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C.-j. K. Lu and J. A. Marks

edge of the IVC, and isolate it with a vessel loop.

– Retract the left renal vein superiorly to

expose the underlying right renal artery, and isolate the artery with a vessel loop.

• Nephrectomy: – Once vascular control is obtained, open

Gerota’s fascia sharply at the lateral edge of the kidney.

– Right nephrectomy: place the left hand

posterior to the kidney, mobilize it medially and anteriorly into the midline abdomen, and ligate and divide the renal vessels.

– Left nephrectomy: place the left hand pos-

terior to the kidney, mobilize it medially and anteriorly into the midline abdomen, and ligate and divide the renal vessels.

19.3.6.2 Potential Pitfalls

When isolating and dividing the renal veins, remember that the right adrenal vein drains directly into the IVC, while the left adrenal vein drains into the left renal vein. Prior to performing a nephrectomy, always conrm the presence of a contralateral kidney! If prior imaging is unavailable, an intraoperative on-table IV pyelogram can be performed to assess the contralateral kidney.

artery conduit. The SMV and portal vein can be ligated; however, a second-look laparotomy to evaluate bowel edema and viability is appropriate. The IMA and IMV can be ligated.

Take-Home Points

• Once the decision is made to take a trauma patient to the OR, notify theanesthesiologist, blood bank, and OR staff, and move quickly. Minimize the “door to cut” time.

• Communicate with theanesthesiologist before releasing the abdominal tamponade.

• Be vigilant with abdominal packing; underpacking results in continued hemorrhage, while over-packing can compress the IVC and decrease venous return.

• Run the entire length of the bowel and quickly control any contamination. Reserve denitive repair for a later time.

• Constantly evaluate the patient for physiological derangements including hypothermia, coagulopathy, and acidosis.

• Decision for damage control surgery should be made prior to the onset of the lethal triad.

• Abdominal compartment syndrome can occur in patients with an open abdomen.

19.3.7 Vascular Injuries: What Can andCannot BeLigated!

The abdominal aorta cannot be ligated! Suprarenal aortic injuries may need repair with a graft, even in the face of contamination. Injuries to the aortic bifurcation can be repaired with extra-anatomical bypasses. All infrarenal IVC injuries can be ligated if necessary. Suprarenal IVC injuries cannot be ligated and may require shunting and repair with greater saphenous vein patch. The celiac trunk can be ligated due to extensive collaterals. The SMA cannot be ligated and should be repaired with a saphenous vein or internal iliac

References

1. Stone H, Strom P, Mullins R. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197(5):532–5.

2. Rotondo M, Schwab C, McGonigal M, Phillips G, Fruchterman T, Kauder D, Latenser B, Angood P. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–82.

3. Johnson J, Gracias V, Schwab C, Reilly P, Kauder D, Shapiro M, Dabrowski G, Rotondo M.Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001;51(2):261–71.

4. Hirshberg A, Walden R.Damage control for abdominal trauma. Surg Clin N Am. 1997;77(4):813–20.

5. Jacobs L, Luk S.Advanced trauma operative management. Woodbury: Cine-Med; 2010.

Fundamentals ofTemporary

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Abdominal Wall Closure

ShelbyResnick andNielsD.Martin

20.1 Introduction

In contemporary surgical practice, a fair amount of surgical jargon surrounds temporary abdominal wall closure. To clarify, a “temporarily closed” abdominal wall is often described as an abdominal wall that has been “left open.” In fact, in the surgical literature, management of a temporary abdominal wall closure is synonymous with management of the “open abdomen” or often termed a “damage control closure” (to be described below), understanding the various nomenclatures will alleviate future confusion.

There are many clinical scenarios that can lead to a temporary abdominal wall closure [1]. While ultimately the techniques of temporary closure are similar, it is important to understand the underlying pathophysiology of each patient to optimize care. In fact, the underlying pathology often drives the decision-making for abdominal wall closure.

