSIVE FLUID RESUSCITATION
NO
secondary or
recurrent ACS
Progressive organ failure
Pre-delivery
and
NO
If IAP consistently:
Pre-delivery
<14 mm Hg <12 mm Hg
Postpartum
IAP >20 mm Hg
Postpartum
YES
Discountinue IAP measurements
and monitor patient for clinical
IAH has resolved
deterioration
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63
agents, such as metoclopramide (gastroparesis
and small bowel ileus) or neostigmine (large
bowel ileus), may be considered. Enteral nutrition can be minimized or interrupted in refractory
IAH, considering the importance of nutrition in
the critically ill. Consider enemas as a nal step.
Evacuation ofIntra-abdominal Lesions or
Fluid
Ultrasound or computed tomography can identify
space-occupying lesions in the abdominal cavity.
Fluid collections may be drained percutaneously
or surgically. Paracentesis is indicated to relieve
IAH or ACS from OHSS, primarily if a respiratory failure occurs [56, 58].
Management oftheUnderlying Disease
Management of the underlying disease, such as
OHSS, decreases the amount of intraperitoneal
uid and, therefore, IAP and IAH.Treatment ranges
from conservative observation to intensive care
admission with IAP monitoring and paracentesis to
relieve ACS [56, 58]. Many consider polycystic
ovaries the most important risk factor for OHSS
[132]. Insulin resistance, hypothyroidism, and
hyperprolactinemia are the most common causes of
polycystic ovaries. After the endocrine disorders are
addressed (levothyroxine and metformin), OHSS
and IAP can be successfully treated [132].
Abdominal Wall Compliance Optimization
Abdominal (wall) compliance is dened as the
ease with which abdominal expansion can occur
and is determined by the elasticity of the abdominal wall and diaphragm. Light sedation in the
ICU increases abdominal compliance. The
patient should be resting comfortably but easily
arousable and able to follow simple commands.
An analgesic agent should be prescribed rst, followed by sedatives if required [139]. Deeper
sedation may be needed to prevent forceful
Valsalva maneuvers and evisceration. Analgesics
and sedatives inhibit pain and awareness if the
neuromuscular blockade is used. The association
between benzodiazepine exposure in the rst trimester and congenital anomalies is controversial
and contradictory. A benzodiazepine infusion
should not be withheld from a critically ill pregnant patient if needed for optimal care.
Neonatology personnel should be alerted to analgesia/sedatives in pregnant women. Epidural
analgesia may also improve abdominal wall compliance and enhance peristalsis [140].
Optimization ofFluid Administration
A negative uid balance is desirable to decrease
extravascular (lung) water and improve IAP in
patients with IAH.The goal should be to achieve
a neutral or negative uid balance by day 3 [28].
Diuretics have not been studied in the ACS population, but furosemide may be safely used in
pregnancy when indicated [141].
Resuscitation is characterized by permissive
hypotension and limitation of crystalloid IV uids and transfusing a 1:1:1 ratio of packed red
blood cells to fresh frozen plasma to platelets to
physiologically reconstitute whole blood [142].
The risk of ACS and associated mortality
increases when the total resuscitation volume
reaches more than 96mL/kg (where most of the
volume was given during the rst 12h) [143].
3.5.2 Operative Treatment
Surgical intervention should proceed expeditiously when either maternal or fetal compromise
cannot be reversed using conservative measures.
Laparotomy alone does not indicate delivery;
however, delivery of a viable fetus (>24weeks
estimated gestational age) may improve conditions for the mother and fetus. Conversely, the
delivery of a nonviable fetus at decompressive
laparotomy cannot be recommended because this
increases blood loss and operative time.
Indications for laparo(s)tomy are [144,
145]:
• oliguria,
• hypotension,
• acidosis,
• intraoperative risk factors for IAH/
ACS,
• abdominal sepsis,
• fetal compromise.
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3.5.2.1 Source Control
Removal of the underlying cause, for example, as
in Meigs’ syndrome [65], has two therapeutic
implications: (1) removal of the (functional)
pathologic process itself and (2) the decrease of
IAP due to the removal of bulky tumor/mass.
