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22 Damage Control Laparotomy
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retract the duodenum and pancreatic head medially. A major pitfall of this maneuver
is injury to the right gonadal vein as it drains into the inferior vena cava.
The Cattell-Braasch Maneuver, also known as a right-sided medial visceral rotation, provides a panoramic view of the entire inframesocolic retroperitoneum. It is
performed in three stages. First, a classic Kocher Maneuver is performed as previously described. The incision is then extended caudally along the Line of Toldt to
fully mobilize the ascending colon. Finally, the incision is extended around the
cecum and along the posterior peritoneum to the Ligament of Treitz while retracting
the bowel up and to the right. These extensions are referred to as the “Extended
Kocher Maneuver” and the “Super-Extended Kocher Maneuver,” respectively. Care
must be taken during this maneuver as the right colon will hang by its mesentery
alone. A major pitfall would be avulsion of the right colic vein off the superior mesenteric vein after an inadvertent pull.
363
Decision: Denitive Repair Versus Damage Control
Once the injuries have been identied and the surgeon knows the state of the patient,
the decision can be made to proceed with denitive repair or to elect for damage
control with stabilization and delayed denitive repair. If damage control is required,
the goals of the initial surgery are to arrest hemorrhage, limit contamination, maintain blood ow, and provide temporary abdominal closure. Operative time is limited
to minimize further hypothermia, coagulopathy, and acidemia. Damage control procedures vary based on the injury but can include resection of necrotic bowel leaving
in discontinuity, shunting, and simple packing.
The indications for damage control surgery are evolving and varied [4, 17–19].
General guidelines include the following:
• Severe Physiologic Insult
– Acidosis (pH <7.2 or Base Decit >15)
– Hypothermia (Core Temperature <34°C)
– Coagulopathy (INR >1.5 or Clinical Evidence)
– Lactate >5
– Intraoperative Ventricular Arrhythmia
• Signicant Blood Loss
– Unable to Control Bleeding by Conventional Methods
– Blood Loss >4L
– Blood Transfusion >10U
• Signicant Injury Pattern
– Difcult to Assess Major Venous Injury
– Major Liver or Pancreaticoduodenal Injury with Hemodynamic Instability
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– Combined Pancreaticoduodenal Injury with Massive Hemorrhage from the
Pancreatic Head
– Devascularization or Massive Disruption of the Duodenum, Pancreas or
Pancreaticoduodenal Complex with Involvement of Ampulla or Ducts
• Need for Staged Reconstruction
– Need to Reassess Bowel Viability
– Unable to Close Abdominal Wall Without Tension
– Signs of Abdominal Compartment Syndrome While Attempting Closure
D. R. Velez and A. J. Duncan
Temporary Abdominal Closure
There are numerous methods available to the surgeon electing to proceed with temporary abdominal closure during a damage control laparotomy. The most common
include negative pressure wound therapy, patch closure, Wittmann patch, Bogota
bag, and a skin-only closure. However, even with many options for temporary
abdominal closure, the goal should still be closure of the abdomen as soon as safe
and feasible. Diaz etal. showed a decreased rate of complications if the abdomen
was closed in less than 8days [20].
Negative Pressure Wound Therapy (NPWT)
Over the past decade, NPWT has become the mainstream in many aspects of surgery. The NPWT closure provides temporary closure with an element of negative
pressure. It helps with both the management of intrabdominal uid and lateral
forces on the abdominal wall. While this has been shown to have improved rates of
fascial closure by some studies, it does come at a signicantly increased cost [21].
It is becoming increasingly utilized and is now essentially available in one of two
options.
The ABThera from KCI is commercially available. It is composed of an initial
polyurethane foam covered with a lm which is placed intraperitoneally. This lm
has perforations that allow uid to be extracted while also keeping the bowel from
adhesion formation. A second oval foam is then placed extraperitoneal to the level
of the skin where an occlusive drape and suction can be applied. Negative pressure
is then generated between 100 and 150mmHg.
The other, less expensive option was rst described by Barker’s group [22]. It is
similar to the ABThera VAC, but it is composed of materials already found within
the operating room, thus limiting the cost. The rst layer uses a perforated nonadherent polyethylene sheet which is placed between the peritoneum and visceral
organs to prevent adhesions of the bowel. The perforations allow for reliable
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evacuation of uid. Over the sheet, surgical towels or sponges are placed. Over
these, drains are placed which give the ability to create the negative pressure. An
adhesive dressing is then placed over the top to nish the seal.
