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103
effectively [16]. It is rapid and easy to perform, but it is associated with a high risk of
intestinal fistulae and in many cases failure to close the fascia requiring complex recon-
structive surgery at a later stage. Transverse laparostomy is a promising alternative, and
isolated reports have shown its effectiveness in reducing IAP [17]. Although it takes
slightly longer to perform than midline laparostomy, same principles of managing the
open abdomen can be applied without additional equipment. The major disadvantage
could be the loss of abdominal and back extensor muscle functions, if fascial closure
could not be achieved. A third alternative used in SAP is the subcutaneous linea alba
fasciotomy, where the fascia is incised through three small skin incisions leaving the
rest of the skin and the peritoneum intact [18]. Although it eliminates the open abdo-
men, it might not be always effective enough [19]. In addition, the subcutaneous fasci-
otomy always results in a ventral hernia requiring repair later on.
Although many temporary abdominal closure techniques (TAC) are in use, the
mesh-mediated vacuum-assisted closure seems to have the highest fascial closure
and lowest enteric fistula rates [20–23] (Figs. 8.1, 8.2, 8.3, 8.4, 8.5).
Fig. 8.1 Applying the
inner plastic layer
Fig. 8.2 Mesh sutured to
the fascia over the
underlying plastic sheath
8 Open Abdomen in Acute Pancreatitis
104
Fig. 8.3 Sponge and
covering air-tight plastic
applied to create negative
pressure
Fig. 8.4 After several
rounds of tightening the
mesh at dressing changes,
the gap is sufficiently
narrow to allow mesh
removal and fascial closure
Fig. 8.5 Delayed fascial
closure
A. Leppäniemi
105
8.6 Necrosectomy
With the new definitions of pancreatic necrosis, acute necrotic collection (ANC)
(Fig. 8.6), and walled-off necrosis (WON) (Fig. 8.7) and better understanding of the
natural progress of the disease process, the management of infected pancreatic
necrosis has undergone a shift toward a more conservative approach as well as post-
poning surgical intervention well after 4 weeks of the onset of the symptoms [1, 9,
10, 24]. Although in the past, the open abdomen strategy was offered as an
Fig. 8.6 CT image of
acute necrotic collection
(ANC)
Fig. 8.7 CT image of
walled-off necrosis (WON)
8 Open Abdomen in Acute Pancreatitis
106
alternative to closed drainage after open necrosectomy, retrospective studies have
shown that the results of the open abdomen strategy are poor compared with closed
and minimally invasive procedures [25].
References
1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of
acute pancreatitis–2012: revision of the Atlanta classification and definitions by international
consensus. Gut. 2013;62:102–11.
2. Halonen KI, Pettilä V, Leppäniemi AK, Kemppainen EA, Puolakkainen PA, Haapiainen
RK. Multiple organ dysfunction associated with severe acute pancreatitis. Crit Care Med.
2002;30:1274–9.
3. Buter A, Imrie CW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunc-
tion determines outcome in acute pancreatitis. Br J Surg. 2002;89:298–302.
4. Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between
early systemic inflammatory response, severity of multiorgan dysfunction and death in acute
pancreatitis. Br J Surg. 2006;93:738–44.
5. Mentula P, Kylänpää-Bäck M-L, Kemppainen E, Takala A, Jansson S-E, Kautiainen H,
et al. Decreased HLA (human leucocyte antigen)-DR expression on peripheral blood mono-
cytes predicts the development of organ failure in patients with acute pancreatitis. Clin Sci.
2003;105:409–17.
6. Mole DJ, Olabi B, Robinson V, Garden OJ, Parks RW. Incidence of individual organ dysfunc-
tion in fatal acute pancreatitis: analysis of 1024 death records. MHPB. 2009;11:166–70.
7. De Waele JJ, Leppäniemi AK. Intra-abdominal hypertension in acute pancreatitis. World
J Surg. 2009;33:1128–33.
8. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B,
Duchesne J, Bjorck M, Leppäniemi A, Ejike JC, Sugrue M, Cheatham M, Ivatury R, Ball
CG, Reintam Blaser A, Regli A, Balogh ZJ, D’Amours S, Debergh D, Kaplan M, Kimball E,
Olvera C. Intra-abdominal hypertension and the abdominal compartment syndrome: updated
consensus definitions and clinical practice guidelines from the World Society of the Abdominal
Compartment Syndrome. Intensive Care Med. 2013;39:1190–206.
9. Mentula P, Hienonen P, Kemppainen E, Puolakkainen P, Leppäniemi A. Surgical decom-
pression for abdominal compartment syndrome in severe acute pancreatitis. Arch Surg.
2010;145:764–9.
10. Besselink MG, van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, Van Goor H, Dejong
CHC, et al. Timing and impact of infections in acute pancreatitis. Br J Surg. 2009;96:267–73.
11. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH,
et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med.
2010;362:1491–502.
Take-Home Messages
The use open abdomen in patients with severe pancreatitis should be limited
to the management of ACS. Surgical decompression should be used only if
nonoperative management fails, but when needed, it should be performed
promptly. Using an adequate temporary abdominal closure technique, such as
the mesh-mediated vacuum-assisted closure, high fascial closure and low
enteric fistula rates can be achieved.
