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9 Contemporary Management of the Open Abdomen 235
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Tab le 9.5 Complexity of open abdomen (modified Bjorck classification) [9, 32]
Grade Description
1. No fixation 1A Clean, no abdominal wall fixation, or bowel adhesions
1B Contamination, no abdominal wall fixation, or bowel
1C Enteric leak, no abdominal wall fixation, or bowel
2. Developing fixation 2A Clean, developing abdominal wall fixation or bowel
2B Contamination, developing abdominal wall fixation or
2C Enteric leak, developing abdominal wall fixation or
3. Frozen abdomen 3A Clean, frozen abdomen
3B Contaminated, frozen abdomen
4. Frozen abdomen with established entero-atmospheric fistula
to abdominal wall
adhesions to abdominal wall
adhesions to abdominal wall
adhesions to abdominal wall
bowel adhesions to abdominal wall
bowel adhesions to abdominal wall
9.3.2 Static Temporary Abdominal Closure
Static techniques, as their name suggests, simply hold the fascial edges apart whilst
protecting the exposed viscera. Their main role is in the stabilisation of a patient
prior to transfer and otherwise should be avoided. They include:
1. Deep retention sutures-heavy gauge, non-absorbable sutures passed through the
full thickness of the abdominal wall and tied in the midline. They have no
evidence to support their continued use and should be abandoned as they confer
no benefit and simply cause pain, skin and muscle necrosis [56].
2. Skin-only closure-involves closure of just the skin with clips or a running
suture. Its main advantage is the speed at which it can be achieved but it may
not adequately decompress the abdomen in cases of ACS, has a high risk of
dehiscence and evisceration and does nothing to deal with the fluid exudate
generated.
3. Bogotá bag (silo technique)-involves the suturing of a sterile plastic sheet (typ-
ically a 3L cystoscopy irrigation bag opened out) to the fascial edges to cover
the viscera. Whilst cheap, simple, and allowing easy visual inspection of the
underlying gut, its main drawback is that it does not prevent adhesion formation
to the abdominal side wall allowing the abdomen to become rapidly fixed and
preventing early fascial closure. In addition, it does not manage fluid exudate or
fistula effluent and oedematous loops of bowel can herniate into the bag, com-
pounding the fixity and making definitive closure of the abdomen impossible
Fig. 9.1.
4. Wound management (Eakin) bag- similar to a stoma bag but larger which often
requires specialist nursing input for both initiation and management of therapy.
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Fig. 9.1 Bogota Bag
It is useful in managing open abdomens with associated enteric fistulation and
catheters on low grade suction can be placed through the bag to remove enteric
content (Grades 3b & 4) Fig. 9.2.
5. Wound packing with gauze rolls-u
sually a short-term option as it requires frequent dressing changes in theatre and there is a risk of the gauze sticking to
exposed bowel loops causing serosal damage and fistulation on removal.
6. Mesh-which is sutured to the fascial edges to prevent evisceration and can be
combined with suction and occlusive dressings to control effluent. Marlex mesh
(permanent synthetic) was advocated by Schein as part of his sandwich technique and was applied with the omentum, if present, interposed between mesh
and bowel [64]. In a later series, Schein identified at least two patients who
developed fistulas as a direct consequence of the overlying mesh [65]. Biologic meshes, derived from animal or human cadaveric dermis have also been
used with mixed results. Contemporary management, if used as a static technique, would advocate dissolvable synthetic mesh (Polyglactin 910-Vicryl™)
as a safer alternative.
