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24 Post-Operative Complications After Emergency Laparotomy
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42. Robinson KA, O’Donnell ME, Pearson D, Kriegshauser JS, Odeleye M, Kalkbrenner K, etal.
Portomesenteric venous thrombosis following major colon and rectal surgery: incidence and
risk factors. Surg Endosc. 2015;29(5):1071–9.
43. Burcharth J, Abdulhady L, Danker J, Ekeloef S, Jorgensen T, Lauridsen H, etal. Implementation
of a multidisciplinary perioperative protocol in major emergency abdominal surgery. Eur J
Trauma Emerg Surg. 2021;47(2):467–77.
44. Ceresoli M, Biloslavo A, Bisagni P, Ciuffa C, Fortuna L, La Greca A, etal. Implementing
enhanced perioperative care in emergency general surgery: a prospective multicenter observational study. World J Surg. 2023:1–9.
45. Pathrikar SG, Jadhav GS, Adhikari GR. The application of enhanced recovery after surgery
protocols in patients with perforated duodenal ulcer. Cureus. 2023;15(3):e35760.
46. Lohsiriwat V, Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: review of literature and current practices. World J Gastrointest Surg. 2019;11(2):41–52.
47. Vinas X, Macarulla E, Brugiotti C, Ramirez JM, Pedregosa A, Sanchez S, etal. Feasibility and
effects of enhanced recovery vs. conventional care after emergency colon surgery for patients
with left colon perforation. Sci Rep. 2020;10(1):7346.
48. Loran DB, Hyde BR, Zwischenberger JB.Perioperative management of special populations:
the geriatric patient. Surg Clin North Am. 2005;85(6):1259–66. xi
49. Middleton M, Wan B, da Assuncao R. Improving hip fracture outcomes with integrated
orthogeriatric care: a comparison between two accepted orthogeriatric models. Age Ageing.
2017;46(3):465–70.
50. Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, etal. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev.
2018;1(1):CD012485.
51. Aitken RM, Partridge JSL, Oliver CM, Murray D, Hare S, Lockwood S, etal. Older patients
undergoing emergency laparotomy: observations from the National Emergency Laparotomy
Audit (NELA) years 1-4. Age Ageing. 2020;49(4):656–63.
52. Joughin AL, Partridge JSL, O'Halloran T, Dhesi JK.Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older
people. Age Ageing. 2019;48(3):458–62.
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Chapter 25
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Open Abdomen asanEffective Therapy
forAbdominal Sepsis, Bedside Assistance
fortheSurgeon
ThijsCornette andFrederikBerrevoet
Introduction
Abdominal sepsis is, after pulmonary sepsis, the second most common cause of
sepsis that needs intensive care management and has a high morbidity and mortality
rate. It can arise from many different pathologies, both infectious and non- infectious.
However, even when the “obvious” focus in a patient with SIRS is non-infectious,
an infectious origin must be excluded. Age, smoking, immunosuppression (e.g.,
cancer, corticosteroids), diabetes mellitus, morbid obesity, acute renal failure, and
dialysis are all predisposing factors that result in higher complication rates [1].
Contained infections result in the formation of an intra-abdominal abscess,
whereas uncontained infection can lead to local or diffuse peritonitis. The etiology
of primary peritonitis is not well understood, but is dened as a spontaneous, diffuse
peritoneal infection with or without intra-abdominal source. Although it can occur
at any age, it is more frequently observed in children. Possible routes of infection
are hematogenous, lymphatic, gastrointestinal, and genital/fallopian tubes (females).
Urinary tract and intra-abdominal foreign body are other possible routes of infection. If peritonitis follows intra-abdominal lesions such as gastrointestinal perforations, ischemia or infected necrosis associated with severe acute pancreatitis, we
dene it as a secondary peritonitis. Tertiary peritonitis refers to a persistent or
T. Cornette
Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
Department of General and HPB Surgery and Liver Transplantation, Ghent University
Hospital, Ghent, Belgium
F. Berrevoet (
Department of General and HPB Surgery and Liver Transplantation, Ghent University
Hospital, Ghent, Belgium
e-mail: Frederik.Berrevoet@UGent.be
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_25
*)
417© The Author(s), under exclusive license to Springer Nature
418
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recurring infection with organisms of low or high virulence. It is seen after multiple
operative attempts to treat secondary peritonitis, particularly in circumstances of
open abdomen, stula formation, and gut dysfunction [2].