A. Leppäniemi
107
12. Petrov MS, Shanbhag S, Chakraborty M, Phillips ARJ, Windsor JA. Organ failure and infec-
tion of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis.
Gastroenterology. 2010;139:813–20.
13. Keskinen P, Leppäniemi A, Pettilä V, et al. Intra-abdominal pressure in severe acute pancreati-
tis. World J Emerg Surg. 2007;2:2.
14. Smit M, Buddingh KT, Bosma B, et al. Abdominal compartment syndrome and intra- abdominal
ischemia in patients with severe acute pancreatitis. World J Surg. 2016;40:1454–61.
15. De Waele JJ, Kimball E, Malbrain M, et al. Decompressive laparotomy for abdominal com-
partment syndrome. Intensive Care Med. 2014;40(Suppl 1):S32–3.
16. De Waele JJ, Hoste EAJ, Malbrain MLNG. Decompressive laparotomy for abdominal com-
partment syndrome – a critical analysis. Crit Care. 2006;10:R51.
17. Leppäniemi A, Mentula P, Hienonen P, Kemppainen E. Transverse laparostomy is feasible and
effective in the treatment of abdominal compartment syndrome in severe acute pancreatitis.
World J Emerg Surg. 2008;3:6.
18. Leppäniemi AK, Hienonen PA, Siren JE, Kuitunen AH, Lindström OK, Kemppainen
EA. Treatment of abdominal compartment syndrome with subcutaneous anterior abdominal
fasciotomy in severe acute pancreatitis. World J Surg. 2006;30:1922–4.
19. Leppäniemi A, Hienonen P, Mentula P, Kemppainen E. Subcutaneous linea alba fasciotomy,
does it really work? Am Surg. 2011;77:99–102.
20. Petersson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated
fascial traction--a novel technique for late closure of the open abdomen. World J Surg.
2007;31:2133–7.
21. Acosta S, Bjarnason T, Petersson U, et al. Multicentre prospective study of fascial clo-
sure rate after open abdomen with vacuum and mesh-mediated fascial traction. Br J Surg.
2011;98:735–43.
22. Rasilainen S, Mentula P, Leppäniemi A. Vacuum- and mesh-mediated fascial traction for pri-
mary closure of the open abdomen in critically ill surgical patients. Br J Surg. 2012;99:1725–33.
23. 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.
24. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines
for the management of acute pancreatitis. Pancreatology. 2013;13:e1–5.
25. Besselink MG, de Bruijn MT, Rutten JP, et al. Surgical intervention in patients with necrotiz-
ing pancreatitis. Br J Surg. 2006;93:593–399.
8 Open Abdomen in Acute Pancreatitis
109
© 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_9
S. Acosta (*)
Department of Clinical Sciences, Vascular Centre, Lund University, S205 02 Malmö, Sweden
e-mail: stefan.acosta@med.lu.se
A. Wanhainen • M. Björck
Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
9
The Open Abdomen in Non-traumatic
Vascular Emergencies
S. Acosta, A. Wanhainen, and M. Björck
9.1 Introduction
Open abdomen treatment is sometimes necessary to save lives in trauma and non-
trauma surgical conditions [1]. The vascular surgeon needs to be aware of the indi-
cations for open abdomen therapy (see Chap. 5), zones of injury and exposure of
major abdominal vessels (see Chap. 6), and preferable temporary abdominal closure
methods in vascular surgery. Besides damage control laparotomy [2] and short-term
open abdomen therapy after major vessel trauma with severe bleeding and associ-
ated intra-abdominal injuries in the often younger patients, long-term open abdo-
men therapy is also necessary in the prevention and treatment of abdominal
compartment syndrome (ACS) in elderly following repair of ruptured abdominal
aortic aneurysms (AAA). Damage control laparotomy or abbreviated laparotomy
with second-look laparotomy may also be an advantageous strategy in the manage-
ment of patients with abdominal catastrophes such as advanced stages of acute mes-
enteric ischemia (AMI). This chapter deals only with open abdomen in non-traumatic
vascular emergencies.
110
9.2 Open Abdomen Following Repair of Ruptured AAA
9.2.1 Abdominal Compartment Syndrome Following
Ruptured AAA
Decompressive laparotomy due to abdominal compartment syndrome (ACS) fol-
lowing open or endovascular repair of ruptured AAA (RAAA) is performed increas-
ingly often. The proportion of patients who develop ACS after open and endovascular
aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (AAA) has been
reported to be around 30% [3] and 20% [3, 4], respectively. Increased blood loss,
hypotension, massive fluid resuscitation, and prolonged occlusion of the aorta with
subsequent reperfusion injury with viscera edema lead to increased risk of intra-
abdominal hypertension or ACS. Perioperative adherence to massive transfusion
protocols with 1:1:1 ratio of units of packed red blood cells and plasma to platelets
may decrease the risk of ACS in massive uncontrolled hemorrhage [5]. If identified
early postoperative, intra-abdominal hypertension can be treated with epidural anal-
gesia, neuromuscular blockade, and diuretics. Such a proactive approach can pre-
vent the development of ACS. When ACS is identified late or when the
intra-abdominal pressure reaches 30 mmHg, emergent decompression laparotomy
is necessary to save life [6]. Recognition and timely management of ACS after AAA
repair is crucial for improvement of survival and development of intestinal ischemia
during ACS is associated with increased mortality [7].