7. Negative pressure wound therapy (NPWT) is strictly speaking a static technique, splinting the wound open and does not specifically apply traction to the
fascia. NPWT dressings can be home-made (Barker or Sandwich pack method)
or commercially available [7, 44, 72]. The home-made version typically uses a
fenestrated, non-adherent plastic sheet to cover the viscera, moist gauze rolls or
packs with a suction drain tube in the middle and an outer layer made from a
surgical incise drape to seal the dressing to the skin. The drain is connected to
9 Contemporary Management of the Open Abdomen 237
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Fig. 9.2 Eakin wound management system
wall suction to control peritoneal fluid losses. Commercially available systems
simplify open abdomen management and have the advantage over home-made
dressings of applying a reliable negative pressure spread consistently over the
dressing. The most recent iteration of this device uses a large fenestrated visceral protection layer (VPL) to protect the bowel and to assist with drainage
of peritoneal fluid. Concerns have been raised about the direct suction effect
on bowel and the subsequent generation of enterocutaneous fistulas, with prolonged use of NPWT [23, 53].Carlson carried out a nationwide audit of UK
open abdomen practice to assess vacuum therapy safety and found an overall
intestinal fistulation rate of 12% but no difference in mortality or development
of fistulas between those treated with and those without NPWT [15] Fig. 9.3.
9.3.3 Dynamic Temporary Abdominal Closure
Dynamic TAC methods are preferred in the contemporary management of the open
abdomen as they increase the likelihood of delayed fascial closure. However, if
used in isolation they do not prevent visceral adhesions to the abdominal side walls
and may generate shear forces leading to increased risk of intestinal fistulation
[45].
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Fig. 9.3 Negative pressure wound therapy (NPWT)
They Include:
1. Dynamic retention sutures-multiple fascial sutures which are progressively
tightened to bring the fascial edges together and then tied to provide definitive
closure. The ABRA™ approximation anchor system is a commercially available version comprising a combination of elastomer bands passed through the
fascia and secured to the skin with buttons [54]. It applies both skin and fascial
traction which in turn achieves closure.
2. Wittmann™ patch (artificial burr)- a Velcro™-like equivalent consisting of two
sheets of material, one with a fuzzy, looped surface and the other with hooks,
which are sutured to the fascial edges and then pressed together, adhering to
9 Contemporary Management of the Open Abdomen 239
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each other like Velcro™ [86]. The patch can be sequentially tightened and
trimmed until fascial approximation is achieved. In addition, a hypobaric wound
shield, comprising sterile gauze to cover the patch, a drain, and a self-adhesive
plastic drape, can be applied to control exudate and measure fluid loss.
3. Mesh mediated fascial traction-here a synthetic mesh of any description (permanent or dissolvable) is sutured to the fascial edges and sequentially trimmed
and tightened like the Wittmann patch. The mesh is ultimately removed when
the fascial edges approximate and these can be directly sutured.
9.3.4 Mixed Techniques
Mixing elements of static and dynamic temporary abdominal closure techniques
offers the best chance of dealing with peritoneal fluid losses, protecting the viscera,
reducing intestinal fistulation, and also achieving delayed primary fascial closure.
Simply put, any dressing that combines active fascial traction by suture, mesh, or
patch with NWPT appears to give the best outcomes.
Bruhin et al. conducted a systematic review of outcomes for NPWT in the open
abdomen and in doing so included evidence from studies concerning the Bogotá
bag, and the artificial burr (Wittmann patch) [13]. They looked at the relative
safety and efficacy for each TAC method split into non-septic and septic/mixed
open abdomens (Table 9.6).
Their findings illustrate that the septic abdomen almost halves the likelihood of
delayed fascial closure, and roughly doubles the mortality and fistulation rate. The
exception is when commercial NPWT is coupled with fascial traction where there
is no obvious difference between non-septic and septic/mixed cases.
