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93
It is important to note that, while the OA approach as a component of DCS has
saved many lives, it is not entirely benign. A prospective registry study of the
American Association for the Surgery of Trauma found that large bowel resection,
large-volume fluid resuscitation, and an increasing number of abdominal re-
explorations were statistically significant predictors of enterocutaneous fistula,
enteroatmospheric fistula, or intra-abdominal sepsis/abscess following DCS [15].
The group from Vanderbilt [16] found that 25% of patients had wound complica-
tions, and only 65% had primary fascial closure.
Fig. 6.3 Sequential fascial closure
1. Fascia is closed with interrupted sutures
2. White sponges are placed over
exposed viscera
3. Sutures are placed
to prevent fascial retraction
4. Skin is closed over
approximated fascia
a
White sponge covers viscera
Skin is closed over
approximated fascia
b
6 The Open Abdomen in Trauma
94
References
1. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during
laparotomy. Ann Surg. 1983;197:532.
2. Cue JI, Cryer HC, Miller FB, Richardson JD, Polk HC. Packing and planned reexploration for
hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique. J Trauma.
1990;30:1007.
3. Morris JA, Eddy VA, Blinman TA, Rutherford EJ, Sharp KW. The staged celiotomy for
trauma: issues in unpacking and reconstruction. Ann Surg. 1993;217:576.
4. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman TM, Kauder DR,
Latenser BA, Angood PA. Damage control: an approach for improved survival in exsanguinat-
ing penetrating abdominal injury. J Trauma. 1993;35:375.
5. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma: a unified
approach. J Trauma. 1982;22:672.
6. Demetriades D, Salim A. Management of the open abdomen. Surg Clin North Am.
2014;94:131–53.
7. Moore EE, Burch JM, Franciose RJ, et al. Staged physiologic restoration and damage control
surgery. World J Surg. 1998;22:1184–91.
8. Matthew S, Smith BP, Cannon JW, et al. Temporary arterial shunts in damage control: experi-
ence and outcomes. J Trauma Acute Care Surg. 2016. doi: 10.1097/TA.0000000000001334.
[Epub ahead of print].
9. Offner PJ, de Souza AL, Moore EE, et al. Avoidance of abdominal compartment syndrome in
damage-control laparotomy after trauma. Arch Surg. 2001;136:676–80.
10. Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of temporary abdominal
closure: a 7-year experience with 112 patients. J Trauma. 2000;48:201–7.
11. Chiara O, Cimbanassi S, Biffl W, et al. International consensus conference on open abdomen
in trauma. J Trauma Acute Care Surg. 2016;80:173–83.
12. Dissanaike S, Pham T, Shalhub S, et al. Effect of immediate enteral feeding on trauma
patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg.
2008;207:690–7.
13. Cirocchi R, Birindelli A, Biffl W, et al. What is the effectiveness of the negative pressure
wound therapy (NPWT) in patients treated with open abdomen technique? A systematic
review and meta-analysis. J Trauma Acute Care Surg. 2016;81:575–84.
14. Burlew CC, Moore EE, Biffl WL, et al. One hundred percent fascial approximation can be
achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma Acute
Care Surg. 2012;72:235–41.
15. Bradley MJ, Dubose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdomi-
nal sepsis after damage control laparotomy: results from the prospective AAST open abdomen
registry. JAMA Surg. 2013;148:947–54.
16. Miller RS, Morris JA Jr, Diaz JJ Jr, et al. Complications after 344 damage-control open celi-
otomies. J Trauma. 2005;59:1365–74.
W.L. Biffl and E.E. Moore
95
© Springer International Publishing AG, part of Springer Nature 2018
F. Coccolini et al. (eds.), Open Abdomen, Hot Topics in Acute Care Surgery
and Trauma, https://doi.org/10.1007/978-3-319-48072-5_7
M. Sartelli (*)
Department of Surgery, Macerata Hospital, Macerata, Italy
e-mail: massimosartelli@gmail.com
F. Coccolini • L. Ansaloni
General, Emergency and Trauma Surgery Department, Bufalini Hospital,
Cesena, FC, Italy
F. Catena
Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
7
Open Abdomen in Patients
with Abdominal Sepsis
Massimo Sartelli, Federico Coccolini, Fausto Catena,
and Luca Ansaloni
7.1 Introduction
Abdominal sepsis is the host’s systemic inflammatory response to bacterial or yeast
peritonitis [2].
