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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_999_Библиотеки_им_академика_М_И_Перельмана
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pressure of approximately 75mmHg is applied. However, the level of suction possibly needs to be adjusted, especially lowered in the presence of a coagulopathy and
increased risk of rebleeding. This procedure takes only a few minutes, which is
particularly advantageous in the context of damage control.
NPWT promotes granulation of the adjacent subcutaneous tissue and reduction
of tissue edema of the abdominal organs. If completely sealed, the nursing effort
with the dressing, other than changing pump canisters and periodically checking the
set suction, is minimal, as well as the risk of contamination of the abdomen. The
commercial pumps control the set suction and give an alarm in case of problems like
obstruction or leakage, which should be corrected promptly.
However, if one assumes that the abdomen will have to remain open for a longer
period of time due to a further increasing edema of the abdominal organs, a retroperitoneal mass as in pancreatitis or hemorrhage, or a questionable perfusion situation of the organs, the incipient retraction of the fascial edges should be prevented.
Again, various techniques are described for this, but we prefer the so-called Koblenz
model, a combination of a visceral protective layer, negative-pressure wound therapy, and dynamic closure techniques [49]. Here, after insertion of the VPL, a polyglactin mesh inlay is sewn into the fascial defect with continuous suturing using 2-0
polyglactin circumferentially in the sense of continuous (mesh-mediated) fascial
traction before the polyurethane sponge is inserted and the dressing is completed
with a negative pressure of 75mmHg.
At the next revision, the adhesive sheet and sponge are then removed and the
polyglactin mesh is subtotally cut along its longitudinal axis and the abdomen is
explored after removal of the VPL.Subtotal cutting of the mesh simplies re-sutured
closure of the mesh. At the end of this procedure, the mesh slit is closed again by a
continuous suture using 2-0 polyglactin. In this process, the size of the mesh can be
diminished at each revision according to the local ndings to approximate the fascial edges (Fig.23.2a, b). Of course, this would also be possible with bridging fascial sutures, but these increase the risk for fascial defects and soft tissue necrosis
with every procedure (Fig.23.3).
In the “Koblenz model” the fascia is only damaged twice, by the mesh xation
suture and the nal fascial suture, which is simplied in this technique. In any case,
the combination of VPL, NPWT, and continuous (mesh-mediated) fascial traction
guarantees a maximized denitive abdominal closure rate.
Another new, alternative technique to prevent fascial retraction in the case of
long-term open abdomen is the use of the Fasciotens Abdomen, for which the rst
promising experience reports also exist for this indication [50]. However, this technique is more complex and also cost-intensive.
S.-A. Engelien and D. R. Bulian
Revisions
In our opinion, a meticulous adhesiolysis of the entire small intestine should be
performed in every revision; otherwise, block formation will occur, which will massively complicate or impede a later complication treatment by, for example, stoma
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Fig. 23.2 (a, b)
Approximating the fascial
edges
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Fig. 23.3 Soft tissue
necrosis after bridging
fascial sutures
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creation. We strongly recommend the implementation of all procedures on one
patient by the same surgical team. The accomplishment of revisions after the elective program by the surgeon on duty leads, in our opinion, to more complications
and a delayed denitive abdominal closure and consequently a prolonged open
abdomen therapy, due to the ignorance of previous ndings. The interval between
revisions depends on the patient’s condition and should not exceed 72h. Even if
some colleagues disagree, in sepsis-related unstable patients as well as in the
absence of evidence of an intraabdominal focus, we tend to wait one more day until
the patient has recovered. In the case of any suspicion, immediate revision is
indicated.
Denitive abdominal closure should be performed as early as possible and as late
as necessary, but depends on several factors, especially intraabdominal ndings and
volume (abdominal organ edema). The requirements for denitive abdominal closure are an adequate minus balance after control of septic or trauma stress response,
resolution of septic capillary leak with consecutive anasarca, secure focal control,
an ensured vitality of the bowel, no need for surgical re-exploration, and no evidence of persistent abdominal compartment syndrome. General, intensive care
treatment recommendations such as uid balance, avoidance of hypothermia, coagulation management, substitution for coagulopathy, adapted catecholamine administration, and nutritional support can have a positive impact on early denitive
abdominal wall closure.