365
Patch Closure
Many different options for use of a temporary abdominal closure have been
described utilizing both permanent and absorbable mesh. Absorbable meshes are
typically placed with the intent of allowing granulation tissue to form for a skin
graft and eventual delayed ventral hernia repair. Non-absorbable meshes, however,
can be used to help with serial approximation of the fascial edges. Both mesh
options have reasonable delayed closure rates but non-absorbable have been quoted
higher at almost 90% [23].
Wittmann Patch
When primary closure cannot be achieved in a timely manner, a Wittmann patch can
be used. This is composed of two opposing sheets that, when pushed together, maintain force against lateral shear, similar to Velcro. The sheets will be attached to fascial edges and tightened every 24–48 h until a primary fascial closure can be
performed. Benets of the Wittmann patch are that it prevents loss of lateral abdominal domain; it is easily placed; and once the initial patch is in place, it requires no
exchange of material, just serially tightening. Once the fascial edges are within a
few centimeters, they can be closed primarily. This method can achieve primary
closure in over 78%–100% of patients [24, 25].
Bogota Bag
Used in Bogota, Colombia for several decades, the Bogota Bag involves the use of
hard intrabdominal plastic as a temporary layer. This was then described by Mattox
after seeing its usage. The original description involved cutting a sterile IV bag into
an oval shape and suturing or stapling it to the skin. Sterile moist towels would then
be placed over it, followed by another iodine drape. While this allows for dressing
changes to be performed at the bedside, which can be advantageous in certain clinical situations, it does not aid in preventing lateral abdominal wall retraction [26,
27]. Furthermore, the Bogota Bag is associated with higher rates of evisceration,
sepsis, and lower primary closure rates. This limits its usage predominantly to areas
that lack resources for other temporary abdominal closures [28]. Reported rates of
closure after a Bogota Bag vary signicantly between 12% and 80% [25, 28].
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D. R. Velez and A. J. Duncan
Skin-Only Closure
Perhaps the most rapid method for containing bowel intra-abdominally while minimizing heat and uid loss can be accomplished with a skin-only closure. This can
be achieved by several options, including towel clamps, staples, or a running suture.
This closure should then be covered with a plastic drape to further decrease heat and
uid loss. While the skin closure can be done exceptionally fast, it does not provide
any additional medial traction to the fascia in helping prevent loss of domain. Skin
only closures are associated with higher rates of complications including evisceration, infection, and loss of skin. Because of increased rates of complications and
other options, few situations call for a skin-only closure.
Vacuum-Assisted Wound Closure andMesh-Mediated Fascial
Traction (VAWCM)
Initially introduced in a small case series by Peterson etal., this technique serves as
a promising hybrid between negative pressure wound therapy (NPWT) and the
Wittmann patch [29]. The rst step involves placement of a perforated plastic sheet
within the peritoneum, followed by placement of a polypropylene mesh that is
sutured to each fascial edge to provide constant medial traction. In between the
plastic sheet and mesh, moist laparotomy pads and drains are carefully placed.
Subsequently, the entire wound is covered with an occlusive dressing, and the drains
are connected to suction with settings similar to those utilized in NPWT.
Regular evaluation of the patient for possible abdominal wall closure is necessary, which typically involves taking the patient to the operating room every few
days or exchanging the laparotomy pads, if needed. Since its initial description,
several additional authors have reported promising results with the use of this technique. Fascial closure rates have been cited as ranging from 60% to 89%, indicating
its effectiveness in aiding wound healing and closure [30–32].
Outcomes andComplications
Damage control laparotomy (DCL) is an important surgical procedure that can help
save the lives of critically ill patients. However, like all surgical operations, it is not
without risks and complications. While it is clear that in true damage control situations, an expedited laparotomy is benecial and can reduce mortality rates, studies
have shown that there are increased rates of specic complications associated with
an open abdomen. In fact, the mortality rate for patients who experience complications with an open abdomen can be as high as 25% [18].
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367
Some of the complications that can occur with a delayed closure of the abdomen
include ventral hernias, enterocutaneous or entero-atmospheric stulas, loss of
abdominal domain, ventilator-associated pneumonia, bacteremia, and sepsis. It has
been found that the risk of these complications can be minimized if the abdomen is
closed within 8days from the index operation [20].
Despite the potential risks associated with DCL, there has been an increase in the
number of these procedures being performed, with estimates suggesting that up to
40% of trauma patients may have an open abdomen [33, 34]. However, due to the
lack of randomized controlled trials, identifying the appropriate indications for
DCL has been left largely to expert opinion.