Key Points
• OA as part of a damage control strategy may be a lifesaving strategy in a
well-selected group of surgical patients with severe abdominal sepsis.
• In critically ill patients with ongoing abdominal sepsis, the open abdomen
may:
– Allow early control of any persistent source of infection removing more
effectively infected or cytokine-loaded peritoneal fluid.
– Prevent abdominal compartment syndrome.
– Defer definitive intervention and anastomosis until the patient is hemo-
dynamically stable and thus better able to heal.
• Negative pressure therapy (NPT) should be used aiming to close the abdo-
men as soon as possible within 1 week.
96
Pathogenic microbial agents trigger cascades of events in sepsis by stimulating
the host’s immune system. Outer membrane component of gram-negative organisms
such as lipopolysaccharide [LPS], lipid A, and endotoxin or gram-positive organisms
such as lipoteichoic acid and peptidoglycan, as well as toxins from anaerobic bacte-
ria or mannan from fungi, may stimulate macrophages and monocytes to produce
tumor necrosis factor-α (TNF-α) and interleukin-1 and interleukin- 6 (IL-1, IL-6),
leading to the production of toxic mediators causing a complex, multifactorial syn-
drome that may evolve into conditions of varying severity and may lead to the func-
tional impairment of one or more vital organs or systems.
Current treatment of severe sepsis involves prompt source control, early appro-
priate antimicrobial therapy, and adequate resuscitation.
Source control encompasses all measures undertaken to eliminate the source of
infection, reduce the bacterial inoculum, and correct or control anatomic derange-
ments to restore normal physiologic function. Its timing and adequacy are the most
important issues in the management of intra-abdominal infections, because inade-
quate and late operation may have a negative effect on the outcome [3, 4].
In certain circumstances, infection not completely controlled may trigger an
excessive immune response, and sepsis may progressively evolve [5].
Such patients may benefit from immediate and aggressive surgical treatment
with subsequent relaparotomy strategies, to curb the spread of organ dysfunctions
caused by ongoing sepsis.
In these patients, an early relaparotomy with surgical lavage of the peritoneal
cavity and evacuation of toxic content and inflammatory cytokines may be crucial
for stopping the septic cascade. This allows better control of the local inflammatory
response and improved outcomes.
Three strategies in the management of these difficult patients have been
reported [1]:
• Relaparotomy on demand (when required by the patient’s clinical condition)
• Planned relaparotomy in the 36–48-h postoperative period (when relaparotomy
is planned after the first operation)
• Open abdomen procedure
The OA concept is closely linked to damage control surgery and may be easily
adapted to patients with ongoing sepsis.
The abbreviated laparotomy for trauma patients was defined as the initial control
of surgical bleeding by simple operative lifesaving techniques. In the intensive care
unit (ICU), subsequent resuscitation corrected hypothermia, acidosis, and coagu-
lopathy. Once the patient had regained their physiologic reserve, definitive re-
exploration and reconstructive surgery was performed with or without final
abdominal closure [6]. This type of management may be applied for patients with
severe abdominal sepsis.
Patients progressing from sepsis to septic shock can present with hypotension
and myocardial depression associated with coagulopathy. These patients are
M. Sartelli et al.
97
hemodynamically unstable and not optimal candidates for complex operative
interventions.
After source control, abdominal closure may be temporary. In ICU patients,
resuscitation is optimized and patients are stabilized. Over the following 24–48 h,
when abnormal physiology is corrected, the patient can be safely taken back to the
operating room for reoperation.
7.2 Relaparotomy
In critically ill patients with ongoing sepsis, OA approach may be required for different
reasons including controlling any persistent source of infection, preventing abdominal
compartment syndrome, and deferring definitive intervention and anastomosis.
Animal models have shown that peritonitis is associated with a significant and
prolonged peritoneal inflammatory response [7]. The levels of selected peritoneal
cytokines have been reported to be significantly different between animals that sur-
vived as compared to those who died following a septic challenge [8].
