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332
M.Y. Nahabedian
Fig. 31.13 ( a ) Intraoperative photograph demonstrating the midline bulge of the linea alba. ( b ) Intraoperative photo-
graph following plication of the midline and lateral fascia
Fig. 31.14 ( a ) Intraoperative lateral photograph demonstrating the degree of abdominal protrusion prior to repair. ( b )
Intraoperative lateral photograph demonstrating the degree of abdominal protrusion following the repair
into the supra aponeurotic space and creating a
dissection plane under direct vision exposing the
linea alba and the anterior rectus sheath. The
repair includes sheath plication and reinforce-
placement of an intraperitoneal mesh can be considered instead of onlay mesh placement. Huguier
has applied this technique in 15 women with goodto-excellent results in 13/15 (87%) [
18 ].
ment with a synthetic mesh. A nonabsorbable
barbed suture is typically used. A drain is placed
and a soft-compression garment is applied.
Complications
Laparoscopic reinforcement of the anterior
abdominal wall can be considered in some patients.
In patients that have had plication of the attenuated
linea alba and anterior rectus sheath, laparoscopic
Complications following rectus diastasis repair
are infrequent and include infection, mesh
extrusion, recurrence, nerve injury, seroma,
31 Diagnosis and Management of Diastasis Recti
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333
Fig. 31.15 Intraoperative photograph following placement of the non-resorbable mesh over the plicated anterior
rectus sheath
Fig. 31.17 Intraoperative photograph following completion of the abdominoplasty
Fig. 31.16 Intraoperative photograph of the redundant
skin and fat constituting the abdominoplasty
complex scar, skin necrosis, contour abnormality, and visceral injury (bladder, bowel). As
with most operations, caution must be exercised when considering this procedure in
women who are active smokers, because
delayed healing and tissue necrosis are more
common in this population of patients [ 17 ].
Emanuelsson has performed a randomized
controlled trial comparing outcomes and complications in women with rectus diastasis managed
Fig. 31.18 Six-month postoperative anterior view following successful diastasis repair and abdominoplasty
with layered closure of the anterior rectus sheath
or retrorectus placement of synthetic mesh [ 19 ].
Superfi cial wound infectio n occurred in 14/57
(24.5%) of which 5/57 (8.8%) were in the suture
repair cohort and 9/57 (15.8%) were in the retrorectus mesh cohort. Postoperative pain was
assessed using a visual analog scale demonstrating an improved reduction in pain in the retrorectus cohort (6.9) compared to the sheath plication
cohort (4.8).
334
M.Y. Nahabedian
Fig. 31.19 Six-month postoperative lateral view
Fig. 31.20 Suture plication of the posterior rectus sheath
Outcomes
Sheath Plication
The outcomes following sheath plication for diastasis recti have been mixed and primarily related
to the type of suture used for the plication.
Al-Quattan in a review of 20 women following
vertical sheath plication alone using an absorbable
suture demonstrated 100% recurrence after 1 year
[ 20 ]. Reasons included a repair that was localized
to the defect only, a repair that addressed only the
horizontal component of the diastasis, and suturerelated fraying of the anterior rectus sheath due to
its fragile nature. Nahas using a nonabsorbable
suture had positive outcomes utilizing a 2-layer
plication repair [ 5 ]. Effi cacy of the repair was
evaluated by postoperative CT scans in 12 women
at 3 weeks, 6 months, and again at a mean of 81
months postoperatively. The inter-rectus distance
was measured 3 cm above and below the umbilicus. They demonstrated no recurrence of diastasis
recti in any patient at all levels studied. Mestak
performed a case-controlled study comparing 51
women that had diastasis recti repair via plication
with an interlocking continuous absorbable suture
(0-PDS) to 10 nulliparous women without a diastasis [ 4 ]. Postoperative assessment was performed
via physical examination and ultrasound in all
women at 12–41 months following the repair.
Ultrasound measurements were obtained at the
midpoint of the umbilicus and xiphoid, at the
umbilicus, and at the midpoint of the umbilicus
and the pubis. The mean inter-recti distance was
essentially equal between the two cohorts. The
authors advocated absorbable sutures because
suture palpability is not a long-term issue.