This has led some authors to suggest that DCL may be overused in situations
where a denitive repair could be performed at the index procedure [18]. However,
a recent matched trial conducted by George etal. found that there was no difference
in mortality or major abdominal complications between patients who underwent a
denitive laparotomy versus those who were left open and could have been closed
at the index procedure. It should be noted, however, that the latter group did have a
higher risk of fascial dehiscence [34].
Conclusion
The trauma laparotomy still follows the same “Operative Sequence” of access and
exposure, temporary bleeding control, exploration, and then decision of denitive
repair versus damage control as outlined by Hirshberg and Mattox over 15years
ago. As operative trauma cases are declining and are increasingly concentrated in a
few centers, the need to maintain adequate surgical training is vital. Today, the
trauma laparotomy serves as a life-saving intervention in the management of
abdominal trauma. It is a tool that every graduating surgical resident and every surgeon taking trauma call should thoroughly understand and be prepared to utilize.
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15. Kobayashi LM, Costantini TW, Hamel MG, Dierksheide JE, Coimbra R.Abdominal vascular
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16. Manzini N, Madiba TE.The management of retroperitoneal haematoma discovered at laparotomy for trauma. Injury. 2014;45(9):1378–83.
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18. Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, Stelfox
HT.Indications for trauma damage control surgery international study G: evidence for use of
damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg. 2021;16(1):10.
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22. Brock WB, Barker DE, Burns RP.Temporary closure of open abdominal wounds: the vacuum
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23. Regner JL, Kobayashi L, Coimbra R.Surgical strategies for management of the open abdomen. World J Surg. 2012;36(3):497–510.
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25. Mahoney EJ, Bugaev N, Appelbaum R, Goldenberg-Sandau A, Baltazar GA, Posluszny J,
Dultz L, Kartiko S, Kasotakis G, Como J, etal. Management of the open abdomen: a systematic review with meta-analysis and practice management guideline from the Eastern
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26. Fernandez L, Norwood S, Roettger R, Wilkins HE 3rd. Temporary intravenous bag silo closure
in severe abdominal trauma. J Trauma. 1996;40(2):258–60.
27. Manterola C, Moraga J, Urrutia S.Contained laparostomy with a Bogota bag. Results of case
series. Cir Esp. 2011;89(6):379–85.
28. Muhammad Y, Gondal KM, Khan UA.Use of the “bogota bag” for closure of open abdominal
wound after exploratory laparotomy—our experience at Mayo Hospital Lahore. J Pak Med
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29. Hadeed JG, Staman GW, Sariol HS, Kumar S, Ross SE.Delayed primary closure in damage
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30. Petersson P, Montgomery A, Petersson U. Vacuum-assisted wound closure and permanent
onlay mesh-mediated fascial traction: a novel technique for the prevention of incisional hernia
after open abdomen therapy including results from a retrospective case series. Scand J Surg.
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31. Petersson P, Petersson U. Dynamic fascial closure with vacuum-assisted wound closure and
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34. George MJ, Adams SD, McNutt MK, Love JD, Albarado R, Moore LJ, Wade CE, Cotton BA,
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Chapter 23
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Abdominal Compartment Syndrome
andEmergency Decompressive
Laparotomy
Sissy-AmelieEngelien andDirkR.Bulian
Abbreviations
ACS Abdominal compartment syndrome
ADH Anti-diuretic hormone
DCL Damage control laparotomy
DL Decompressive laparotomy
ECMO Extracorporeal membrane oxygenation
IAH Intraabdominal hypertension
IAP Intraabdominal pressure
ICU Intensive care unit
IVC Inferior vena cava
MODS Multiple organ dysfunction syndrome
NPWT Negative pressure wound therapy
PCD Percutaneous drainage
RVEF Right ventricular ejection fraction
WSACS World Society of the Abdominal Compartment Syndrome
S.-A. Engelien
Department of Plastic Surgery, Hand Surgery, and Burn Center, Cologne-Merheim Medical
Center (CMMC), Witten/Herdecke University, Cologne, Germany
e-mail: engelien@web.de
D. R. Bulian (
Department of Abdominal, Tumor, Transplant and Vascular Surgery, Center for
Interdisciplinary Visceral Medicine (CIV), Cologne-Merheim Medical Center (CMMC),
Witten/Herdecke University, Cologne, Germany
e-mail: dirk.bulian@uni-wh.de
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_23
*)
371© The Author(s), under exclusive license to Springer Nature
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S.-A. Engelien and D. R. Bulian
Introduction/Background
Intraabdominal hypertension (IAH) and especially the abdominal compartment
syndrome (ACS) often describe inadequately diagnosed clinical entities accompanied by an increased morbidity and mortality.