The reduction of the local inflammatory response can be best achieved with
mechanical surgical control by reducing the load of cytokines and other inflammatory
substances [9] and by preventing their production, thus removing the source itself. In
some patients, more laparotomies are required to complete source control, and OA
allows the surgeon to perform subsequent planned laparotomies more efficiently.
The final decision to perform a reoperation on a patient is based on the patient
generalized septic response and on the lack of clinical improvement during early
postoperative period [10, 11].
However, these conditions are not well defined [12] and often relaparotomy may
be performed too late. In patients with ongoing sepsis, OA allows easy second look
to control the source of infection and evacuate inflamed and toxic content.
7.3 Prevention of Abdominal Compartment Syndrome
The systemic inflammatory response syndrome, increased vascular permeability,
and aggressive crystalloid resuscitation predispose to fluid sequestration with the
formation of peritoneal fluid. These changes associated with forced closure of
the abdominal wall may result in increased intra-abdominal pressure (IAP) lead-
ing to intra-abdominal hypertension (IAH) and abdominal compartment syn-
drome (ACS).
ACS is a potentially lethal complication on splanchnic, cardiovascular, pulmo-
nary, renal, and central nervous systems.
Especially in patients with severe peritonitis, the physiological effect of ACS to
gastrointestinal tract may aggravate the abdominal sepsis.
The earliest and most effective means of treating ACS in high-risk patient may
be surgical decompression. Presumptive decompression should be considered at the
7 Open Abdomen in Patients with Abdominal Sepsis
98
time of laparotomy in patients who demonstrate risk factors for ACS [1]. The deci-
sion to perform a laparostomy in patients with abdominal sepsis should be always
based on the intraoperative judgment of the surgeon.
7.4 Delayed Intestinal Anastomosis and Definitive
Intervention
An additional advantage of the OA strategy in abdominal sepsis is to delay the
bowel anastomosis [12] in patients hemodynamically stable and thus unable to
heal.
In patients with severe secondary peritonitis and significant hemodynamic insta-
bility and compromised tissue perfusion, primary anastomosis is at high risk for
anastomotic leakage resulting in increased mortality.
In these patients, consideration should be given to initially control the source of
peritoneal contamination and delay the bowel anastomosis [13].
7.5 Fascial Closure
Following re-exploration, the goal is early and definitive closure of the abdomen, in
order to reduce the complications associated with an open abdomen.
Early definitive closure is defined as fascial abdominal closure achieved less than
7 days after the initial OA procedure. It allows to prevent or reduce the risk of these
complications [14, 15].
Delayed fascial closure is defined as fascial abdominal closure achieved 7 or
more days [16, 17].
In order to evaluate whether early fascial abdominal closure had advantages
over delayed approach, a systematic review and meta-analysis was published in
2014 [18].
The study confirmed the clinical advantages of early fascial closure compared
with delayed closure in the treatment of patients with open abdomen.
In patients with delayed abdominal wall closure, fascial edges lateralization may
lead to unfavorably high tensile midline forces, and fascial closure may be more
problematic. In these patients, abdominal wall closure should approximate the fas-
cial edges progressively and incrementally, each time the patient should undergo
surgery until it is completely closed.
The ideal temporary abdominal closure (TAC) method should protect the abdom-
inal contents, prevent evisceration, allow removal of infected or toxic fluid from the
peritoneal cavity, prevent the formation of fistulae, avoid damage to the fascia, pre-
serve the abdominal wall domain, make reoperation easy and safe, and facilitate
definitive closure [1].
Several materials can be used to achieve temporary closure of the abdomen:
gauze, mesh, impermeable self-adhesive membrane dressings, zippers, and negative
pressure therapy (NPT) techniques.
M. Sartelli et al.
99
A systematic review and meta-analysis of the open abdomen and temporary
abdominal closure techniques in non-trauma patients was published in 2015 [19].
The overall quality of the included studies was low, and the indications for open
abdominal management differed considerably. Negative pressure therapy (NPT)
was the most frequently described TAC technique (38 of 78 series).
The highest weighted fascial closure rate was found in series describing NPT
with continuous mesh or suture mediated fascial traction and dynamic retention
sutures. Weighted rates of fistula varied from 5.7% after NPT with fascial traction,
14.6% for NPT only, and 17.2% after mesh inlay.