3.5.2.2 Planned Relaparotomy
As a rule, 24–48 h after the initial surgery for
intra-abdominal sepsis or suspected organ vitality, the patient should be taken back to the operating room for reoperation. Reoperation should be
performed in this time frame because (1) the
abdominal exploration, lavage, drainage, and
source control may be more difcult later due to
the intraperitoneal adhesions and risks of bowel
injury [146] and (2) the progress of organ ischemia, mostly bowel, does not result in ischemic
perforation and (stercoral) peritonitis.
3.5.2.3 Decompression Laparotomy
The ideal temporary abdominal closure (TAC)
method should [147, 148]:
• protect the abdominal contents,
• prevent evisceration,
• allow removal of infected or toxic uid from
the peritoneal cavity,
• prevent the formation of stulas,
• avoid damage to the fascia,
• preserve the abdominal wall domain,
• make reoperation easy,
• safe,
• facilitate denitive closure,
• allow for postoperative fetal heart rate
monitoring,
• allow space for uterine growth.
Intraoperatively, free intraperitoneal uid or
blood [54] should be evacuated. After several
abdominal washouts with Ringer’s lactate at
37–40°C, the type of laparotomy closure is chosen [128]. Many different techniques of TAC
have been introduced, but groups are small and
heterogenous, making a comparison of techniques and outcomes difcult [149]. The advantages and disadvantages of different forms of
TAC are summarized in Table3.4.
Primary closure appears particularly challenging in the abdomen with the growing gravid
uterus and low IAP requirements. It is nevertheless a key endpoint in a pregnant woman to protect the fetus and ensure a vaginal delivery. If the
denitive fascial closure is not possible, another
option may be skin-only closure to cover the
exposed viscera and protect it, minimizing further injury to the exposed bowel. Ostomies
should be placed as lateral as possible to be adequate [151].
Decompression laparotomy with various types
of TAC (Fig.3.9) is indicated for ACS, not the
cause of ACS [128]. Delayed repair by bridging
biological meshes in the open abdomen management has not been completely claried. All
guidelines and recommendations until 2021 do
not discuss pregnant patients.
Vacuum-Assisted Closure (VAC)
Only several cases are published involving negative pressure wound therapy or VAC on laparotomy wounds of gravid patients. There were no
adverse effects on the fetus [117, 152, 153]. The
initial value of negative pressure is not studied.
Some started with less negative pressure
(−75 mmHg), with an increase if no adverse
effects were present (−100mmHg) [117], while
others started at maximum negative pressure
(−125mmHg) [153].
3.5.3 Obstetric Management
With ACS, the benets of continuing pregnancy
must be balanced against the risks of clinical
deterioration to the mother and fetus. A low
threshold for delivery is warranted while carefully monitoring for signs of compromised uteroplacental perfusion.
Therapeutic similarities (delivery of the fetus)
were identied in the pattern of progressive
multi-organ dysfunction in IAH and preeclampsia, resulting in abdominal decompression. The
placenta is the mediating factor for the maternal
systemic inammatory response, and the delivery
of the placenta could be the cure for preeclampsia. Therapeutic delivery as a treatment modality
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Table 3.4 Advantages and disadvantages of different types of temporary abdominal closure techniques [146, 150]
Technique Equipment Advantages Disadvantages
Skin-only closure Skin staples, towel
clips, or sutures
‘Bogota’ bag Sterile 3L saline bag
cut and shaped and
sutured to fascial edges
Opsite Sandwich
Technique
Absorbable mesh Vicryl or similar mesh Absorbable mesh, infection
Nonabsorbable
mesh or Commercial
‘zipper’
Vacuum-assisted
closure (VAC)
Abdominal
reapproximation
anchor
System (ABRA)
Polyethylene sheet,
Opsite dressings,
abdominal packs, 2
suction drains, and
wall suction
Commerical Whittman
patch
Commercial equipment Prevents the loss of the abdominal
Series of elastomers
xed to button anchors
Cheap, available, minimizes heat
and uid loss
Cheap, available, minimizes heat
and uid loss
Cheap, available, minimizes heat
and uid loss; controlled and
measurable
resistance, protects from
evisceration; can be skin grafted
Abdominal reexploration is easy,
maintains the abdominal domain,
and gradual abdominal closure is
possible
domain, collects and monitors
uid loss, decreases ACS, and
causes no damage to the skin or
abdominal fascia
Continuous defect decrease due to
constant tension on elastomers
Damage to the skin, the risk of
evisceration, no control of uid
loss, the incidence of ACS
Damage to the fascial edges,
the risk of evisceration, and no
control of uid loss. Allows
some assessment of intestinal
viability
Incomplete uid control and
need for available wall suction
The high rate of subsequent
incisional herniation
Commercial equipment is
required, and multiple trips to
the operating theatre are usually
required for closure
Expensive commercial
equipment is required. Usually
requires general anesthesia to
change the VAC system
Daily dressing changes
65
for the underlying cause is presented in various
chapters depending on the cause.