S.-A. Engelien and D. R. Bulian
Nutritional Replenishment
Sufcient enteral nutrition, including oral nutrition if tolerated, should be provided
immediately when possible due to nitrogen loss through the open abdomen and
preferred to parenteral nutrition. Contraindications to this are only a lack of bowel
continuity after damage control surgery, signs of intestinal obstruction, and high
enteroatmospheric stulae, where enteral nutrition via transstular access to aboral
positioning is not possible. Within such circumstances, parenteral feeding will be
required. Sedation and ventilation are dependent on the patient’s intensive care status and not on the presence of an open abdomen.
Technique ofDenitive Abdominal Wall Closure
In denitive abdominal closure, complete fascial suture should be aimed. In this
regard, fascial suture is possible with or without mesh reinforcement.
Without the use of mesh reinforcement, fascial suture is performed as a direct
suture or with the Ramirez component separation technique if complete approximation of the fascia is not primarily possible but can thereby be achieved [51]. Fascia
suturing is possible continuously or with interrupted sutures. We prefer the former
with a very slowly absorbable monolament elastic thread (poly-4- hydroxybutyrate).
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In any of these cases, the skin should be closed; otherwise, a vacuum therapy kit
should be applied subcutaneously. Another alternative is the combination of component separation with the implantation of a (partially resorbable) mesh in the sublay
position, which potentially can reduce the risk of hernia in the future.
If approximation of the fascia and closing of the skin is not achievable by this
either, granulation and mesh graft coverage of the remaining defect is an inappropriate solution and should be avoided. It results in a thin covering of the abdominal
organs that is barely protective, hardly mechanically resilient, and thereby bulging
due to the positive intraabdominal pressure. This is often referred to as a hernia
mistakenly, but this is not correct, since there is no hernia sac. Therefore, it generally leads to the need for tertiary abdominal wall reconstruction after 6–12months
with again a high morbidity and mortality.
It requires excision of the epithelium covering the defect, complete adhesiolysis,
and abdominal wall reconstruction, usually with component separation. To achieve
this, pretreatment with Botox injections into the oblique abdominal muscles is usually required 4–6weeks beforehand [52].
An alternative bridging of a remaining fascial defect can be done with a mesh in
inlay technique. In this case, synthetic meshes should be avoided if possible due to
wound contamination and the associated risk of infection. At best, biological meshes
should be used, which in turn are quite costly. Polyglactin meshes offer a comparable but only short-term benet. They are considerably less expensive, but are also
absorbed much more quickly, which means that the redressing effect is quickly
eliminated.
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Complications ofEDL andFurther Treatment withOpen
Abdomen Therapy
As a result of open abdomen therapy, enteroatmospheric stulas and frozen abdomen may develop. The potential impossibility of a secondary abdominal wall closure with a persistent laparostoma (by denition not a hernia) and, if necessary,
skin-graft coverage has already been described above.
Open abdomen management therefore means keeping an eye on early, secondary
abdominal wall closure and the avoidance of secondary complications right from
the beginning, that is, already when performing the EDL.
Treatment forEnteroatmospheric Fistula
Due to shear forces, especially in the case of adhesions of the intestine to the ventral
abdominal wall at the wound edge of the dehiscent fascia, a defect of the intestinal
wall may occur, resulting in an enteroatmospheric stula. The incidence of stula is
approximately 10% [53, 54]. Sometimes, due to pathogenesis, more than one stula
occurs at the same time.
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Fig. 23.4 Enteroatmospheric stula
S.-A. Engelien and D. R. Bulian
The hazards of these stulas are bleeding, uncontrollable loss of uids, electrolytes, and bile acids, which must be replaced accordingly, as well as the impossibility of enteral nutrition and a leaky coverage of the laparostoma with subsequent
dermatitis even of the adjacent healthy skin (Fig.23.4).