The type and orientation of suture material
used for diastasis repairs has also been comparatively studied. Nahas has compared diastasis
repair techniques using absorbable
(0- polydiaxone) sutures to nonabsorbable (2-0
nylon) sutures. CT scans obtains at 3 weeks and 6
months demonstrated no signifi cant difference
between the two suture techniques [ 16 ]. Ishida, in
a cadaveric study, compared horizontal versus
vertical suture repair. A dynamometer was used
to determine th e amount of force required to disrupt the suture repair [ 21 ]. There was signifi -
cantly higher difference in the strength required
for rupture for the vertical suture placement, thus
vertical orientation was recommended.
31 Diagnosis and Management of Diastasis Recti
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335
Retrorectus Repair
Outcomes following the retrorectus repair have
been demonstrated to be effective. Batchvarova
et al. have utilized this technique in 52 women
with up to 11 years of follow-up [ 17 ]. They con-
tend that posterior plication alone may not be suffi cient in all cases and for that reason have
decided to place a vicryl mesh into the retrorectus
space. The benefi t of the mesh in that location
was to redistribute the forces placed on the
posterior sheath repair, reducing the risk of recurrence. According to Batchvarova, a resorbable
mesh such as vicryl is preferred because it effectively relieves fascial tension, is resorbed by 6
weeks, is placed in an extraperitoneal position,
and does not increase the incidence of
complications.
In the Emanuelsson study, SF-36 outcomes
were compared following repair via anterior
sheath plication versus retrorectus mesh placement [ 19 ]. The results demonstrated improve-
ment in both cohorts following the repair with no
technique demonstrating superiority over the
other. Subjective improvement in muscle strength
was improved more in the retrorectus cohort
compared to the suture cohort (6.9 vs. 4.5, Likert
scale, 0–10, p = 0.01).
Endoscopic/Laparoscopic
The most frequent adverse event with the
endoscopic technique is seroma (23%) [ 10 ]. In
the 21 patients from the Luque study, there
were no hernia or diastasis recurrences at
20-month follow- up [ 10 ]. The mean inter-rec-
tus distance was significantly improved 1
month following the procedure with preoperative measurements ranging from 24 to 39 mm
and postoperative measurements ranging from
2.1 to 2.8 mm. One- and 2-year follow-up did
not change from the 1-month measurements
(2.5–3.7 mm). Patient satisfaction was
assessed on a visual analog scale and graded
with a mean score of 8.7.
Summary
The etiology, diagnosis, and management of
diastasis recti is now well understood and has
demonstrated success in management.
Multiparous women are at highest risk for developing diastasis recti. Diagnosis is easily made by
clinical examination and symptomatology.
Management options vary and will depend on the
degree of separation between the rectus abdominis muscles. Simple plication has been effective
for mild-to-moderate diastasis. The use of resorbable or non-resorbable mesh placed as an onlay
or in the retrorectus space has been effective for
moderate-to-severe diastasis.
References
1. Azer H, et al. Collagen fi bers in linea alba and rectus
sheath. J Surg Res. 2001;96:127–34.
2. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The
relationships between inter-recti distance measured
by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up
study. J Orthop Sports Phys Ther. 2011;41(6):
435–43.
3. Brauman D. Diastasis recti: clinical anatomy. Plast
Reconstr Surg. 2008;122:1564.
4. Mestak O, Kullac R, Mestak J, et al. Evaluation of the
long-term stability of sheath plication using absorbable sutures in 51 patients with diastasis of the recti
muscles: an ultrasonographic study. Plast Reconstr
Surg. 2012;130:714e.
5. Nahas FX, Ferreira LM, Augusto SM, Ghelfond
C. Long-term follow-Up of correction of rectus diastasis. Plast Reconstr Surg. 2005;115:1736.
6. Elkhatib H, Buddhavarapu RS, Henna H, Kassen
W. Abdominal musculoaponeuretic system: magnetic
resonance imaging evaluation before and after vertical
plication of rectus muscle diastasis in conjunction with
lipoabdominoplasty. Plast Reconstr Surg. 2011;128:733e.
7. Nahas FX. An aesthetic classifi cation of the abdomen
based on the myoaponeurotic layer. Plast Reconstr
Surg. 2001;108:1787–95.
8. Rath AM, Attali P, Dumas JL, et al. The abdominal
linea alba: an anatomo-radiologic and biomechanical
study. Surg Radiol Anat. 1996;18:281–8.
9. Beer GM, Schuster A, Seifert B, et al. The normal
width of the linea alba in nulliparous women. Clin
Anat. 2009;22:706–11.
10. Luque JB, Luque AB, Valdivia J, et al. Totally endoscopic
surgery on diastasis recti associated with midline hernias.