S. Resnick • N. D. Martin (*) Trauma and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA e-mail: shelby.resnick@uphs.upenn.edu;

niels.martin@uphs.upenn.edu

Temporary abdominal wall closure was rst widely described in the latter part of the twentieth century by vascular surgeons whose patients developed abdominal compartment syndrome following major abdominal aortic aneurysm surgery [2]. These patients underwent massive volume resuscitation, and only by leaving the abdomen open, with a temporary dressing, could the lethality of compartment syndrome be overcome.

In the early 1990s, this technique was combined with the surgical “temporization” of other intra-abdominal injuries in the trauma literature; together, it was called “damage control.” The term originated with the US Navy and describes the process of temporizing damage to a ship, just enough to maintain sea and battle worthiness, until the vessel could return safely for full repairs. Surgically, damage control temporizes traumatic abdominal injuries to allow for a stabilization of patient physiology and hemodynamics [3]. Only the most immediately life-threatening issues are addressed at the index operation. The nal step of the damage control index operation is creation of a temporary abdominal closure.

The temporary abdominal wall closure in damage control allows for shunting of vascular injuries, packing of solid organ injuries, and controlling contamination that may result in bowel discontinuity. The ultimate destination of the damage control patient is the intensive care unit,

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where hemodynamic and physiologic stabilization occurs prior to denitive surgical treatment. Therefore, the temporary abdominal closure is primarily managed outside of the operating room.

Beyond vascular and trauma surgery, temporary abdominal closures may be necessary following any abdominal surgery where the patient suffers a signicant base decit, low pH, hypothermia, large blood loss or requirement for blood transfusion, hypotension, high lactate, coagulopathy, or high degree of contamination [4]. The etiologies of these patients include intra- abdominal sepsis, abdominal compartment syndrome, pending abdominal compartment syndrome, hemorrhagic pancreatitis, and ruptured abdominal aortic aneurysms. Temporary abdominal wall closure also facilitates “secondlook” surgery for reexamination in the setting of mesenteric ischemia. Finally, occasionally the abdomen is either opened or left open to treat extraabdominal pathology such as refractory elevated intracranial pressure [5]. In this setting, the open abdomen lowers central venous pressure and allows for improved venous outow from the brain. In total, these general surgery indications for temporary abdominal wall closure occur at a higher frequency than trauma. A 2017 multicenter study ordered the indication from most to least frequent as peritonitis, trauma, vascular emergencies, ischemia, pancreatitis, and abdominal compartment syndrome [6].

Regardless of indication, the methods and techniques of temporary abdominal closure are similar, based on the concept that the fascial edges and skin are not approximated leaving the intra-abdominal viscera exposed. This temporary anatomy requires unique technical and medical management knowledge and skills. Understanding the various options and their specic advantages and disadvantages and recognizing potential complications are now a necessary component of surgical training.

20.2 General Concepts

Techniques for temporary abdominal wall closure have evolved in the past three decades to optimize the function and safety of the temporary closure.

Beyond providing a “dressing” to the abdominal wall defect, the technique has several other goals. This includes protecting the abdominal viscera from desiccation and infection while allowing for uid control. Abdominal uids should optimally be prevented from pooling in the recesses of the peritoneum and also be adequately quantied upon removal. Peritoneal uid often contains cytotoxic inammatory mediators and endotoxins, including IL-6, IL-10, TNFand CRP, which have been thought to play a contributing role in the development of multiple organ dysfunction syndrome. Animal studies have suggested that reducing the concentration of these mediators can help prevent inammatory progression; however this mechanism has not been denitively shown in clinical studies [

An ideal temporary abdominal wall closure system would also facilitate eventual formal fascial closure and minimize the chances of longterm ventral hernia formation. This is generally achieved by preserving fascial integrity, preventing fascial retraction (without creating pathologic tension), and decreasing the risk of adhesion and stula formation. Additionally, the technique should be easy to use by practitioners in the operating room and at the bedside in the intensive care unit. It should allow for rapid removal and placement and be valuably priced.

The most frequently employed temporary abdominal wall closure methods include patch techniques and/or negative pressure therapy systems. Older methods which include simple skin closure or silo methods are mentioned here for thoroughness; however, for the above optimization reasons, both the skin only and silo techniques are generally avoided if possible.

alpha, TNF-beta,

7, 8].

