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Part III
Incisional and Ventral Hernia
The Open Abdomen: Indications and Management
Helen J. Thomson and Alastair Windsor
24
Introduction
In 1897, McCosh [1] noticed that after surgery for sepsis, it
could be difficult to fit all the bowel back into the abdominal
cavity. He described leaving the original incision partly open
to allow time for the bowel to settle. The outcomes were not
good by modern standards, but this partially open abdomen
did show benefits in some patients.
Ogilvie’s paper of 1940 [2] described complications of
abdominal war wounds including burst abdomen, hernias,
residual abscesses and fistulae. He suggested that if at the
end of surgery the midline defect was more than 3 inches
wide, no attempt should be made to close it, as this would
cause too much tension. He suggested inlaying a shaped
piece of canvas covered in Vaseline, secured with sutures, to
‘close’ the abdomen without tension. This achieved control
of abdominal contents and allowed healing, whilst protecting
the bowel.
Indications for the Open Abdomen
Over the last 20 years, the therapeutic ‘open abdomen’ (OA)
has become more widely used. It can be a useful tool in the
treatment of the abdominal catastrophe. New techniques for
its management have been developed, and outcomes are
improving.
Many indications for open abdomen have been described:
severe abdominal sepsis, severe acute pancreatitis, damage
control laparotomy, surgery for major haemorrhage, bowel
ischaemia or where a relook laparotomy is planned. Other
indications include prevention of or treatment of intra-
abdominal hypertension (IAH) or abdominal compartment
syndrome (ACS).
OA should not be seen as a panacea but a very useful therapeutic measure to be used in certain specific conditions.
Wherever possible, primary closure of the abdomen should
be carried out, even if further laparotomy may be needed
[3–6]. The indications cited in the literature come down to
the same two true indications for OA—prevention of IAH/
ACS and treating it once it is established. OA should not be
used as an easy way to re-enter the abdominal cavity for
planned relook laparotomy.
Abdominal Compartment Syndrome
IAH and ACS were defined by the international conference
of experts on intra-abdominal hypertension and abdominal
compartment syndrome and published in 2006 [3].
IAH is defined as sustained or repeated pathological
elevation of IAP ≥12 mmHg. Abdominal compartment
syndrome (ACS) is defined as a sustained IAP >20 mmHg
that is associated with new organ dysfunction/failure. It
may be primary, secondary or recurrent. Primary ACS is
associated with injury or disease in the abdomino-pelvic
region, whilst secondary ACS refers to conditions that do
not originate from the abdomino-pelvic region. Recurrent
ACS refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary
or secondary ACS [3].
Causes of IAH/ACS
IAH/ACS may be caused by factors arising within (primary)
H.J. Thomson, MD, FRCS, FDS RCS (*)
Pinderfields Hospital, Wakefield, UK
e-mail: helen.thomson2@midyorks.nhs
A. Windsor, MD, FRCS
University College Hospital, London, UK
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_24
or outwith (secondary) the abdomen. The risk factors for the
development of ACS are any condition that increases the volume of the abdominal contents or decreases the compliance
of any of the anatomical walls that confine that space or a
combination of both as well as more general patient factors
357
358
H.J. Thomson and A. Windsor
[7–9]. Whatever the causes, they have to be of a relatively
acute onset in order to overcome the body’s natural compensatory ability.
Intra-luminal volume of the gut may be increased by gastric dilatation, ileus, pseudo-obstruction, toxic megacolon or
any volvulus. We should also consider massive abdominal
hernia repair in this group. If a significant amount of abdominal contents are returned into the abdominal cavity without
addressing any preoperative domain loss, the intra- abdominal
pressure will increase. Increased extra-luminal volume may
be solid as in rapidly growing tumours or more often fluid
such as peritoneal dialysis, ascites, intra-abdominal infection
or collections, haemoperitoneum or pneumoperitoneum,
which may be iatrogenic as in laparoscopic surgery. In any
critically ill patient, fluid shifts can follow massive resuscitation and can lead to secondary ACS [10].
Limitations on abdominal wall compliance can affect any
of the soft tissue boundaries of the abdominal cavity.
Ventilated patients with high PEEP have a functional splinting of the diaphragm. The anterior abdominal wall’s compliance is decreased after abdominal surgery, major burns or
trauma and prone positioning of the patient. Obesity and
high BMI also affect the abdominal wall’s compliance as can
pregnancy.