T. Cornette and F. Berrevoet
Sepsis andSeptic Shock
In 2016 new denitions for sepsis and septic shock were proposed by Singer etal.
[3]. The systemic inammatory response syndrome or SIRS term can still be used
to describe a systemic response to a sterile hit or an infection. However, there is an
insight that sepsis does not follow a continuum from infection and sepsis to shock.
Severe sepsis is a term that is no longer used, as it caused confusion. Sepsis is now
dened as a life-threatening organ dysfunction caused by a dysregulated host
response to infection. Septic shock entails higher mortality, demanding vasopressors (>65 mmHg), or exhibiting a lactate > 2 mmol/L after hypovolemia was
excluded [3].
Organ Dysfunction
It can be quantied by the Sequential Organ Failure Assessment (SOFA) score [4]
for screening purposes, to assess severity, to predict outcomes, and as follow-up in
the intensive care unit/ICU (Table25.1). It has higher specicity than the previous
SIRS criteria, but lower sensitivity [5]. The q-SOFA score is an abbreviated score
for patients outside the ICU [6]. It focusses on low blood pressure (SBP
(≤100mmHg)), high respiratory rate (≥22/min), or altered mentation (GCS≤14).
Fullling two of the three criteria in the q-SOFA score is an indication for ICU
hospitalization. For surgeons, however, the SIRS criteria (Sepsis-2) remain the most
important tool for detecting a septic patient, as it has the highest sensitivity for early
detection of inammation and infection, both crucial for early treatment [1]. To
fulll the SIRS criteria the patient must have two out of the four criteria:
– Body temperature over 38°C or under 36°C
– Heart rate >90/min
– Respiratory rate >20/min or partial pressure CO2<32mmHg
– Leukocyte count>12,000 or less than 4000/mL or over 10% immature forms
Patients with abdominal sepsis often require standard surgical exploration as a
crucial component of their management, although multiple minimally invasive procedures seem to achieve the same target with less morbidity [2, 7].
25 Open Abdomen as an Effective Therapy for Abdominal Sepsis, Bedside Assistance…
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a
Dopamine >15 or
epinephrine >0.1 or
<100 (13.3) with
respiratory support
support
norepinephrine 0.1
a
Dopamine 5.1–15 or
epinephrine ≤0.1 or
norepinephrine ≤0.1
a
dobutamine (any
dose)
419
partial pressure of oxygen
2
for at least 1h
−1
min
−1
0 1 2 3 4
mmHg (kPa) ≥400 (53.3) <400 (53.3) <300 (40) <200 (26.7) with respiratory
2
/FIO
2
O
a
Respiration
System Score
Table 25.1 Sequential (sepsis related) organ failure assessment (SOFA) score. (Gyawali etal.) [4]
P
<1.2 (20) 1.2–1.9 (20–32) 2.0–5.9 (33–101) 6.0–11.9 (102–204) >12.0 (204)
≥150 <150 <100 <50 <20
−1
μL
3
−1
Cardiovascular MAP ≥70mmHg MAP <70mmHg Dopamine <5 or
Liver bilirubin, mg dL
Coagulation platelets, ×10
<1.2 (110) 1.2–1.9 (110–170) 2.0–3.4 (171–299) 3.5–4.9 (300–440) >5.0 (440)
15 13–14 10–12 6–9 <6
b
−1
)
−1
Central Nervous system (CNS)
Glasgow Coma Scale scare
Urine output, mL per day <500 <200
(μmolL
Renal Creatinine, mg dL
fraction of inspired oxygen, MAP mean arterial pressure, PaO
2
Glasgow Coma Scale scores range from 3 to 15: higher score indicates better neurological function
Catecholamine doses are given as μgkg
FIO
a
b
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T. Cornette and F. Berrevoet
Key Surgical Steps
Identication of the source: It may not be apparent or diagnostic imaging techniques are inconclusive.