20.2.1 Skin Only

Skin-only closures utilize penetrating towel clamps or staples to close the skin. This technique provides few of the advantages achieved with more sophisticated temporary closure techniques and leaves the patient at a much higher risk for development of abdominal compartment syndrome.

20 Fundamentals ofTemporary Abdominal Wall Closure

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20.2.2 Silo Techniques (“Bogota Bag”)

The silo technique is commonly known as the “Bogota bag” named after the Colombian surgeon who introduced it in the 1980s. It refers to the use of any translucent, nonadherent, sterile bag used to cover the abdominal cavity. Commonly, an IV, dialysate, or irrigation bag is used for this technique and is sewn to the skin edge, circumferentially around the wound. The silo technique does allow for visual inspection of the abdominal viscera at the bedside. It is also inexpensive and requires few materials, making it a reasonable option in resource-poor environments. However, it lacks the capabilities of more advanced temporary closure systems in terms of uid control and the ability to accommodate for increasing intra-abdominal pressures.

267

20.2.3 Patch Techniques

Patch techniques involve the use of a prosthetic material sewn to the edges of the fascia effectively “bridging” the defect. This allows for easy reentry on subsequent explorations and in theory prevents fascial retraction. At each reoperation, the fascial edges can be more closely approximated and the patch progressively trimmed to allow for eventual primary closure of the fascia, at which time the patch is completely cut out of the fascia. A disadvantage of using this method is that each time the fascia is sutured to the patch, there is a potential to damage the fascial layers which need to stay intact for primary closure to be possible. The potential for fascial damage is further accentuated in hypotensive, critically ill, and/or malnourished patients where the puncturing of suture holes through the fascia can lead to fascial ischemia and necrosis, especially when repeated tightening of the patch is performed. Patch options include synthetic materials such as polytetrauoroethylene and Vicryl mesh. There are patch techniques that minimize fascial manipulation during serial explorations, such as the Wittmann Patch [9] (Fig. 20.1). Patch techniques can be

Fig. 20.1 Patch technique. A Wittmann Patch is sewn to the fascia and then closed over the protective layer with a

Velcro

-like closing technique

combined with negative pressure therapy to help control and quantify peritoneal efuent.

20.2.4 Negative Pressure Therapy Systems

The most common contemporary techniques in temporary abdominal wall closure involve a negative pressure therapy system (NPTS). Most applications are commercial in nature and are highly utilized, in part, due to ease of use. Additionally, there is increasing literature supporting a higher primary fascial closure rate, even after long-term applications. NPTS allow for control of the abdominal uid efuent and its quantication. The dressings themselves are relatively compliant, thus minimizing (but not negating) progression of increased abdominal hypertension to frank abdominal compartment syndrome. There are two main types of NPTS, towel-based and

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sponge-based. NPTS employs the use of a nonadherent protective layer opposing the bowel that is perforated to allow for uid efuent, combined with an overlying sponge, gauze, or other porous materials in the subcutaneous space, and an outer, occlusive dressing. Once sealed, controlled suction can be placed on the porous layer to create the negative pressure and draw off accumulating uids and toxic metabolites. Noncommercial methods can be performed with products commonly found in most operating rooms.

20.3 Technical Considerations

20.3.1 Patch Technique

The commercially available Wittmann Patch™ is comprised of two sheets of biocompatible material which attach to each other using a Velcro®-like closing technique, one with micro hooks and the other with loops. Each sheet is sutured to the abdominal fascia. The abdominal wound can then be easily opened and closed by pulling them apart or pressing them together, respectively. The entire patch is then covered with a hypobaric wound shield (HWS) to help prevent contamination and promote removal of fluid. The classically described HWS is similar to the towel-based NPTS, the Barker VAC (see below), where a sterile gauze is used to cover the wound and the patch. A drain is then placed across the gauze and placed to wall suction. Finally, the entire wound site is covered with a plastic adhesive drape to seal it. In lieu of a hypobaric wound shield as described above, some surgeons opt to use a commercial negative pressure wound system for more robust fluid management and measurement.