General risk factors for development of ACS include sepsis, shock or hypotension and increase age. Having the head
of the bed raised to more than 30° has also been shown to be
a risk factor.
If one considers that many patients have more than one
risk factor, clinicians should perhaps be more alert to the
possibility of the development of ACS, even in elective
cases. For instance, laparoscopic bariatric surgery by definition occurs in obese patients and can involve having the head
of the bed elevated significantly, mechanical ventilation with
possibly high PEEP and the pressures of the pneumoperitoneum may need to be high. Abdominoperineal resection is
an abdominal operation that can involve a significant period
in the prone position whilst being ventilated.
It is, therefore, important not to consider ACS and IAH to
be a condition only occurring in the critically ill or emergency patient. Clinicians must be aware of its causes and be
alert to the early signs so that elective patients do not become
critically ill.
The World Society of the Abdominal Compartment
Syndrome (WSACS) recommendations suggest that if a critically ill patient has two or more risk factors for developing
ACS, they should have IAP measured [9]. The suggested frequency of IAP monitoring in the intensive care setting ranges
from twice a day to continuously [11, 12], whilst some
papers suggest it should be measured every 4–6 h [13].
The simplest and most widely used method is by measuring bladder pressures [14]. This has been shown to equate
well with directly measured IAP. The bladder is catheterized,
and a transducer attached to the catheter drainage system is
zeroed at the mid-axillary line, a similar method to that of
CVP monitoring. 20–25 ml of saline is instilled into the bladder, and the tubing is clamped for 30 min to allow detrusor
activity to settle prior to the pressure reading being made.
The pressure is then recorded at end expiration when pressures should be at their lowest. The patient positioning
should be the same for every measurement as the amount of
‘heads-up’ does affect the pressure. If having the patient
supine for the measurement is not possible, then the actual
position should be recorded to allow accurate duplication for
subsequent readings.
If the bladder cannot be used, e.g. pelvic injury, haematoma or mass or after cystectomy, pressure measurements
can be made using other accessible intra-abdominal areas
such as the stomach, rectum, vagina and IVC or by direct
intra-abdominal catheter. Other organ systems can also show
signs of impending IAH/ACS such as gradually increasing
ventilator pressures and worsening oliguria or anuria. If
these are seen, this should lead to initiation of IAP monitoring if it is not already in place.
Treatment of IAH/ACS
Ideally, treatment should begin as soon as there is a suspicion
of raised IAP in order to try to prevent this evolving into IAH
or ACS. Initial management should be aimed at treating any
reversible factors that are contributing to the raised IAP. This
will depend upon the underlying cause(s) and the degree of
IAH/ACS. If we think back to the risk factors, it can be seen
that there are many options for non-surgical management.
Diagnosis of IAH/ACS
Diagnosing IAH/ACS starts with being alert to its possibility. A high index of suspicion is needed based on the patient
as a whole as well as knowing the risk factors [8]. Clinical
examination is not accurate at diagnosing raised intraabdominal pressure (IAP).
Medical Management of IAH/ACS [15]
Decreasing the Intra-abdominal Volume
Decompression of a dilated GI tract may be relieved by
direct drainage such as properly placed NG tube on free
drainage and rectal catheter. Endoscopic colonic decompression may also be indicated. Gastrocolic prokinetic medication
24 The Open Abdomen: Indications and Management
359
and enemas have been suggested as well as decreasing or
stopping enteral intake.
Extra-luminal fluid can be drained percutaneously. This
may require ultrasound or CT-guided drainage if a specific
collection is being targeted. If there is large-volume ascites,
the rate of drainage needs to be closely monitored, and the
patient may require albumin replacement.
Improving Abdominal Wall Compliance
As can be seen in any patient after open abdominal surgery,
if their analgesia is inadequate, they avoid movement because
this requires the use of the core abdominal muscles and they
have shallow breathing. Once analgesia is optimized, the
functional splinting of the diaphragm and abdominal wall
resolves. Therefore, ensuring adequate analgesia is a simple
first step to try to improve abdominal wall compliance. This
can be combined with the use of sedation. In burn patients,
escharotomy may be needed to allow any expansion of the
abdominal or chest wall, especially for circumferential fullthickness burns.
Treatment of Other Factors
The management of fluid shifts associated with critical illness
is a careful balance of maintaining adequate perfusion without
causing overload. Accurate fluid balance with goal- directed
management should be instigated early. WSACS suggests
aiming for a zero to negative fluid balance by day 3 with any
ongoing resuscitation using hypertonic fluids or colloids.