Knowledge of these conditions is of major importance in both medical and surgical intensive care units (ICU), the emergency department, and the general ward. An
adequate diagnosis and immediate therapy are necessary to improve the outcome.
For the diagnosis, identifying risk factors and monitoring of the intraabdominal
pressure play a key role [1–3].
Patients with abdominal diseases most frequently die from infectious complications: peritonitis, on the one hand, due to a primary inammatory disease or ischemia of an abdominal organ with bacterial translocation or organ perforation; on the
other hand, after complicative abdominal surgery with anastomotic insufciency or
bowel injury, but also from intraperitoneal hemorrhage or mechanical causes such
as intestinal obstruction. Another abdominal cause of lethal disease progression is
untreated abdominal compartment syndrome (ACS). It describes a mismatch of
space required by the abdominal organs including their blood supply and the available abdominal volume. Especially in the case of both, an increased space requirement of abdominal or retroperitoneal organs and reduced space inside the abdominal
cavity, the development of an ACS is more likely.
The abdominal wall is physiologically very distensible compared with other
compartments such as the skull. An increase of intraabdominal volume can usually
be tolerated for a certain period of time without a negative impact on organ function.
However, this distensibility has its limits, especially when the volume increase
occurs in a short period of time. Conservative therapeutic measures are usually
insufcient making emergency decompression laparotomy (EDL) a rarely necessary but often life-saving procedure in visceral as well as in burn medicine.
IAH leads to organ dysfunction and even organ failure via disturbance of abdominal organ perfusion. Usually, the kidneys are the rst to be affected. In addition, an
increase of the intraabdominal pressure leads to a pathological diaphragmatic elevation, which culminates in ventilatory dysfunction and lung failure. These consequences have a relevant impact on the mortality of critically ill patients.
Since ACS can be seen as a consequence of other pathologies, EDL is only a
symptomatic and not a causal therapy of the underlying disease. Moreover, EDL is
part of the complication management, which, on the other hand, requires prolonged
treatment for secondary abdominal wall closure and involves additional, severe
complications such as enteroatmospheric stulas. In this regard, the surgical technique and the EDL approach have a crucial inuence on the EDL-associated complication rate and the secondary abdominal wall closure rate. EDL buys time for
further therapy of the underlying disease by preventing a short-term lethal course
due to multiorgan failure and improving organ function. Thereby, the overall outcome can be improved.
23 Abdominal Compartment Syndrome andEmergency Decompressive Laparotomy
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Denitions
A compartment syndrome describes an elevated pressure inside an inextensible anatomical space like the cranial, abdominal, and thoracic cavity, which leads to a
compromitted tissue perfusion.
In a normal weight person, the physiological pressure in the abdominal cavity is
5mmHg, whereas in highly obese patients, an increased baseline IAP of 9–14mmHg
can be found.
IAH is dened as an IAP >12mmHg and subdivided into four Grades (Grade I
IAP 12–15mmHg, Grade II IAP 16–20mmHg, Grade III IAP 21–25mmHg, Grade
IV IAP>25mmHg). The denition of ACS includes an IAP >20mmHg combined
with a newly emerging organ dysfunction or organ failure. Acute elevations in IAP
have shown similar effects in obese patients, but the threshold IAP associated with
organ dysfunction is assumed to be higher in this population [4–9].
Epidemiology
Concerning the epidemiology of IAH and ACS, data show signicant differences.
Causal may, on one hand, be the level of awareness among clinicians. In teaching
hospitals, ACS is claimed to be diagnosed more often compared to district hospitals.
On the other hand, the epidemiology depends on the studied population.
In general, critical patients show a higher risk in developing ACS than noncritical patients. Most studies focused on homogenous populations showing signicant differences in concerning the incidence rate. So, an overall incidence of IAH
and ACS cannot be numbered [7, 10].
Incidence
For IAH including ACS, the following incidences are described: aortic surgery,
39.7% (33.3% elective and 61.5% emergency surgery); liver transplant, 59.5%;
severe and acute pancreatitis, 85.7%; major trauma, 58.8–72.8%; mixed ICU,
39–48.9%; and septic shock, 18.9–68%.
If we consider only ACS, the incidences are aortic surgery, 5.2%; liver transplant,
7.7%; mixed ICU, 2–6%; septic shock, 28%; and severe acute pancreatitis, 57% [6].
Due to advanced recognition and management of IAH as well as improved intensive care and perioperative treatment including uid management optimization,
critically ill patients progressively survive the initial phase. The incidence of IAH
persists and is probable to increase, whereas the incidence of ACS lessens [6, 11].
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