Source control: Draining an abscess, resecting a diseased or perforated organ,
repairing an anastomotic leak, or removing necrotic tissue are typical maneuvers.
By addressing the source, surgeons aim to eliminate or minimize ongoing contamination, preventing the further spread of infection and allowing the body's immune
system to better combat the sepsis.
Debridement: Removal of infected or necrotic tissue is commonly performed.
This helps eliminate bacteria, toxins, and debris, promoting wound healing and
reducing the risk of recurrent infection. Debridement also aids in removing potential sources of ongoing sepsis and contributes to the overall management of the
patient. Irrigation has been routinely used in the past; however, it is not recommended anymore. At least in the context of trauma, even with heavy contamination,
outcomes are not improved and new abscess may appear [7].
Evaluation of complications: Exploration allows surgeons to assess peritonitis,
abscesses, and adhesions; provide appropriate treatment; and determine the need for
additional interventions or specialized care.
Damage andSource Control Surgery
Damage control surgery (DCS) is a surgical intervention with rapid termination
when a good level of control is achieved over a life-threatening bleeding or contamination. It is surgery to keep the patient alive rather than correct anatomy. If adequate
stabilization is obtained, a more profound resuscitation on the ICU is performed and
physiology is corrected. Closure of the abdominal wall can be further delayed if
necessary [8]. Surgical source control consists of debridement of necrotic or infected
tissues, drainage of abscesses or infected uid collections, and denite control over
the source of contamination. The sequence for damage control in the septic abdomen is slightly altered from the trauma procedure. The rst phase, ground zero, can
be longer to accommodate a good level of resuscitation until a safe induction of
anesthesia can be performed. The urgency to operate can be evaluated by the SOFA
score, the presence of shock, and the severity of organ system involvement.
Role ofRelaparotomies inSeptic Patients
Relaparotomies are frequently needed and should eventually be planned in circumstances of extensive and incompletely controlled abdominal sepsis. In some patients,
peritoneal infection can deteriorate quickly to an excessive inammatory response
25 Open Abdomen as an Effective Therapy for Abdominal Sepsis, Bedside Assistance…
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(SIRS), causing organ failure. An early reintervention with evacuation of toxic content and inammatory cytokines may be crucial for stopping the septic cascade [9].
The origin of secondary peritonitis and perioperative ndings at emergency laparotomy tend to be poor indicators for early relaparotomy, whereas signs of progressive or persistent organ failure in the early postoperative phase seem more reliable.
A proposed model by Kiewiet etal. showed a signicant correlation when six variables are combined, that is heart rate, hemoglobin level, body temperature, no defecation, the extent of contamination found at initial laparotomy, and the need for
inotropic medication. This model is then combined with CT scan ndings [10]. The
development of elevated intra-abdominal pressure (IAP) during the early postoperative period is associated with increased risk of prolonged postoperative peritonitis
and could be used as a predictor of early relaparotomy [11].
421
Intra-abdominal Hypertension (IAH) andAbdominal
Compartment Syndrome (ACS)
According to severity, IAP can be classied as Grade I: IAP 12–15mmHg; Grade
II: IAP 16–20mmHg; Grade III: IAP 21–25mmHg; and Grade IV: IAP>25mmHg
[12]. Hyperacute forms exist, representing elevations in IAP that last only a few
seconds or minutes as a result of laughing, straining, coughing, sneezing, defecation, or physical activity. They have limited surgical interest. The acute modality
corresponds to IAH developing over a period of hours and is seen primarily in surgical patients as a result of trauma or intra-abdominal hemorrhage. Subacute cases
occur over a period of days and are the most encountered form in medical patients.
Chronic examples evolve along months (i.e., pregnancy) or years (i.e., morbid obesity, intra-abdominal tumor, peritoneal dialysis, chronic ascites, or cirrhosis).
Intrinsically they don’t represent emergencies; however, they may place patients at
risk for developing either acute or subacute IAH when critically ill [13].