Haemodialysis or haemofiltration also has a role in fluid management. If a patient is more stable, diuretics may be used.
Patient positioning to ensure that the head of bed is not
raised more than 30° has been suggested. In the intensive
care unit setting, neuromuscular blockade can also be tried.
Surgical Management of IAH/ACS
If, despite the initiation of the medical therapies detailed
above, the IAP remains >20 mmHG with new organ dysfunction or failure, surgical decompression needs to be considered. It is key that once it is clear that medical management
is not effective, there should be no delay in proceeding to
surgical decompression to maximize the chance for resolution of any actual, or impending, organ failure [15]. At this
point, the post-decompression management of the patient
also needs to be considered with planning for how the
abdominal wound will be managed [16]. Various options for
surgical decompression are available [17].
If the patient has developed IAH/ACS following surgery,
then reopening the prior incision is the most sensible option
as long the incision is adequate to create sufficient decompression and still allow safe wound management. Otherwise,
the quickest, easiest and most commonly used approach is a
vertical midline incision through the linea alba. The drawbacks include the exposure of much of the small bowel, risking fistulation, and the rapid retraction of the recti laterally.
Other surgical options include using a transverse incision,
which takes longer to perform but prevents the lateralization
of abdominal wall. One downside is that this incision is likely
to involve transection of the nerves that supply rectus abdominis as they travel in an inferomedial direction, which can in
turn lead to atrophy of that portion of the rectus. A rooftop
incision has been described for cases where the underlying
condition has a hepatopancreaticobiliary cause, as this would
enable more appropriate access for managing the underlying
condition, as well as abdominal decompression.
Another option that has been described is subcutaneous
linea alba fasciotomy. This technique involves three small
skin incisions to allow access to the fascia of the linea alba.
This is then divided subcutaneously, leaving the majority of
the abdominal skin, as well as the peritoneum, intact.
Although this has the benefit of maintaining a contained
abdomen and minimizes the lateralization of the recti, it also
limits the amount of decompression achieved. When one
considers that the aim of the decompression is to ensure a
resolution to the IAH and ACS, it could be suggested that
limiting the release achievable is counter-productive.
Management of the Open Abdomen
The open abdomen is associated with significant morbidity
and complications relating to the underlying condition as
well as the management of the open abdominal wound itself.
When contemplating leaving the abdomen open, the surgeon
should already have a management plan for the short,
medium and long term, which must include aims at preventing and managing the possible complications. Patient with
open abdomen require a multidisciplinary approach to their
care [18]. In the early stages, this will be led by the intensivists, with a supporting team of nurses, nutritionists, surgeons
and physiotherapists [19]. More long term, these patients
may need psychological support. On top of this, the open
abdominal wound itself needs specific clinical management.
Intensive Care
The initial period after surgical abdominal decompression is
focused on stabilizing the patient and continuing measures
360
H.J. Thomson and A. Windsor
aimed at treating the original cause of ACS. As such, many
of the measures started as part of attempted medical management should be continued.
The open abdomen is a source of significant heat loss, and
regaining and maintaining body temperature are important.
This is achieved using warmed fluids and air warmers on the
ventilator circuit as well as warming blankets. Fluid therapy
should be goal directed. The use of vasopressors, and possibly adrenal support by means of IV steroids, may reduce the
chance of fluid overload.
Management of sepsis should follow the same guidelines
as for those patients who do not have an open abdomen.
There is no indication for long-term antimicrobials unless
there is unresolved intra-abdominal sepsis. Any antibiotics
used will be guided by local antimicrobial policy and should
be specific to the case.
Nutrition
Critical illness, including conditions causing IAH/ACS,
tends to cause a highly catabolic state with increased nutritional requirements. The state of open abdomen itself has
been shown to be a source of significant protein and nitrogen loss thus compounding any nutritional deficit. It has
been estimated that an additional 2 g of nitrogen is lost for
every 1 L of abdominal fluid output [20]. The nutritional
needs of these patients must be assessed as early as possible
so as to allow prompt resumption of nutrition by the best
route possible.
If the gastrointestinal (GI) tract is intact and accessible,
early enteral nutrition with the correct nitrogen balance has
significant benefits [21]. In elective GI surgery, early (within
24–48 h) enteral nutrition (EN) has been shown to preserve
GI function and integrity and decreased rates of postoperative complications without any increase in anastomotic leak
rates. Studies of early EN in the open abdomen have also
reported decreased fistulation rates and increased rates of
fascial closure. Byrnes et al. [22] also showed there was a
reduced level of bowel injury in patients who had EN prior
to fascial closure. Other studies have shown a reduced rate
of ventilator-associated pneumonia in patients receiving
early EN [23].