In Fig. 7.1, the flowchart for the open abdomen procedure in patients with ongo-
ing abdominal sepsis is illustrated.
Conclusions
Outcomes of complicated intra-abdominal infections accompanied by severe
sepsis are related to early diagnosis, early surgical management with source con-
trol, aggressive critical care management, and aggressive and early optimization
of physiology.
OA as part of a damage control strategy may be a lifesaving strategy in selec-
tive patients with severe abdominal sepsis. Once severe sepsis has been con-
trolled, definitive surgical reconstruction should be performed as soon as
possible.
Critically illpatient with ongoing sepsis
Damage control surgery
Delayed definitive operati
on
Open Abdomen
management
Open abdomen
Delayed fascial closure
Preventing ACS
Re-source control
Early fascial closure
ICU resuscitation
Fig. 7.1 Flowchart for the open abdomen procedure in patients with ongoing abdominal sepsis
7 Open Abdomen in Patients with Abdominal Sepsis
100
References
1. Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chia a O,
Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP,
Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R,
Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA,
Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore
EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES
position paper. World J Emerg Surg. 2015;10:35.
2. Sartelli M, Catena F, Di Saverio S, Ansaloni L, Malangoni M, Moore EE, et al. Current con-
cept of abdominal sepsis: WSES position paper. World J Emerg Surg. 2014;9(1):22.
3. Marshall JC. Principles of source control in the early management of sepsis. Curr Infect Dis
Rep. 2010;12(5):345–53. doi:10.1007/s11908-010-0126-z.
4. Marshall JC, al Naqbi A. Principles of source control in the management of sepsis. Crit Care
Clin. 2009;25(4):753–68.
5. Koperna T, Semmler D, Marian F. Risk stratification in emergency surgical patients: is the
APACHE II score a reliable marker of physiological impairment? Arch Surg. 2001;136(1):55–9.
6. Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan GL Jr. Abbreviated lapa-
rotomy and planned reoperation for critically injured patients. Ann Surg. 1992;215(5):476–83.
7. Martineau L, Shek PN. Peritoneal cytokine concentrations and survival outcome in an experi-
mental bacterial infusion model of peritonitis. Crit Care Med. 2000;28(3):788–94.
8. Hendriks T, Bleichrodt RP, Lomme RM, de Man BM, van Goor H, Buyne OR. Peritoneal
cytokines predict mortality after surgical treatment of secondary peritonitis in the rat. J Am
Coll Surg. 2010;211:263–70.
9. Schein M. Planned reoperations and open management in critical intra-abdominal infections:
prospective experience in 52 cases. World J Surg. 1991;15:537–45.
10. Van Ruler O, Lamme B, Gouma DJ, Reitsma JB, Boermeester MA. Variables associated
with positive findings at relaparotomy in patients with secondary peritonitis. Crit Care Med.
2007;35(2):468–76.
11. van Ruler O, Kiewiet JJ, Boer KR, Lamme B, Gouma DJ, Boermeester MA, et al. Failure of
available scoring systems to predict ongoing infection in patients with abdominal sepsis after
their initial emergency laparotomy. BMC Surg. 2011;11:38.
12. van Ruler O, Lamme B, de Vos R, Obertop H, Reitsma JB, Boermeester MA. Decision making
for relaparotomy in secondary peritonitis. Dig Surg. 2008;25(5):339–46.
13. Ordoñez CA, Pino LF, Badiel M, Sánchez AI, Loaiza J, Ballestas L, et al. Safety of performing
a delayed anastomosis during damage control laparotomy in patients with destructive colon
injuries. J Trauma. 2011;71(6):1512–7.
14. Ordonez CA, Sanchez AI, Pineda JA, et al. Deferred primary anastomosis versus diversion in
patients with severe secondary peritonitis managed with staged laparotomies. World J Surg.
2010;34:169–76.
15. Demetriades D, Salim A. Management of the open abdomen. Surg Clin North Am.
2014;94(1):131–53.
16. Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdo-
men. World J Surg. 2012;36(3):497–510.
17. Godat L, Kobayashi L, Costantini T, Coimbra R. Abdominal damage control surgery and
reconstruction: World society of emergency surgery position paper. World J Emerg Surg.
2013;8(1):53.