Diagnosis
When undetected, ACS is an independent predictor of mortality [14–16]. The exact
clinical symptoms that dene ACS are not well dened. Abdominal distention can
be observed, but is not sensitive, nor specic to diagnose ACS, as well as respiratory
complications or urine output due to renal non-perfusion. The surgeon must always
be aware of the possibility of developing ACS) and has to exclude it actively from
the differential diagnosis in critically ill patients.
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T. Cornette and F. Berrevoet
The Open Abdomen Treatment
The open abdomen has to be distinguished from a “burst abdomen” after primary
closure of a laparotomy incision where the fascial dehiscence is unintended and
unforeseen [17]. Here we deal with an abdominal wall defect when it is impossible
or not desired to fully close the wound after surgery. Temporary Abdominal Closure
(TAC) devices are easily placed and removed, resulting in a quick re-access when
necessary.
Three well-described scenarios can lead to the creation of an open abdomen:
surgical packing to control coagulopathy with massive bleeding, and to achieve the
shortest possible time to get back to the ICU [18]; severe abdominal compartment
syndrome demanding decompression of the internal organs [12]; selected cases of
severe peritonitis, to accommodate possible swelling due to edema of the internal
organs, or when subsequent laparotomies are envisaged to treat intra-abdominal
infection and complications [19].
Modalities ofOpen Abdomen
Björk etal. proposed a classication system for open abdomen in 2009 that was
revised in 2016 (Table25.2) [20, 21]. This clarication, aside from bringing uniformity in description, allows to describe the evolution of the open abdomen during
treatment. There is a numerical triage of 1–4, with Grade 1 having no adherences
between bowel and abdomen or no lateralization. Grade 2 where xation is being
developed as opposed to Grade 3 where there is a frozen abdomen. When an enteroatmospheric stula is already established it is categorized as Grade 4 and considered
as a continuous enteric leak into the open abdomen. The numerical value is combined with a letter, where A is clean, B is contaminated, and C is when an enteric
leak is present in Grade 1–3 [21].
Mentula etal. showed a signicant decrease in mortality in a small retrospective
series of 26 patients with an abdominal compartment syndrome following severe
acute pancreatitis. The overall mortality was 46%, but patients who received an
Table 25.2 Open abdomen
classication, amended by
Björk etal. [21]
1A Clean, no xation
1B Contaminated, no xation
1C Enteric leak, no xation
2A Clean, developing xation
2B Contaminated, developing xation
2C Enteric leak, developing xation
3A Clean, frozen abdomen
3B Contaminated, frozen abdomen
4 Established enteroatmospheric stula,
frozen abdomen
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early open abdomen within 4 days of disease onset were less at risk (18%) in comparison to patients who underwent surgery after 5 days or more who suffered 100%
mortality [22]. Controversies remain concerning timing and actual benets of open
abdomen in this setting, given the risks of infection, uid and protein decit, enteroatmospheric stulas, and ischemia-reperfusion syndrome.
423
The Role ofOpen Abdomen inSepsis
Current guidelines do not recommend routine use of open abdomen management
for secondary peritonitis, in the light of the alluded to risks, notably enteroatmospheric stula and fascial dehiscence, despite the benets of preventing ACS and
providing rapid and easy relaparotomies [1]. It should however be considered for
patients with secondary peritonitis in which a high risk for ACS development is
estimated, or when a number of relaparotomies is to be expected [17].
Surgical Techniques forOpen Abdomen Management
Fascial closure has to prevent evisceration without pressure building up. Abdominal
uid accumulations need to be evacuated to decrease volume (pressure) and to prevent bacterial proliferation due to uid stasis. Fistula formation should be prevented
by means of gut protection from exposure, drying, ischemia, and friction with rough
surfaces. With an eye on future closure, which is a similarly essential component of
surgical planning, the technique must also preserve the fascia from lateral retraction
so as to facilitate easy primary fascial closure.
These criteria can be met by different techniques and closure devices involving
both static and dynamic measures (Fig.25.1). In 2018 the European Hernia Society
published their Guidelines on the management of open and burst abdomen. Looking
at the existing evidence there is a clear advantage in using dynamic fascial closure
techniques compared to static options. The pooled fascial closure rate results comparing static (33.9%) versus dynamic techniques (75.9%) were clearly in favor of
the dynamic techniques [23].