Patients with any degree of concurrent intestinal failure
pose a more difficult problem. For patients with fistulae, parenteral nutrition (PN) alone may be best in the early stages to
try to achieve spontaneous fistula closure if appropriate.
Stomas or fistulae that are relatively distal (more than 1 m
from the duodenojejunal flexure) may be able to be managed
by EN with treatment for high-output stoma added as needed.
In the initial postoperative phase, they may require additional PN support to ensure nutritional requirements are met.
Proximal stomas will need PN until restoration of bowel
continuity can be achieved.
Classification of the Open Abdomen
In 2009, Bjorck et al. described a classification system for OA
[24]. This followed from the consensus meetings on IAH and
ACS. The original system was devised to provide a grading
system to allow consistency in the description of the OA and
therefore allow comparison between studies. The updated
consensus definitions and clinical guidelines from WSACS
2013 revised the Bjorck classification as it was felt that the
gradings should take into account the complex and variable
nature of OA with the overall aim that a higher grade of OA
was associated with the likelihood of poorer outcome [9, 25].
This revision took into account the ‘fixity’ of the abdominal wall and contents, ranging from none through developing adhesions up to the ‘frozen’ abdomen. The presence of
enteric leakage was also clarified. Leakage of enteric contents without an established fistula formation was considered a much better prognosis that an established
enteroatmospheric fistula (EAF). EAF is being defined as ‘a
permanent enteric leak embedded in granulation tissue’.
This is a much more complex situation than a stoma or
enterocutaneous fistula draining away from the OA wound
for which the OA is classified as clean since it does not
directly impact on the OA wound.
The system was shown to have good reliability when
tested [26].
Grade Description
1A Clean, no fixation
1B Contaminated, no fixation
1C Enteric leak, no fixation
2A Clean, developing fixation
2B Contaminated, developing fixation
2C Enteric leak, developing fixation
3A Clean, frozen abdomen
3B Contaminated, frozen abdomen
4 Established enteroatmospheric fistula, fixed frozen
abdomen
Open Abdomen Classification
System 2013 [9]
This classification system can be used to grade the OA in a
specific patient and can monitor its development over time.
This can in turn direct any ongoing management decisions.
The aim of any treatment is being to prevent a worsening of
the OA score.
24 The Open Abdomen: Indications and Management
361
Management of the Open Abdominal Wound
There are recognized complications of the open abdomen
that relate to the wound itself. These include evisceration,
damage to abdominal organs and desiccation of the bowel
predisposing it to fistula formation, loss of fluid and protein,
bleeding and infection. With the midline open, the muscles
of the lateral abdominal wall are unopposed which leads to
lateralization of the recti and loss of domain, which in turn
makes ventral hernia a more likely outcome.
Temporary abdominal closure (TAC) has evolved as OA
has been more widely used and understood. The ideal TAC
system is one that can minimize the risk of these complications occurring and prevent worsening of the grade of open
abdomen. It has to control and protect the abdominal contents and prevent their adherence to the abdominal wall or to
the dressing itself. It should maintain as far as possible the
integrity of the abdominal wall in order to make definitive
fascial closure more straightforward whilst not causing
IAH. It should also be simple to apply, prevent fluid loss,
facilitate nursing care and allow easy access to the abdominal cavity for re-laparotomy [27]. Ideally it should also be
cost-effective.
Temporary Abdominal Closure (TAC)
There has been a steep learning curve in the management of the
open abdominal wound. This has been associated with advances
in wound management techniques and equipment [28].
The earliest and most simple techniques were aiming to
cover and control the abdominal contents and prevent evisceration whilst trying to prevent excess fluid losses.
Approximation of the skin edges, using towel clips or simple
sutures, without closing the fascial layer does this to a degree,
but as with the subcutaneous midline fasciotomy, closing the
skin limits the decompression achieved and reintroduces an
element of abdominal pressure which may be sufficient to
cause recurrent ACS.
The Bogota bag [29] was the next step. An appropriately
sized piece is cut from a sterile fluid bag and shaped to fit the
defect. This is then sutured to the skin edges. It does allow
good decompression but does not address many of the other
problems associated with OA management.
