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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure 16-1.
Chapter 16 • Managing the Open Abdomen 291
Figure 16-2.
Figure 16-3.
292 Section V • Other Abdominal Wall Procedures
2. Pharmacologic Management
Whether or not a patient who has an open abdomen needs to remain paralyzed and intubated
has been questioned. Obviously, if the patient is critically ill or if there are other reasons why
intubation and paralysis are necessary, these will take precedence over the open abdomen. If,
however, the patient does not have acute physiologic derangements, then weaning of paralysis
and just maintaining the patient on sedation is reasonable. Whereas some would extubate these
patients, in this author’s experience, extubation is not warranted for patients who are going back
to surgery frequently and who also usually have other medical issues that are being addressed.
The other pharmacologic question is that of antibiotic use. There have been no randomized
controlled trials and very few case-control series using antibiotics with an open abdomen if
there is no gross contamination or infection. Thus, antibiotics in clean and clean-contaminated
cases cannot be justified beyond 24 hours. If the wound is contaminated or infected, then prophylactic/therapeutic antibiotics should be administered. The length of time depends on the
severity of contamination or infection and the patient’s other comorbidities. One final issue is
the abdomen that has laparotomy pads in place to control bleeding. These patients should be
placed on prophylactic antibiotics because of an increased incidence of intraabdominal abscess.
Nutrition also can be considered a pharmacologic intervention. There is no contraindication to
enteral nutrition just because the abdomen is open. Although there may be other reasons not to
institute enteral feedings, the presence of an open abdomen is not one of them.
Chapter 16 • Managing the Open Abdomen 293
3. Planned Open Abdomen
There is a subset of incisional hernia patients for whom it is known before surgery that the
patient will need to have an open abdomen after the initial operation. Candidates include hernias with loss of domain, significant abdominal wall infection, and multiple abdominal wall
fistulae. With infection and fistulae, definitive hernia repair often has to wait until there is
decontamination of the abdominal wall. With loss of domain, the abdominal domain often has
to be “reclaimed” by stretching the rectus and lateral abdominal complexes, and this requires
the patient to have an open abdomen.
3. Operative Steps
1. Decision to Leave the Abdomen Open
The decision to leave an abdomen open depends on the clinical scenario, as previously stated. It
does not matter if the patient’s condition is acute or chronic; anatomy and physiology are what
drive the decision. Once the decision is made, the steps are similar no matter the reason.
294 Section V • Other Abdominal Wall Procedures
2. Technique
The focus of the technique is to maintain the anterior abdominal domain, and, if a fistula is
present, to control effluent while still providing for visceral protection.
All visceral surgery should be completed, if possible. Once this is done, a temporary coverage for
the intestine is fashioned. This can be a plastic drape, iodine-impregnated drape (Figs. 16-4 to
16-9), or a commercially available visceral drape (Figs. 16-10 to 16-13). The key point is to get
the drape under the abdominal wall and passed all the way laterally to the paracolic gutters. The
author believes that some sort of support of the visceral drape is needed to accomplish this. The
Barker technique, in which an operative towel is sandwiched between two iodine-impregnated
drapes, is favored. This provides enough support such that the covering will not shift once placed.
After the visceral coverage is in place, drains are placed over the cover in the abdominal wound.
For a midline laparotomy, these drains are not placed in the gutters of the wound but instead
looped in the superior and inferior recess of the wound. This is where most leakage occurs and
thus is where the drains need to be.
A blue operative towel is placed over the drains and is then covered by another sheet of iodineimpregnated plastic. Before placing this final sheet of plastic, the drains are connected to wall
suction and maintained on wall suction until just before transfer out of the operating room.
Figure 16-4.
Chapter 16 • Managing the Open Abdomen 295
Figure 16-5.
Figure 16-6.
296 Section V • Other Abdominal Wall Procedures
Figure 16-7.
Drapes advanced to
Figure 16-9.
paracolic gutter
Figure 16-8.
Operative towels
Drain
Iodine-impregnated
plastic drapes
Figure 16-10.
Figure 16-11.
Chapter 16 • Managing the Open Abdomen 297
Figure 16-12.
Figure 16-13.
298 Section V • Other Abdominal Wall Procedures
3. Fascial Closure
While none of these patients are candidates for complete fascial closure, most patients can have
part of their abdominal wall reapproximated at each operation (Figs. 16-14 to 16-16). Every
time a patient goes to the operating room, an attempt should be made to bring at least some of
the fascia back together. This may be just one or two stitches, but in the end, it is progress, and
progress is what is needed in these difficult patients.
4. Postoperative Care
1. General Care Issues
General postoperative care is used in all patients. Ensuring adequate resuscitation, appropriate
antibiotic therapy, and nutritional support are critical. These patients have very large wounds,
and they need all of the aforementioned in place to allow for healing.
Most patients are admitted to an intensive care unit. As previously stated, management of paralysis and intubation are made on a case-by-case basis, depending on what other issues are present.
Another aspect of postoperative care is maintaining the dressing. The drains should be kept
to low continuous wall suction. This keeps fluid from building up under the dressing and dissecting the dressing away from the abdominal wall, leading to leakage from the dressing. This
leakage is bad in that it does not allow for quantification of fluid from the abdomen, in addition
to leading to maceration of the skin.
2. Reoperation
Patients should be taken to surgery whenever it is felt that more progress can be made with
regards to their closure. Usually this means every day or every other day. At the time of these
procedures, every attempt should be made to reapproximate some fascia.
Figure 16-14.
Chapter 16 • Managing the Open Abdomen 299
Figure 16-15.
Figure 16-16.
300 Section V • Other Abdominal Wall Procedures
3. Complications
The main complication unique to this patient population is enteroatmospheric fistula. While
surgeons are used to managing enterocutaneous fistulae, this fistula is present in the middle of a
large visceral block of tissue. Early identification and management of the fistula effluent is critical. If there is any question that a fistula has developed, the patient should be taken to the operating room and evaluated. Presence of a fistula usually means the abdomen cannot be entirely
closed. However, one can proceed with as much fascial closure as possible, possibly sparing the
patient from a very large ventral hernia defect.
5. Pitfalls/Pearls
The major pitfall in management of the open abdomen is giving up too quickly. While it is easier
to just place some type of mesh coverage over the abdomen and wait to skin graft, the cost of
this to the patient in terms of both lost productivity and dollars has been well documented.
With the appropriate dressing in place, patients have been serially closed over the course of
three weeks.
If dressings are not applied in such a way that the viscera are protected, then each dressing
change can debride away some of the bowel serosa, and this will lead to a fistula. If a negative
pressure wound therapy (NPWT) system is being used over the viscera, then it either needs to
be covered in plastic, or a nonadherent type sponge needs to be used.
A time will come when the patient is not getting any better, and the reason for this is the open
abdomen. This patient has developed tertiary peritonitis, and the only way they are going to
get better is to cover the viscera. In this patient, a biologic-type mesh is believed to be the most
appropriate closure. It prevents adhesions (good for reoperation at a later date); protects the
viscera during dressing changes (lower fistula rate); and in select patients, may function as their
definitive closure.