Atema et al. conducted a systematic review and meta-analysis of 74 studies
concerned with temporary abdominal closure techniques in non-trauma patients
treated with an open abdomen [3]. There was only one randomised controlled trial
and 19 prospective studies; the remaining 53 all being retrospective. The review
covered 4358 patients, 79% of which had secondary peritonitis, many of whom
were taken from mixed series of both trauma and sepsis. The overall weighted
Tab le 9.6 Outcomes of temporary abdominal closure dressings for open abdomen [13]
Method Pathology Patients
Commercial
NPWT
Commercial
NPWT & traction
Home-made
NPWT
Wittmann Patch Non-septic 155 (7) 68 13.7 3.1
Bogotá bag Mixed 396 (8) 26.6 30.3 6.6
Non-septic
Septic/mixed
Non-septic
Septic/mixed
Non-septic
Septic/mixed
(no studies)
337 (7)
941 (22)7247.5
188 (5)
270 (7)
551 (8)
238 (5)
Delayed fascial
closure (%)
81.9
74.6
57.7
35.2
Mortality (%) Fistula (%)
16.5
26
24.6
22.8
16.9
40.5
3.7
12.1
6.7
5.5
6
–
240 D. A. J. Slade
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mortality rate was 30%, with 12.1% developing intestinal fistulation. The most
frequent indication for an open abdomen was a planned relaparotomy. NPWT was
the most frequent TAC employed, and in the 6 series where it was combined with
either suture or mesh-mediated fascial traction, the highest rates of delayed fascial closure were achieved at 73.6% and 73.1% respectively (range 34.2–73.6%).
Moreover, combined NPWT and fascial traction techniques were associated with
the lowest weighted mortality of 11.1% and a fistulation rate at just 5.7% (95% CI
2.2–14.1).
Whilst the methodological quality of the individual studies in these systematic
reviews of trauma and sepsis patients was low, the finding that early fascial closure
reduces fistulation rates and subsequent mortality is a recurring theme.
Willms et al. reported factors influencing fascial closure after open abdomen
treatment from the European Hernia Society (EHS) registry covering 630 patients
[85]. The majority of patients had an open abdomen for peritonitis (46%), with
ACS (20.5%), burst abdomen (11.3%) and trauma (9%) being the next most frequent indications. Achieving fascial closure was associated with reduced mortality
(23%, 34/148 vs 14.1%, 51 of 311 patients (p = 0.015)) and a lower incidence of
enteroatmospheric fistula (5.5% vs 17.6% (p < 0.001)). Of interest only 30% of
these patients were treated according to an established standard treatment protocol,
with management of all other cases decided by individual surgeon preference. In
a separate publication, Willms also demonstrated the significant impact a visceral
protection layer (VPL-protective fenestrated sheet placed over the viscera which
prevents sidewall adhesions and dissipates suction) in a propensity-score matched
analysis of 68 patients with peritonitis split evenly into those that were and were
not managed with a VPL [84]. The enteroatmospheric fistulation rate was 14.7%
without VPL and just 2.9% when VPL was used.
9.3.5 Vacuum-Assisted Wound Closure Using Mesh-Mediated
Fascial Traction
We can reasonably conclude, that irrespective of the aetiology for the open
abdomen, the management strategy associated with the lowest mortality and fistulation rates and highest delayed fascial closure rate, comprises three essential
treatment components:
•
commercial NPWT
•
a visceral protection layer (VPL)
•
dynamic fascial traction
Practically, the easiest way to provide dynamic fascial traction is with mesh sutured
to the fascial edges which can be windowed and then progressively cinched with
a running heavy gauge suture at each dressing change (Fig. 9.4). Its use in combination with NPWT was first described by Petersson in seven patients with mixed
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Fig. 9.4 Vacuum-assisted wound closure using mesh-mediated fascial traction (MMFT)
aetiology for an open abdomen)) [46]. They dubbed it vacuum-assisted wound closure with mesh (VAWCM) and whilst only a small pilot series, it was striking that
all patients achieved delayed fascial closure, one at 52 days out, with no enteric
fistulation.
There followed a rash of publications and by the time the European Hernia
Society (EHS) published guidelines on management of the abdominal wall in the
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context of the open abdomen, they included four randomised controlled trials comparing fascial traction to no fascial traction, 14 observational studies of VAWCM,
and 6 of NPWT with other forms of fascial traction [37]. The majority of patients
had peritonitis (66%), the pooled proportion achieving delayed fascial closure was
75.9% (95% CI 63.2–88.5%) and the enteric fistulation rate was 4.3% (95% CI
2.5–6.2%). The EHS guideline group concluded not only that dynamic TAC tech-
niques should be used in patients with Grade 1 & 2 open abdomens but also
that they were preferred over static ones (Strong recommendation, low quality of
evidence).