In a similar manner to the Wittmann Patch™, polytetrauorethylene (PTFE) patches can be used to accomplish the same goals. Sewn to the edges of the abdominal fascia, the patch is then sewn together down the center, cut to reopen and resewn at each subsequent closing of the abdomen.

20.3.2 Towel-Based NPTS (Barker VAC)

The Barker VAC is a towel-based NPTS.A threelayered occlusive dressing is used to apply negative pressure and can be formed quickly and inexpensively with materials found in most operating rooms. In one of the original papers by Barker, the technique was estimated to cost $126, though likely higher now due to ination [10] (Table20.1).

The Barker Drain System provides to some degree the same advantages as the commercial negative therapy systems. It is generally much less expensive than commercial products and can be created with simple materials. However, it does not remove uids as efciently as the commercially available products [11].

Table 20.1 Materials and steps for placement of the Barker VAC

Materials Placement steps

• Polyethylene drape: Barker initially described the use of the 3M™ Steri-Drape™ large towel drape 1010; however, in a pinch, a sterile X-ray cassette cover will also sufce

•

Surgical towels

• Two 10mm at silicone drains with bulb

Y adapter

•

• Adhesive drape (Ioban)

• Skin adhesive (Mastisol or tincture of benzoin)

1. Obtain a polyethylene drape

2. Cut 1cm slits in a polyethylene sheet to allow for drainage of the peritoneal uid

Place the sheet between the viscera and anterior abdominal wall

20.2)

(Fig.

4. Place moist surgical

towels over the drape in the subcutaneous space

Lay the two at drains over the towels The skin is dried

6. and prepped with an adhesive

7. An adhesive sheet is placed across the wound and adhered to the skin (Fig.20.3)

8. The drains are connected via the y-connecting adapter and placed to wall suction

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Fig. 20.2 Visceral protection. All contemporary forms of temporary abdominal closure involve the placement of a nonadherent sterile covering to protect the abdominal viscera and prevent adhesion formation

Table 20.2

pressure therapy system (ABThera™)

1. Place the protective layer over the abdominal

2. The football-shaped foam piece is then sized to the

3. Prep the skin with an adhesive, i.e., Mastisol

4. The adhesive drape is then placed to cover the foam

5. A 2.5cm hole is cut in the adhesive and foam where

6. Connect the NPT machine and canister. Initial

Placement steps for the commercial negative

contents. The layer may need to be trimmed to t the abdomen. If this is the case, it is important to not leave any exposed foam sponge so as to prevent any direct exposure of the sponge to the bowel which may cause injury

dimensions of the subcutaneous space. It should be in contact with all wound edges but not overlapping the skin, which will help to apply medial tension

tincture of benzoin, to promote adhesion, especially in areas of skin overlap or high moisture, like groin creases

and surrounding skin. The importance of this step cannot be underestimated. For people with a large body habitus, an assistant to help hold back the skin, so a good seal with no gaps can be achieved, is paramount. Any gaps will create subsequent challenges for the device and care team. Cutting the large adhesive sheet into smaller more manageable sheets can help in more heavily creased areas. Additionally, shaving off excessive body hair will be appreciated by the patient at the time of removal and can help with achieving a better seal

the interface suction pad will be placed. Choose a location that will be most effective for ow and the position of the tube; this is generally centrally on the device. Adhere the suction pad over the cut hole (Fig.20.4)

settings should be set based on the physiology of the patient. The usual set pressure is 125mmHg continuous

Fig. 20.3 Towel-based negative pressure therapy system (Barker VAC). Using materials found in most operating rooms, the Barker VAC creates an inexpensive, three- layered occlusive dressing to which negative pressure is then applied

20.3.3 Sponge-Based NPTS (ABThera™)

In contrast to the Barker VAC, commercially available, sponge-based abdominal NPTS are designed to more evenly distribute the negative pressure and to better drain the recesses and dependent portions of the abdomen [11]. Some studies have indicated that use of an instillation feature available on some commercial NPTS can decrease the number of intestinal adhesions, help prevent dehydration, and facilitate re-exploration [4] (Table20.2).