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M.Y. Nahabedian
The advantages of a minimally invasive approach.
Prospective cohort study. Hernia. 2015;19(3):493–501.
11. Benjamin DR, van de Water ATM, Peiris CL. Effects
of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic
review. Physiotherapy. 2014;100:1–8.
12. Akram J, Matzen SH. Rectus abdominis diastasis.
J Plast Surg Hand Surg. 2014;48(3):163–9.
13. Restrepo JCC, Ahmed JAM. New technique of plication
for abdominoplasty. Plast Reconstr Surg. 2002;109:1170.
14. Tadiparthi S, Shokrollahi K, Doyle GS, et al. Rectus
sheath plication in abdominoplasty: assessment of its
longevity and a review of the literature. J Plast
Reconstr Aesthet Surg. 2012;65:328–32.
15. Ferreira LM, Castilho HT, Hochberg J, et al.
Triangular mattress suture in abdominal diastasis to
prevent epigastric bulging. Ann Plast Surg.
2001;46:130.
16. Nahas FX, Augusto SM, Ghelfond C. Nylon versus
polydioxanone in the correction of rectus diastasis.
Plast Reconstr Surg. 2001;107:700.
17. Batchvarova Z, Leymarie N, Lepage C, Leyder P. Use
of a Submuscular resorbable mesh for correction of
severe postpregnancy musculoaponeurotic laxity: an
11-year retrospective study. Plast Reconstr Surg.
2008;121:1240.
18. Huguier V, Faure JL, Doucet C, Giot JP, Dagregorio
G. Laparoscopic coupled with classical abdominoplasty in 10 cases of large rectus diastasis. Ann Chir
Plast Esthet. 2012;57:350–5.
19. Emanuelsson P, Gunnarsson U, Strigard K, Stark
B. Early complications, pain, and quality of life after
reconstructive surgery for abdominal rectus muscle
diastasis: a 3-month follow-up. J Plast Reconstr
Aesthet Surg. 2014;67:1082–8.
20. Al-Qattan MM. Abdominoplasty in multiparous
women with severe musculoaponeurotic laxity. Br
J Plast Surg. 1997;50:450.
21. Ishida LH, Gemperli R, Longo MVL, et al. Analysis
of the strength of the abdominal fascia in different
sutures used in abdominoplasty. Aesthetic Plast Surg.
2011;35:435–8.
Negative Pressure Wound Therapy
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Terri A. Zomerlei and Jeffrey E. Janis
Introduction
Abdominal wall defects, whether spontaneous,
traumatic or iatrogenic in origin, are a complex
and heterogeneous problem and can challenge
surgeons of all experience levels. One tool that
that should be in the modern surgeon’s armamentarium of useful adjuncts for complex abdominal
wall repair is negative pressure wound therapy.
Originally designed to expedite healing in
chronic wounds such as diabetic foot ulcers, negative pressure wound therapy (NPWT) is a simple mechanical device that provides suction over
a wound bed [ 1 – 4 ]. Suction is a long-established
surgical practice method utilized for drainage of
wounds. The advantages of formal negative pressure wound therapy devices versus simple suction are many and include the ability to tailor
wound interface materials, to exchange canisters
capable of removing large quantities of exudate,
and the option to control both the level of suction
(in millimeters of mercury) and the frequency of
the suction (continuous vs. noncontinuous/intermittent). An important safety feature of all NPWT
T. A. Zomerlei , M.D., M.S. (*)
J. E. Janis , M.D., F.A.C.S.
Department of Plastic Surgery , Ohio State University
Wexner Medical Center , 915 Olentangy River Road,
Suite 2100 , Columbus , OH 43212 , USA
Terri.Zomerlei@osumc.edu;
e-mail:
Jeffrey.Janis@osumc.edu
32
devices is the alarm system that warns the user of
loss of seal, or excessive fl uid output [ 1 ]. Some
specially designed NPWT units are also capable
of instillation of isotonic solutions that contain
antibacterial or antimicrobial agents. NPWT
units vary in size and some units have been
developed that are portable and even disposable.
All NPWT devices share a similar basic structure
with the key components of each device consisting of a suction pump capable of generating negative pressure (with power supplied by either
battery or electric cord), tubing, a storage canister for effl uent, a sealing apparatus and wound
interface material.
Mechanism of Action
There have been many speculations regarding the
mechanisms of action behind NPWT and its ability to expedite wound healing. While the exact
mechanism of NPWT is largely unknown, it is
generally accepted that it is likely a medley of
infl uences that contribute to the success of NPWT
in healing both acute and chronic wounds.