Two years later Poortmans and Berrovoet reported an update on dynamic clo-
sure techniques in the open abdomen with the sole purpose of strengthening the
previous EHS guidelines through additional systematic review [51]. They found a
further 13 observational cohort studies, with 9 describing mesh-mediated fascial
traction in combination with NPWT. They were unable to strengthen the recommendation with improved evidence due to patient and study heterogeneity but were
able to demonstrate equivalent fascial closure rates with dynamic techniques of
between 72–93%. At the same time, Petersson & Petersson conducted a systematic review of VAWC using mesh-mediated fascial closure covering 600 patients
across 15 articles [48]. The review and findings were predictably similar to that of
Poortmans and Berrevoet but the authors also analysed six studies which covered
long-term outcomes following delayed fascial closure, specifically describing an
incisional hernia rate of 21–54% and two studies that described 33–42% of patients
requiring subsequent surgery for their incisional hernia. The long-term incisional
hernia rate is predictably above 30% in patients undergoing VAWCM achieving
successful delayed fascial closure [83].
In an attempt to reduce the associated long term incisional hernia rate, Peters-
son described a modification of VAWCM in a pilot study of just 11 patients which
combines mesh-mediated fascial traction with the onlay mesh techniques used for
incisional hernia prophylaxis in high risk patients [47]. The modification involves
dissecting the rectus fascia from the subcutaneous fat for a distance of 3–4cms
around the incision. A heavyweight polypropylene mesh is divided into two halves
and sutured to the fascia in two rows: the outer row at the lateral margin of the
fascia and the inner row at the fascial edges with running 2/0 sutures. A visceral
protection layer (VPL) is placed over the intestines and the mesh halves sutured
together under tension. A commercial NPWT system is applied as for VACWM.
Progressive traction and trimming of the mesh at each dressing change leads to
approximation of the fascial edges, at which point the NPWT system is removed,
the two parallel strips of mesh are sutured together using a 2/0 suture and the skin
closed. The secure attachment of the two mesh halves allows greater traction to
be applied to the fascia and at the end of therapy provides fascial reinforcement.
Placing the NPWT system over the mesh sutured to the fascia ensures the mesh
remains clean and encourages rapid ingrowth of granulation tissue through the
holes in the mesh speeding up its incorporation. Using this technique, the investigators achieved 100% complete fascial closure with no mortality or fistulation.
22% patients developed an incisional hernia at a median follow up of 467 days.
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9.3.6 Immediate Management of an Enteroatmospheric
Fistula
As soon as an enteroatmospheric fistula develops during open abdomen therapy,
the management changes irrevocably. Attempts at fascial traction must cease and
the wound has to be left to heal by secondary intention. It is unusual for these
fistulas to heal spontaneously as they have no overlying soft tissue, and the edges
are fixed to granulation tissue or other loops of bowel. In addition, surgical repair
cannot be achieved until the wound has epithelialized and the neoperitoneal cavity
re-established, a process that can take up to 6 months [76]. The effluent contains
proteolytic enzymes which can lead to agonisingly painful excoriation of wound
edges and skin along with secondary infection from bacteria [69]. Wound management must employ suction to remove effluent and prevent its prolonged contact
with the wound bed. This can be achieved by the addition of catheters to the wound
management bag attached to low grade wall suction. Alternatively, it is possible to
continue with NPWT as long as the fistula and exposed bowel is protected. Numerous innovative techniques for isolating the fistula have been described including
creation of a chimney or “Chimney-Vac”, using a wound protection device or
purpose-built “Donuts” [10, 67, 75]. Whatever technique is employed it is essential that the NPWT does not generate further fistulas through direct damage to the
remaining exposed bowel and if concern exists then conversion to a simple wound
management (Eakin) bag with low grade wall suction is safer [28].