Indications for emergent CS are (1) obstetric,
(2) uterus obstructs the operative eld (mostly in
trauma patients), and (3) maternal cardiopulmonary resuscitation (see Chap. 2). Fetal distress is
an indication of the emergent CS of the viable
fetus. The fetus is considered viable at a gestational age of 24weeks. Fetal heart rate<100bpm,
prolonged deceleration for >1min, or recurrent
late decelerations prompt emergent delivery
[154]. The survival of infants born at 23–25weeks
gestation was only 40% compared with those
delivered at 26 weeks (80%) after maternal
trauma. With spontaneous hepatic rupture,
emergent CS is indicated. Due to underlying
HELLP syndrome and secondary coagulopathy
from massive bleeding, sutures on the uterus are
sometimes not hemostatic. In such cases, pelvic
packing is indicated. If unsuccessful, a total
abdominal hysterectomy should be performed
[127].
The question remains whether expectant
obstetric management is feasible when open
abdominal management is deemed necessary for
maternal care. Due to a small number of cases
with different etiologies and weeks of pregnancy,
conclusions cannot be drawn, but 75% (3/4
patients) had further normal pregnancies [122,
148, 150, 152].
3.5.3.1 Burst Abdomen
The management of a burst abdomen is difcult
for both the surgeon and the obstetrician. Whether
to close the abdomen and when and how to
deliver the fetus depend on maternal and fetal
factors. Therapeutic principles are the same as in
the nonpregnant population, with the possibility
of an additional procedure for lowering IAP and
salvaging the fetus—CS (Fig.3.10).
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a
b
cd
Fig. 3.9 (a) The gravid uterus is in the inferior half of the
laparostomy; (b) the open abdomen is ‘closed’ with
vacuum- assisted closure. (Reproduced with permission
from [152] under the CC BY 2.0); (c) the open abdomen
3.5.3.2 Postpartum
At the postpartum IAP at various times following
CS, the mean pressure remained below the cutoff value of 12mmHg, within the non-IAH range.
The IAP was 7.4±3.8mmHg [20] when measured immediately after surgery; 6.4±5.2mmHg
[18] or 10.8mmHg (95% CI: 4.5–18) at 1h after
surgery [30]; and 9.8± 3.0 mmHg at 24h [5].
Thus, postpartum values of IAP appear to be
lower than those during pregnancy and outside
the range for IAH, even for critically ill pregnant
patients [9]. IAP values after delivery are similar
in critically or noncritically ill obstetric patients,
irrespective of risk factors for IAH seen in the
ICU.Obese patients (BMI >30kg/m2) have sig-
is temporarily closed with Bogota bag. (Reproduced with
permission from [122]); (d) the technique of abdominal
reapproximation anchor system. (Reproduced with permission from [150] under the CC BY 4.0)
nicantly higher preoperative IAP levels than
nonobese patients (15.7 vs. 12.4mmHg, respectively) (Fig.3.11). However, this difference also
disappears after delivery [30], and values are by
the standard value of IAP following uncomplicated abdominal surgery (10–15 mmHg) [66,
155]. Many factors have been described to
explain this physiological increase after surgery,
but the two main factors in obstetrics are the persistent increase in uterine size and the CS itself.
Every pregnant woman admitted to ICU
after delivery should be monitored for IAP.
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