The theories regarding the mechanism of
action of NPWT can be categorized into three
broad concepts: fl uid-milieu, alteration or reduction of bacterial burden, and application of
mechanical stress.
Wound healing is not a simple linear process
but rather a complex series of exchanges among
mediators and cells [ 2 ]. The environment or
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_32
337© Springer International Publishing Switzerland 2016
338
T.A. Zomerlei and J.E. Janis
milieu in which these interactions occur can have
a negative or positive effect on the woundhealing process [ 3 ]. The interstitial edema that
accumulates in wounds can potentially compromise the delicate microcirculation causing deleterious effects on oxygen content delivery to the
end tissues. The subatmospheric pressure exerted
by NPWT units effi ciently draws this excess fl uid
out of the wound bed thus improving the healing
environment of the wound. The composition of
the wound extracellular matrix is determined by
a dynamic balance among overall matrix synthesis, deposition, and degradation. Wound extracellular matrix itself is a key regulator of cell
adhesion, migration, proliferation, and differentiation during tissue repair [ 1 ]. NPWT can
improve the extracellular wound matrix by
removing negative impactors on the woundhealing milieu. These factors, which can act as
local tissue toxins, include acute phase proteins,
proteolytic enzymes, specifi c cytokines, and
metalloproteinases. A recently published systematic review of the molecular bases behind NPWT
mechanism of action suggests that, in contrast,
promotion of wound healing occurs by modulation of cytokines to an anti-infl ammatory profi le,
and mechanoreceptor/chemoreceptor-mediated
cell signaling. These interactions then culminate
in angiogenesis, extracellular matrix remodeling,
and deposition of granulation tissue [ 4 ].
Another hypothesized mechanism of action of
NPWT is the reduction of overall bacterial burden. Controlled animal studies have demonstrated logarithmic declines in bacterial burdens
with use of NPWT, though this has not been able
to be reproduced in clinical studies [ 5 , 6 ]. It is
thought NPWT may act to decrease the overall
bacterial burden of a wound in three ways. First,
the closed environment acts as a physical barrier
to the encroachment of adjacent skin fl ora.
Second, the subatmospheric pressure exerted by
the unit physically moves any existing bacteria
away from the wound with the interstitial effl uent. Lastly, as demonstrated in animal studies by
Morykwas, application of subatmospheric pressure at 125 mmHg to in vivo tissues improves
blood fl ow levels fourfold [ 6 ]. This increase in
oxygen in the local tissues not only interferes
with the growth of anaerobic bacteria but also
provides additional substrate for neutrophils to
use for the oxidative bursts that kill bacteria.
An additional hypothesis on the mechanism of
action of NPWT focuses on the biomechanical
properties offered by the porous foam interface
and the exerted negative pressure. There is a
growing body of evidence that suggests healing
tissue responds and adapts to the functional
demands placed on it. These demands can be
subdivided in those that exert macrostrain versus
microstrain to the wound. The macrostrain theory
postulates that the mechanical force from the
interaction of the negative pressure with the
wound interface is transmitted to the wound
edges drawing them closer together [ 7 ]. In 2004,
Saxena fi rst introduced the concept that NPWT
improves granulation through application of
micromechanical forces or microstrain. Their tissue studies revealed that contact with the foam
dressing particularly had physical effects on the
tissue and noted an increase in the undulating
contour of tissues corresponding to the pore
geometry on the foam. The surface irregularities
imposed by contact with the foam pores increased
the surface area that could be subjected to negative pressure without an increase in the overall
wound footprint. Specifi cally, the microstrain
theory asserts that when more individual cells
can be subjected to the application of subatmospheric pressure and the mechanical strain and
deformational forces leading to cell stretch, cell
proliferation and angiogenesis are stimulated
leading to promotion of wound healing [ 8 ].