If a NPTS is used in the setting of signicant bleeding and/or coagulopathy, the suction should be placed at a lower level (~75mmHg) for the rst 48 h to avoid persistent hemorrhage and allow clotting of blood vessels. The output canister should be closely monitored for signs of ongoing bleeding. Suction should also not be in direct contact with bowel. Any anastomosis created during surgery should be placed in the abdomen away for the NPTS.

20.4 Practical/Safety Precautions

Damage control laparotomy has decreased mortality rates in emergency surgery, but morbidity following the technique is still signicant. Complications following an open abdomen are divided into early

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Fig. 20.4 Commercial negative pressure therapy system (ABThera™). A suction pad is placed in a location that will be most effective for ow and the position of the tube. An open abdomen is not a contraindication to enteral feeding, and temporary abdominal closures can be used in conjunction with feeding tubes

and late complications. Prevention and early recognition of complications can be facilitated with a high level of suspicion, comprehensive postoperative critical care, and optimal nutritional support.

20.4.1 Early Complications

Patients requiring temporary abdominal closure often require massive volume resuscitation and intra-abdominal packing or have continued hemorrhage making them an at-risk population for the development of abdominal compartment syndrome. Even with an open abdomen, patients can develop intra-abdominal hypertension and compartment syndrome and should therefore be monitored closely. Monitoring options include bladder pressure transduction as well as physiologic assessments of urine output, airway pressures, and blood pressure. Development of abdominal compartment syndrome with a temporary abdominal closure in place requires immediate attention. The temporary abdominal closure should be immediately released or removed. Every attempt should be made to keep the abdominal viscera covered to prevent further damage or desiccation of the bowel, often a new dressing can be fashioned to the dimensions of the larger wound.

S. Resnick and N. D. Martin

Patients with temporary abdominal closure are also at high risk for malnutrition for multiple reasons including critical illness, lack of enteral feeding secondary to intestinal injury or held for procedures, and high-volume protein loss from the peritoneal cavity uid efuent. Peritoneal uid is estimated to contain 3 g/dL of protein, with net daily losses frequently quantied in liters, placing patients at an extremely high risk for protein-calorie malnutrition [12]. This additional protein loss should be taken into account when calculating caloric needs for repletion in a patient with an open abdomen.

20.4.2 Postoperative Care

Patients with a temporary abdominal wall closure should be monitored in the intensive care unit. Optimal care of the underlying pathology in combination with management targeted at the open abdomen, including controlled volume resuscitation and appropriate ratios of blood products, has been associated with a survival advantage [13].

Hypertonic saline has been suggested in the literature to help facilitate earlier abdominal wall closure. While the exact mechanism in humans has not been well described, the concept is that the higher concentration of saline functions to decrease overall uid administered and additionally may shift uid into the vascular system and decrease the capillary leak that occurs, thus preventing visceral edema. In a study of 23 patients who received 3% sodium chloride at 30 mL/h immediately after damage control surgery through postoperative day 3 or fascial closure (whichever occurred sooner), there was a 100% abdominal wall closure rate by day 7 [14].

Enteral nutrition is encouraged in all critically ill patients, especially those with an open abdominal wall. Studies have demonstrated that the use of enteral feeds in patients with an open abdomen is associated with decreased morbidity and mortality and increased rates of fascial closure [15]. Additionally, patients with a temporary abdominal closure do not require paralysis or deep sedation. Standard sedation goals are acceptable in

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this population. In fact, if the patient meets the usual pulmonary criteria, extubation is also acceptable with an open abdominal wall.

20.4.3 Late Complications

While the abdomen should not be closed if the patient remains at a signicantly high risk for development of abdominal compartment syndrome, once the required surgical procedures have been completed, every attempt should be made to close the abdomen in a timely fashion. The sooner the abdomen is closed after the initial operation, the lower the likelihood of complications, including stula formation and loss of domain leading to hernia formation.