Static Management
Static open abdomen management does not facilitate sequential tightening of the
abdominal wall in-between operations. Such encompassed the Bogota bag [24],
which is still popular in certain low-income countries due to its availability and low
cost, in the face of lack of resources. A temporary absorbable mesh or Gore-Tex
mesh was sutured to both fascial edges (inlay); however, this technique seems
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T. Cornette and F. Berrevoet
a
c
e
b
d
f
Fig. 25.1 (a) Bogota bag; (b) Gore-Tex mesh; (c) zipper mesh; (d) Ventrol™; (e) Wittmann
patch™; (f) mesh-mediated fascial traction
associated with a higher incidence of stula formation [25, 26]; A mesh with a zipper for easy re-access to the abdominal cavity; however, similar dangers [27] to the
previous one; Ventrol™ (B.Braun, Melsungen, Germany) plates, to relieve strain
on wounds and prevent infection [28]; Even negative pressure wound therapy
(NPWT) is also considered a static measure as it does not prevent fascial retraction.
It consists of a bowel protecting layer, a soft spongy material, followed by an adhesive bandage with a small opening for drain connection to continuous suction [29].
Dynamic Management
Dynamic techniques combine the temporary closure of the abdominal cavity with
active fascial traction: They are represented by a number of devices and resources.
The Wittmann patch™ (Starsurgical, Burlington, WI, USA) is a velcro-like device
25 Open Abdomen as an Effective Therapy for Abdominal Sepsis, Bedside Assistance…
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for re-approximating the abdominal wall and bridging for future abdominal entries.
It consists of two sheets respectively with hooks and loops, which are pressed
together to form a secure closure, but easily peeled apart for re-entry surgery. The
overlap is adjusted to get the desired tension and allow accommodation for swelling
[30]. Dynamic retention sutures anchored to the skin on the outside of both wound
sides have been used in the past [31, 32]. Although sometimes effective, they may
incur some risks namely pain, hernia, and infections. Moreover the effectiveness in
preventing wound dehiscence is debated.
425
NPWT andMesh-Mediated Fascial Traction (MMFT)
This combination is now considered the gold standard, with fascial closure rates up
to 90% [33–36]. A mesh is sewed in at both sides of the open fascia on which tension is applied and covered by NPWT [33, 34]. Treatment should begin as early as
possible, preferably within 24–48h after open abdomen management has started.
This was studied by Berrevoet etal. in a cohort of 152 patients, in which early
MMFT and NPWT had a signicantly better fascial closure rate compared to
patients who started three or more days later (p<0.001) [34] (Fig.25.1).
How toPerform NPWT+MMFT
Under sterile conditions a visceral protective layer (VPL), either a commercial type
or a self-made coverage, is placed deep to the anterior abdominal wall as a protective barrier between the abdominal content and the overlying mesh, aiming to
reduce the frequency of enteroatmospheric stula formation [37, 38]. In case there
is a need for a temporary protective ostomy a poor location should meticulously be
avoided, as it can make future OA management and NPWT or TAC placement a real
challenge. They should be placed as laterally as possible to allow maximal medial
mobility of the abdominal wall during closing [39].
A heavyweight polypropylene mesh is sewn to the fascia by overlapping
2–2.5 cm, using a non-absorbable monolament 2/0 suture. When using MMFT
technique it is advised to use a small pore mesh for traction. Large pore meshes are
not suitable for heavy traction as they are too elastic and will be torn during the
process [34]. The mesh is then divided down the middle to introduce the VPL.The
negative pressure wound therapy system (NPWT) can be applied when no recent
anastomoses are present and preferably no bile leak or active bleeding either. Next
to drainage, the NPWT increases granulation and angiogenesis by stimulating cell
reproduction and proliferation [34] (Fig.25.2).
It is important to drape the VPL as lateral as possible circumferentially, reaching
the paracolic gutters as well as the subdiaphragmatic space, to achieve best uid
drainage out of the abdominal cavity and to prevent uid collection formation and
abscesses. Traction is then applied on the level of the mesh when suturing the two
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