Foam vs. Gauz e
The ability to tailor wound interface materials
allows for customization of NPWT to the wound
bed. By and large, there are two different dressing types that have been explored in the literature; dressing that have a gauze interface and
those with a foam substrate. While studies have
determined that the pressure transfer to the
wound bed is similar in gauze and foam dressings, there may be particular clinical circumstances in which one product may be superior to
another [ 9 , 10 ]. Gauze dressings offer ease of
application because they do not have to be cut
32 Negative Pressure Wound Therapy
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339
and shaped to the wound bed. Some studies also
report that patients experience less pain during
dressing changes with gauze, which is likely
related to having less tissues ingrowth with the
dressing material [ 11 ]. In addition, as cost sav-
ings become an increasingly more pressing matter to our health system, gauze dressings may
offer a fi nancial advantage both in cost of materials and labor expenses. In a recent randomized
trial, the daily cost of NPWT was found to be
$96.51 for foam-based dressings versus $4.22 for
gauze-based dressings. Likewise NPWT foam
dressings were associated with increased time
spent on the dressing change with the average
time spent clocked at 31 min versus 19 min for
the gauze group [ 12 ].
Since the inception of NPWT, foam dressings
have been the more traditional wound interface
material. Foam dressings are available in multiple shapes and sizes that are then cut to size to fi t
the wound bed during the dressing application.
Several different foam contract dressings are currently employed and they are commonly known
and referred to based on their color [ 13 ].
“Black” or open-cell polyurethane foam is the
most traditional NPWT dressing and consists of
reticulated large open pores (400–600 μm) making it particularly well suited for wounds that
produce large amounts of exudate. The black
foam is also hydrophobic and the large pore size
allows for maximal interaction between the subatmospheric pressure provided by the NPWT and
the wound bed, which results in optimizing granulation tissue formation [ 14 ].
Polyvinyl alcohol, or “white” foam, in contrast is hydrophilic and has a small, dense pore
allocation (60–270 μm) making is less adherent
to the wound. This composition also results in
less removal of exudate and diminished ability of
the NPWT to produce granulation tissue. This
may be preferable in circumstances where the
wound is shallow or overlying prosthetic implants
or if its over/near areas that are sensitive to desiccation or pressure.
Green foam is composed of polyurethane and
has an open pore structure that facilitates the
monitoring of the wound bed. Green foam pore
size is similar to that of black foam, but the tensile strength is superior allowing for less foam
residue in the wound bed when the foam interface material is removed [ 15 ].
Silver sponges are either polyurethane or
polyvinyl sponges that have been coated in silver
substrate. The silver coating on the sponges has
been found to decrease the odor of infected
wounds likely by decreasing the wound bacterial
load. Silver-coated sponges are particularly well
suited for wounds where contamination is still
present (Fig. 32.1 ). The antimicrobial ability of
silver dressing is attributed to the strong oxidative activity of the silver nanoparticle (AgNP)
surfaces and the release of silver ions into the
biologic environment [ 16 ]. The oxidative activity
and the effects of the silver ions themselves are
thought to trigger a series of negative effects on
the structures and functions of cells including
cytotoxicity, immunological responses, and even
cell death.
Subatmospheric Pressur e
An additional feature of modern NPWT units is
the ability to vary the level of negative atmospheric pressure that is placed over a wound bed.
Animal model blood fl ow studies completed by
Morykwas in 1996, plotted blood fl ow changes
measured with a Doppler needle fl ow probe in
soft-tissue and muscle against varying levels of
subatmospheric pressure. The blood fl ow changes
in both tissues demonstrated similar bell-shaped
responses. The application of 125 mmHg of negative pressure produced the optimal response in
the tissues with a peak blood fl ow of four times
baseline values. Levels of pressure above 400
mmHg were found to have deleterious effects on
granulation tissue formation, likely because
blood fl ow decreased as the capillary bed blood
fl ow was shut down when attempting to overcome perfusion pressure. Based on in vivo studies, pressure levels in the range of 75–125 mmHg
are desirable for the microdeformation and strain
that produces robust granulation tissue formation
[ 17 ]. Clinically, the application of pressure over
a wound can produce discomfort and while a
pressure of 125 mmHg is generally the “default”
setting from NPWT, this level may need to be
adjusted lower based on patient tolerance.
340
T.A. Zomerlei and J.E. Janis
Fig. 32.1 A patient with a complex abdominal wall presented for take-down of an enterocutaneous fi stula ( a, b ).
Following fi stula take-down, the fascial defect was
In addition to demonstrating the optimal pressure to induce peak blood fl ow, Morykwas and
his colleagues also compared constant applications of pressure to intermittent pressure application. In the intermittent studies, peak increases
in local blood fl ow declined when “off” intervals
were less than 2 min. Based on these results, a
5-min-on/2-min-off cycle for intermittent NPWT
was considered optimal for maximizing blood
fl ow and granulation formation. These settings
were then used in head-to-head comparisons with
continuous NPWT. The mean increase in granulation tissue formation for the wounds that
repaired with a large pore biologic mesh. A silver NPWT
sponge was used for treatment of the contaminated softtissue defect because of its antimicrobial properties ( c, d )
received the intermittently prescribed negative
pressure was signifi cantly higher than wounds
subjected to continuous pressure, specifi cally the
intermittently treated wounds demonstrated a
near 100%increased rate of granulation tissue
formation versus a 60%increase in the continuous pressure-treated wounds [ 17 ].