18. Chen Y, Ye J, Song W, Chen J, Yuan Y, Ren J. Comparison of outcomes between early fascial
closure and delayed abdominal closure in patients with open abdomen: a systematic review
and meta-analysis. Gastroenterol Res Pract. 2014;2014:784056.
19. Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open
abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg.
2015;39:912–25.
M. Sartelli et al.
101
© Springer International Publishing AG, part of Springer Nature 2018
F. Coccolini et al. (eds.), Open Abdomen, Hot Topics in Acute Care Surgery
and Trauma, https://doi.org/10.1007/978-3-319-48072-5_8
A. Leppäniemi
Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki,
Haartmaninkatu 4, P.O. Box 340, 00029 HUS Helsinki, Finland
e-mail: Ari.Leppaniemi@hus.fi
8
Open Abdomen in Acute Pancreatitis
Ari Leppäniemi
8.1 Introduction
While in the majority of patients acute pancreatitis is a mild, self-limiting disease,
about 15% of the patients develop severe disease defined by the development of
persistent organ failure [1]. The mortality in acute pancreatitis is mainly associated
with multiple organ failure (MOF), whereas the risk of dying is minimal in patients
with no or transient organ dysfunction [2–4]. MOF develops early during the course
of acute pancreatitis, over half of the patients with severe acute pancreatitis (SAP)
have signs of organ dysfunction on hospital admission, and most of the organ dys-
functions develop within the first 4 days after admission [3, 5]. Over half of the
deaths occur within the first week from onset of the disease, and deaths usually
occurred within a week after manifestation of MOF [6]. Treatment modalities of
Key Points
• Monitor and treat increased intra-abdominal pressure in severe acute
pancreatitis.
• Early midline laparostomy is required in abdominal compartment syn-
drome resistant to nonoperative management including percutaneous
drainage of pancreatic ascites.
• Mesh-mediated vacuum-assisted closure is the safest and most effective
temporary abdominal closure technique in open abdomen.
• Leaving the abdomen open as part of surgical necrosectomy is not warranted.
102
MOF are supportive including fluid replacement therapy, vasopressors, mechanical
ventilation, and renal replacement therapy when necessary.
8.2 Abdominal Compartment Syndrome
Abdominal compartment syndrome (ACS) may aggravate MOF, and therefore,
monitoring of intra-abdominal pressure (IAP) is crucial for identification of patients
at risk of ACS [7]. Development of ACS should be prevented and if possible treated
by conservative methods including percutaneous drainage of pancreatic ascites, if
present in large amounts confirmed by ultrasound examination. Surgical decom-
pression is the last but the most effective way to decrease IAP and should not be
postponed too late if patient has developed ACS [8, 9].
8.3 Infected Pancreatic Necrosis
Patients with acute pancreatitis have a considerable risk for developing secondary infec-
tions including bacteremia, pneumonia and infection of pancreatic or peripancreatic
necrosis. Extrapancreatic infections occur predominantly during the first week of ill-
ness, whereas pancreatic necrosis becomes infected later [10]. Organ failure, early bac-
teremia, and the extent of pancreatic necrosis are associated with increased risk of
infected necrosis. Surgical necrosectomy is the last resort if more conservative manage-
ment including percutaneous drainage fails [11]. The mortality is very high in patients
with persistent organ failure complicated with infected pancreatic necrosis [12].
8.4 Open Abdomen
While open abdomen by itself is a morbid procedure and should not be used lightly,
there are two clinical conditions where open abdomen can be used as a treatment
strategy in patients with SAP, either to treat intra-abdominal hypertension (IAH)
and ACS or as a method to treat infected pancreatic necrosis.
While IAH is present in the majority of patients with SAP treated in an intensive
care unit (ICU), ACS develops in a fraction of them, usually within the first few
days and associated with excessive fluid resuscitation [7, 13]. Recent studies show
also that intra-abdominal ischemia is common in SAP patients with ACS [14].
8.5 Surgical Decompression
Surgical decompression has a marked effect on organ function, especially among sub-
sequent survivors [9, 15]. The most common technique for surgical decompression is
the vertical full-thickness midline laparostomy, but other alternatives such as transverse
laparostomy or subcutaneous linea alba fasciotomy have been described. Currently the
most widely used is the midline laparostomy that has been showed to decrease IAP
A. Leppäniemi