While the ideal timeline for return to the operating room has not been fully described, it is well agreed upon that delays in returning to the operating room are associated with a decrease in the ability to achieve primary fascial closure. Pommerening etal. found that for each additional hour beyond 24 that a patient was delayed returning to the operating room was associated with a

1.1% decrease in the likelihood of primary fascial closure [16]. This same study found that complication rates were increased in patients who returned beyond 48h. Additionally, functional outcomes, including quality of life, pain, and return to work, are improved in a patient who undergoes abdominal wall closure within the rst 7days [17].

Primary closure of the abdominal fascial edges is usually possible when the fascial edges are 3–7 cm apart. Separations any greater than this require more complex surgical techniques to achieve denitive closure. Some cases may require component separation with myofascial aps if adequate skin coverage is unavailable. In cases of severe contamination or in abdomens unable to be closed beyond 8days, consideration of a planned ventral hernia is necessary. To create a planned ventral hernia, a synthetic absorbable mesh, frequently Vicryl, is sewn to the fascial edges to encourage granulation tissue formation over the bowel while preventing further loss of domain. Once granulation has occurred, a splitthickness skin graft is placed for ultimate cover-

age. This results in a ventral hernia that can be repaired 6–12months later.

20.4.4 Enterocutaneous Fistula (ECF)

Enterocutaneous stulas are a dreaded complication after an open abdomen, the incidence of which can run from 5 to 15% [11]. Not only do ECFs create a signicant reduction in quality of life, but they also carry a signicant mortality risk given the increased incidence of sepsis, malnutrition, dehydration, and electrolyte imbalances. A correlation exists between the number of days of temporary closure and ECF development [6, 18]. Other risk factors for stula formation include bowel injuries and anastomoses, colon resections, large volume resuscitation, intra-abdominal sepsis, increased number of repeat explorations, and use of a permanent mesh directly in contact with the bowel [18]. NPTS can be used to control ECF efuent and prevent breakdown and further contamination of surrounding tissues. Additionally, skin grafting around the stula can allow for ultimate placement of a wound manager device. ECFs often create complex wounds, and whenever possible, a skilled wound therapist should be involved in planning and creating the appropriate wound managing systems.

20.5 Future Directions/ Current Controversies

Temporary abdominal wall closure along with the associated care models such as damage control has become lifesaving tools for the acute care surgeon. As the indications for leaving an abdominal wall open have expanded beyond the trauma patient, there is increasing concern that this valuable technique is being over utilized, leading to unnecessarily high rates of complications. Patients are now surviving their initial insult, and many will face complications and repeat surgeries stemming from the temporary closure. For some, the mortality benet has been traded in for long-term morbidity. In a single-center retrospective study of a Houston

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trauma center, the authors found that 20% of patients who underwent a damage control laparotomy did not meet traditional indications [19]. The same group subsequently instituted a quality improvement project which decreased the number of traumatic open abdomens by 16% without changing mortality rates [20]. Future efforts will likely continue to redene the appropriate indications for temporarily closing the abdominal wall in both trauma and emergency surgery populations.

Take-Home Points

• Temporary abdominal closure is a frequently employed technique in trauma and other aspects of emergency surgery that require a “damage control” approach.

• Temporary abdominal closure techniques should control uid losses and minimize loss of domain, in addition to providing coverage/ protection of the bowel and intra-abdominal contents.

• There are many options available to the surgeon for temporary abdominal closure, which include silo techniques, patch techniques, and negative pressure therapy systems. Each has advantages and disadvantages associated with them.

• A patient with a temporary abdominal closure can still develop an abdominal compartment syndrome and should be closely monitored.

• When using NPTS, low suction should be used for the coagulopathic patient. The canister should be carefully monitored for signs of ongoing surgical bleeding.

• When using temporary abdominal closure devices, care must be taken to avoid injury to the bowel. If a negative pressure system is used, a barrier to protect the bowel from direct suction should be employed.

• All attempts to decrease the amount of time the patient has an open abdomen should be made. Patients should return for initial attempt at closure within 48h, if possible.

• Delay in closure increases complications including uid loss, protein loss, stula forma-

tion, and ventral hernias.

• Temporary abdominal closure alone does not necessitate paralysis or deep sedation nor prevent liberation from mechanical ventilation or enteric feeding from occurring. These elements of care should be evaluated on a case- by- case basis.