While intermittent pressure application can
achieve increased rates of granulation tissue formation there are two problems that can be
encountered with its use. The fi rst is the application of pressure can produce discomfort and, in a
sensitive patient, the pain would be experienced
32 Negative Pressure Wound Therapy
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341
every few minutes with the cycling of the unit. In
addition, in wounds that produce a large amount
of effl uent, the “off” period may allow fl uid to
accumulate and breach the adhesive barrier
resulting in loss of suction.
Instillation Therapy
A more recent development in NPWT science is
the development of units that have the ability for
instillation. Antimicrobials or antibiotics in an
isotonic fl uid delivery system can be loaded into
the units and then instilled over an acutely or
chronically infected wound [ 18 ]. The interval
and duration of the negative pressure can be controlled as well as the type of solution instilled and
the solution dwell time. Several fl uids that have
been explored in the literature include silver
nitrate, Dakin’s solution, and mixed antibiotic
solution [ 13 ]. An instillation fl uid that has been
utilized and studied specifi cally with use of
NPWT is Prontosan (B. Brain, Inc.; Bethlehem,
Pa.). Prontosan is composed of polyhexamethylene biguanide also known as Polyhexanide,
which functions as a preservative that inhibits the
growth of microorganisms and Betaine, a surfactant, which serves as a cleanser and provides
immediate debridement [ 1 , 19 ]. The positive
effect of polyhexanide-containing irrigation is
thought to be from reduction of bacterial load and
biofi lm formation. NPWT with simultaneous irrigation has been found to further reduce bioburden over NPWT-treated wounds alone. In
addition, using NPWT with installation capabilities in grossly infected wounds may have the
advantage of potentially reducing trips to the
operating room for washouts [ 20 ].
Negative Pressure Wound Therapy
and Abdominal Wall Reconstruction
Full-Thickness Abdominal Defect s
Abdominal wall defects present primarily in two
varieties, partial-thickness defects and fullthickness defects and the clinical applications of
NPWT differs for each.
Full-thickness defects of the abdominal wall
commonly occur after surgical intervention to
manage a serious insult to the abdomen.
Circumstances such as, abdominal trauma, peritonitis, decompression of abdominal compartment syndrome, or ruptured aneurysm repair,
commonly lead to damage control laparotomies.
In those circumstances, it is not only not possible
to close the abdomen, but also is usually not safe
to do so. In this situation, NPWT can be used as a
bridge to future more defi nitive closure.
Application of NPWT in the situation of an “open
abdomen” serves several purposes, including
removing exudates and decreasing bowel edema,
removing wound contamination, maintaining a
closed, moist environment for abdominal viscera
and minimizing loss of domain. Early adaptations of NPWT utilized to contain the abdominal
contents and evacuate infectious material
involved the use of an inert, fenestrated plastic
sheeting in contact with the viscera, towels, or
laparotomy packs placed on top of the sheeting,
drains hooked up to wall suction on top of the
towels or packs, and an occlusive dressing to seal
the wound. Modern NPWT devices for the open
abdomen come ready-made with improved function and ease of use. As visceral edema and exudate are reduced by the negative pressure, the
fascia is able to be more closely approximated
allowing for either primary repair of the fascia, or
repair with use of mesh (Fig. 32.2 ). Commonly,
the patient is returned to the operating room every
3–5 days to perform further washout and attempt
primary fascial closure or fascial closure with the
use of mesh, once contamination is minimized.
Goals with management of the open abdomen
are primarily twofold—reduction of mortality
rate and achievement of a high fascial closure
rate. A consensus document from an expert advisory panel outlining best practices for management of the open abdomen was published in 2009
[ 21 ]. Both the expert advisory committee and a
systematic review from the same year deduced
that use of a NPWT unit was the superior technique for temporary abdominal closure (TAC).
Closure rates were found to be highest with
NPWT, ranging between 78 and 93%. In addition, the incidence of fi stulas compared to other
techniques was likewise reduced with NPWT
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