Bridging meshes have also been described to act as
TAC. Mesh is cut to the shape of the fascial defect and then
sutured to the fascial edges. Re-entry to the abdomen is
achieved by making a new ‘midline incision’ through the
mesh. This can in turn be sutured closed, and as the intraabdominal pressure and oedema reduce, the mesh can be
more tightly closed in an attempt to bring the recti back
towards the midline. Non-absorbable meshes were associ-
ated with an increase in fistula formation [30] that wasn’t
seen with resorbable meshes [31]; however, the trade-off was
an acceptance that the patient will develop a delayed hernia.
The Wittmann patch [32] acts in a similar way. Two
opposing sheets that resemble Velcro™ are cut to fit the
wound with one sheet being secured to each side of the
defect. In order to gain entry to the abdomen for relook, the
sheets could be disconnected from each other and at the end
of the procedure the Velcro reapplied. By adding tension on
closing the patch, some medialization of the recti could be
achieved.
All of the above methods concentrate on the wound edges
and coverage of the abdominal contents. None address the
domain loss or the developing adhesions between viscera
and the abdominal wall which will cause fixity and lateralization and in turn a frozen abdomen. With all of these techniques, it was accepted that it was necessary to achieve
fascial closure within 7–14 days [18], or the combination of
adhesions, abdominal wall fixity and lateral retraction of the
recti would make early fascial closure impossible, and this in
turn would necessitate a planned ventral hernia.
Negative-pressure wound therapy (NPWT) for OA was
first described by Barker et al. [33, 34]. The procedure
involved placing a perforated polyethylene sheet into the
abdominal cavity to lie between the viscera and the abdominal wall to prevent fixity. This was covered by a moist sterile
surgical towel and two drains placed on top of that. A plastic
drape was then applied over the top to create a seal and the
drains attached to suction. They reported a 2–3% fistulation
rate, but a fascial closure rate was only 30%.
For the last 15 years, we have had access to commercial
NPWT devices designed specifically for managing OA. With
similarities to Barker’s system, a fenestrated membrane is
placed between the abdominal viscera and the abdominal wall.
Polyurethane sponges are then cut to size to fit and then placed
in the abdominal wall defect before an adhesive clear membrane is used to seal the abdomen. A sealed suction unit is then
applied on top of the sponge area, and variable negative pressure can be applied. This system has been shown to decrease
the amount of exudate from the abdomen. The updated version, ABThera™, has a modified first membrane that aims to
create a more equal distribution of the negative pressure.
When applied correctly, the benefits of NPWT are the
prevention of fixity of the abdominal wall to the viscera
which gives more time to try to achieve fascial closure if
needed. The sponges placed in the defect also encourage
granulation of the wound edges and are seen to decrease the
overall size of the defect.
For all systems, the aim is best management of the OA
whilst working towards fascial closure. All systems need to
be changed every 48–72 h. At each relook, as well as careful
washout of any residual infection, there should be an attempt
362
H.J. Thomson and A. Windsor
to close or partially close the defect. Where complete closure
is not possible, one or two interrupted sutures at either end of
fascial defect can be placed at each dressing change to gradually close the defect.
The National Institute for Health and Care Excellence
(NICE) reviewed NPWT for the open abdomen in 2013 [35]
and concluded that they lead to reduced exudate, earlier fascial closure, lower morbidity and reduced length of hospital
stay. The commercial systems have been compared to
Barker’s original technique; they achieve better rates of early
fascial closure [36]. Other benefits included the promotion of
tissue granulation.
The risk of developing enteric fistulation associated with
NPWT has been debated, but more recent studies have shown
no statistically significant increased risk of fistulation with
NPWT [37]. Fistulation rates are higher in patients with
abdominal sepsis, probably due to the bowel being inflamed
and oedematous [38]. Exposed anastomoses are also at risk
of fistulating. In order to minimize the chance of fistula formation, any anastomoses should be buried, and wherever
possible bowel should be covered by omentum. Direct contact of suction to bowel should be avoided. Where there is
insufficient omentum, a layer of a sterile non-adherent dressing such as Mepotil™ can be applied prior to placement of
the membrane.
In an attempt to increase the rate of early fascial closure,
systems to add medial traction to the fascia, such as ABRA
[39, 40], have been described to use in conjunction with
NPWT [41]. Some have shown a fascial closure rate of 80%,
but there is still a tendency to develop incisional hernias due
to the underlying nature of critically ill patients [42].