In this case, wound dressings no longer adhere here and the resulting skin erosion and dermatitis worsen. Repeated suturing of the stula should not be performed
in our opinion, because it regularly leads to an enlargement of the defect. It should
be preferred to establish a funnel directly over the stula and to attach an ostomy
bag in a notch of the abdominal vacuum therapy kit covering the rest of the wound
for passive drainage and stula stabilization (Fig.23.5).
Commercial items also exist for this purpose. The stula secretion can then passively drain into the stoma bag via the funnel, protecting the surrounding wound
surface from the irritating intestinal secretion. In some cases, it is also possible to
feed the patient enterally via a catheter inserted into the aboral branch of the stula.
However, this should only be done after exclusion of a passage obstruction aborally
of the stula, for example, by means of CT with contrast medium via the aboral
stula branch. To make the vacuum dressing tight, additional stoma paste can be
applied to the wound edge. We also recommend early skin-graft coverage of the
surrounding granulation tissue so that an ostomy bag can then be tightly adhered to
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Fig. 23.5 Dressing for an
enteroatmospheric stula
389
the skin surrounding the stula. Abdominal wall reconstruction in the presence of
an enteroatmospheric stula is otherwise almost impossible in the primary setting.
Skin grafting on the surrounding granulation tissue succeeds more frequently than
thought, despite the frequent initial fecal contamination.
More than half of enterocutaneous stulas close with conservative therapy,
although this is successful in about 75% in the upper gastrointestinal tract and in
only about 35% in the lower gastrointestinal tract [55]. However, after open abdomen, the spontaneous closure rate is only 37% [56]. Conservative therapy is complex and consists of uid and electrolyte replacement, pharmacotherapy, nutrition,
adequate therapy for sepsis, as well as skin protection and wound care.
The denitive therapy for enteroatmospheric stulas in case of failed conservative treatment is surgical and consists of a combination of complete adhesiolysis,
resection of the stula-bearing bowel loop with anastomosis, and abdominal wall
reconstruction, possibly with prior bilateral Botox inltration into the oblique
abdominal muscles, and possibly with Ramirez component separation. We avoid the
use of mesh for reinforcement in these cases because of the risk of infection due to
bacterial contamination. Alternatively, a two-staged procedure with secondary
abdominal wall reconstruction can be performed by a component separation according to Ramirez with implantation of a partially absorbable mesh in sublay position.
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S.-A. Engelien and D. R. Bulian
This should be performed approximately 7days after primary adhesiolysis, bowel
resection, anastomosis, and temporary abdominal wall closure, for example, according to the “Koblenz model“for temporary fascial approximation.
Alternatively, the Fasciotens Abdomen can be used, even if this signicantly
limits the patient’s mobilization during the treatment [50].
We consider the use of biologic meshes, which is recommended as an ultima
ratio in cases of a contaminated situs, because of so far not convincing results.
However, surgical revision of the stula with the intention of repairment and reconstruction of the abdominal wall should only be performed after 6–12months at the
earliest, as long as the patient has recovered and is able to bear sufcient physical
strain for this major intervention by then. In the meantime, the patient should receive
adequate enteral and/or parenteral nutrition to optimize the patient’s nutritional and
immunologic status, which eventually leads to a decrease in the complication.
Preventing Enteroatmospheric Fistulas
The simplest thing to do is to prevent the formation of enteroatmospheric stulas. In
this regard, we believe that complete adhesiolysis of the entire small bowel at each
revision to prevent severe adhesions that could later be resolved only at the risk of
intestinal wall lesions and extensive insertion of the VPL, as described above, are
the key points of treatment [57]. Adhesiolysis should be avoided only if the intestinal loops are severely inamed and edematous, as manipulation could backre and
result in additional stulas. However, these alterations are usually due to inadequate
adhesiolysis in the previous procedures, which underlines the importance of having
the same team manage the patient every time.
Acknowledgments The authors would like to thank Arnulf G.Willms, Sebastian Schaaf, and all
other members of the Open Abdomen Group within the European Registry of Abdominal Wall
Hernia (EuraHS) for their support in the eld of this topic.
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