The mainstays of management are encapsulated by the SNAP algorithm.
•
elimination of Sepsis with Skin protection and pSychological input
•
Provision of safe Nutrition
•
elucidation of fistula Anatomy
•
followed eventually by a corrective surgical Procedure some 6 months or later
[30].
Sepsis continues to be the main cause of mortality, and in one review accounted
for 15% of deaths in the early management of 286 fistula patients [52]. Aggressive
elimination and management of IAS is essential to prevent its progression to multiorgan failure and death.
Close attention to skin care helps to reduce the pain associated with a fistula.
Immediate management of the effluent includes accurately measuring fistula output
and if > 500mls/day, steps should be taken to reduce the volume which include the
use of the antidiarrheal drugs loperamide and codeine. Protein pump inhibitors may
also effectively reduce output by diminishing gastric and biliary secretions. There
is no evidence to support the use of octreotide in these patients [69]. Clinical psychological input to address the distress, subsequent mistrust in medical teams, pain,
body image, sexual well-being and even post-traumatic stress is invaluable. Holistic care for these patients is usually best provided in specialist tertiary units which
can offer expert nursing and psychological support in the early phase of management extending for up to 6 months before corrective surgery can be planned.
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Nutrition can be oral if the fistula is easily visible and there is no concern that
it is feeding an abscess cavity, perpetuating IAS or complicating fluid or wound
management. Frequently parenteral nutrition is required to manage the metabolic
consequences of a fistula, replace fluid and electrolyte losses and to provide essential calories. Nutrition can also involve enteral feeding into a fistula or stoma if
fluoroscopy can demonstrate at least 75 cms of healthy, unobstructed and fistula
free downstream small bowel. This can be by placement of a gastrostomy tube
into the open bowel and simple enteral feed or by chyme reinfusion, both of which
have been shown to reduce dependence on parenteral nutrition even to the point
of replacing it and to improve the quality of the defunctioned bowel to facilitate
future reconstructive surgery [49, 76].
Anatomical mapping in contemporary management involves the combination
of CT scanning and fluoroscopy including meal and follow through and fistulograms where appropriate. All defunctioned bowel must be imaged to assess its
length, quality, and to rule out occult strictures or downstream fistulas which could
complicate future reconstruction. The information derived from these studies also
allows prognosis and decision-making in terms of regaining enteral autonomy after
reconstructive surgery. If biliary or urinary tract involvement is suspected then
ultrasound, magnetic resonance imaging or cystograms may be required. The overriding premise is to ensure that all of the surgical anatomy is understood prior to
any procedure.
Reconstructive surgical procedures for enteroatmospheric fistulas are invariably
challenging, prolonged and high-risk operations. Consent and planning should prioritise what is most important to the patient and the likelihood of achieving goals
such as resection of fistulas, regaining enteral autonomy and repair of the significant abdominal wall defect discussed with the supporting information gained from
anatomical mapping. In many cases, a compromise needs to be reached, particularly in relation to the abdominal wall defect, the surgery for which is usually
limited by the associated contamination from the fistula [69].
9.4 Conclusion
Whilst an open abdomen has been shown to be a life-saving technique in the management of acute surgical illness, it is also associated with significant mortality and
morbidity. Contemporary management should start with assessing whether an open
abdomen is actually required. If deemed necessary then the patient should be managed with a treatment algorithm involving commercial NPWT, dynamic traction
and protection of the exposed viscera with a VPL. The aim should be to achieve
safe fascial closure of the abdomen as rapidly as possible. This starts with rapid
correction of physiology in trauma, timely and effective source control for sepsis,
medical management of IAH, and swift decision making around deferred anastomoses, gut resection, or stoma formation in ischaemia. Communication between
surgical, critical care and anaesthetic teams should be clear and with an onus on
returning to theatre to start fascial traction or perform fascial closure as soon as
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