Definitive Abdominal Closure
As stated earlier, the plan for definitive closure of the abdominal wall should be considered early in the management of
the patient with open abdomen. The only reason for leaving
the abdomen open is to prevent or treat IAH/ACS. The TAC
methods, if correctly used, can prevent the lateralization of
recti and fixity of the abdominal wall which should allow
fascial closure to be achieved once the cause of the ACS has
been resolved and the bowel oedema and dilatation have
settled. This should be carried out as soon as possible. If
complete fascial closure is achieved at the index admission,
it can be defined as early (within the first 8 days of formation
of OA) or delayed (after 8 days or more) abdominal fascial
closure (EAFC, DAFC) [43]. Gradual closure of the defect
with a few sutures at either end of the fascial defect when
possible will increase the chance of total fascial closure or at
least minimize the residual defect [5].
Once abdominal wall fixity has occurred, fascial closure
will be impossible [44] until the abdominal wall and contents
have recovered fully, usually at least 6 months. In these cases
other methods of restoration of the abdominal wall need to
be applied.
The use of bridging mesh to support the defect has already
been discussed as a TAC method. However, for some patients,
temporary may mean 6 months or more, which equates to the
period of recovery prior to elective abdominal wall reconstruction. It is well documented that abdominal closure using
a resorbable mesh bridge results in a planned ventral hernia.
Newer biologic meshes have been used to bridge defects, but
their strength is derived from contact with other tissue planes
rather than simply being sutured to a fascial edge. They also
have a tendency to stretch over time if used for bridging. This
means that with time, a delayed bulge at the site of the defect
is likely, and whilst it may not represent a true hernia, it is
likely to have a similar effect on the patient. Either type of
mesh, when used as a fascial bridge, can be dressed with
NPWT that will encourage granulation tissue ingrowth and
cause the overall defect size to decrease. Once the wound has
completely granulated, it can be skin grafted or left to
epithelialize.
Definitive abdominal wall reconstruction should be
delayed until the skin graft shows signs of lifting from the
underlying bowel, which is a sign that the abdomen may be
suitable for further surgery. Some patients decide that they
would rather live with their hernia than undergo further
surgery.
Component separation techniques can be used to achieve
fascial closure without tension. They are unlikely to be successful in the frozen abdomen or one with any degree of
abdominal wall fixity as they will not achieve as much medialization as usual due to the tethering effect of the underlying
bowel. Anterior component separation requires lifting of
large lipocutaneous flaps, which, in the presence of infection, creates increased risks for wound breakdown. It may be
preferable to reserve this technique for a delayed abdominal
wall reconstruction rather than use this option early. Where
acute component separation may be useful is to achieve fascial closure in patients with no fixity, in an uncontaminated
abdomen that would otherwise require bridging.
Wounds complicated by enteroatmospheric fistulae create
their own set of difficulties. NPWT dressings can still be
used if the fistula is isolated from the area being subjected to
NPWT. This is complicated and time-consuming even in
centres with the necessary expertise. Once the wound has
granulated, it is treated in the same way as for the bridging
mesh. It can be allowed to epithelialize, although this takes
time and is difficult to isolate the fistula whilst epithelialization occurs. Skin grafting is useful, but fistula isolation without disturbing the graft can be problematic. Once healed, the
24 The Open Abdomen: Indications and Management
363
patient can have definitive abdominal wall reconstruction
and fistula repair at the same time. This is a complex procedure which should be carried out in a centre with the necessary expertise and should not be attempted until the fistula
and graft mature, usually between 6 and 12 months.
Timing of definitive abdominal wall reconstruction should
not only be based on the state of the healing wound. The timings should be considered as a minimum, not an absolute.
Many of these patients will have been in a hospital environment for months. It is important to ensure that they are ready
for further surgery nutritionally, physically, emotionally and
psychologically. There is no urgency to undertake abdominal
wall reconstruction.
Summary
The open abdomen is a useful technique but is subject to
many risks. Its use should be limited to the prevention or
treatment of ACS, where non-surgical options have failed.
Creating an open abdomen is the easy part of a complicated
patient management pathway that needs to be managed by a
multidisciplinary team with a heavy early reliance on the
intensive care team. Planning for the short-, medium- and
long-term management should be in process from early in
the treatment pathway. Definitive abdominal fascial closure
may take many months to achieve, and some patients may
choose to live with a residual hernia, rather than subject
themselves to further surgery.
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