9.2.2 When Deciding to Leave the Abdomen Open
The frequency of patients with RAAA in series reporting damage control lapa-
rotomy in non-trauma patients varies between 5 and 25% [8–11] (Table 9.1). In
one report of 13 patients, the abdomen was temporarily closed by vacuum pack
technique, with or without retroperitoneal packing after repair of RAAA, in order
to prevent ACS. This damage control management with early decision in leaving
Table 9.1 Frequency of vascular diseases in series of damage control laparotomy for non-trauma
patients
First author (year)
Country
Vascular
disease (%)
Ruptured
AAA (%)
Acute mesenteric
ischemia (%)
Finlay (2004) [8] United
Kingdom
4/12 (33) 3/12 (25) –
Freeman (2005) [29] Australia 20/20 (100) – 20/20 (100)
Person (2009) [30] Israel 10/31 (31) – 10/31 (31)
Subramanian (2010)
[31]
USA 13/88 (13) – 13/88 (13)
Tadlock (2010) [9] USA 13/13 (100) 13/13 (100) –
Goussous (2013) [10] USA 30/111 (27) 5/111 (5) 25/111 (23)
Khan (2013) [11] New Zealand 15/42 (36) 2/42 (5) 13/42 (31)
S. Acosta et al.
111
the abdomen open resulted in earlier ICU arrival for intense resuscitation of pro-
found shock, persistent coagulopathy, acidosis, and hypothermia and a mortality
of 54% [9].
The decision to leave the abdomen open may also be taken at the end of the
operation: The abdomen may simply be left open since the abdomen may be impos-
sible to close due to, for instance, excess of fluid infusion perioperatively and swell-
ing of the abdominal compartment. Sometimes, the surgeon starts to suture the
fascial edges together but removes the suture, since closure would have resulted in
a too tense abdomen and the risk of developing ACS. Fascial closure followed by
on-table intra-abdominal pressure measurement may also result in removal of the
fascial suture to allow full abdominal decompression. The abdomen is more often
reopened after open repair at a second operation due to development of secondary
ACS. Decompressive laparotomy may be performed directly or as a second opera-
tion after EVAR. Relaparotomy after open repair and laparotomy after EVAR may
also be performed if intestinal, usually colonic, ischemia develops, a condition that
coexists with ACS [12].
9.2.3 Prolonged Open Abdomen Therapy May Be Necessary
The elderly patients with AAA often have, in contrast to younger trauma patients,
coexistent comorbidities and compromised physiological functions such as cardiac,
pulmonary, and renal insufficiency [13], leading to a relative therapeutic resistance to
reduce the fluid overload that usually arises after an emergency repair of RAAA. Thus,
the duration of open abdomen therapy is often prolonged, before abdominal closure is
possible. It is therefore very important to have a durable dressing system that mini-
mizes the risk of further complications and facilitates complete fascial closure.
9.2.4 Temporary Abdominal Closure in AAA Repair
In a recent systematic review, the most effective TAC was the vacuum-assisted
wound closure and mesh-mediated fascial traction (VACM; Fig. 9.1) after AAA
repair [14]: The primary fascial closure rate varied from 96 to 100% in three studies
[15–17]. The median time to closure of the open abdomen in these three studies
ranged from 10.5 [16], 17 [15] to 36 [17] days. No patient with long-term open
abdomen therapy with the technique was left with a planned ventral hernia. The
graft infection rate was 0% [16, 17] to 6.7% [15]. The reported graft infection rate
after vacuum pack treatment has also been reported to be very low, 0% [9, 18] to
7.1% [19]. In the prospective study [15] referred to above, 2 out of 30 patients
developed enteroatmospheric fistulae after open abdomen therapy with the VACM
method. Both had an underlying intestinal ischemia, underwent bowel resections,
and died. Incisional midline hernia occurred in 9 of 15 patients at 1-year follow-up
with computed tomography. Three (20%) incisional hernias were symptomatic, of
which two were repaired.
9 The Open Abdomen in Non-traumatic Vascular Emergencies
112
The VACM is as a good alternative for the treatment of a clean, Grade IA, open
abdomen after AAA repair [20]. The method facilitates high primary fascial clo-
sure rates even after several weeks of open abdomen therapy since this combined
technique with NPWT and mesh-mediated fascial traction counteracts lateral
retraction of the fascia. Achievement of high fascial closure rates with this tech-
nique have been reproduced in general surgery patients [21–25]. As soon as there
are intestinal and/or infectious complications, affecting the grading of the open
abdomen, the primary delayed fascial closure rate decreases, and the risks of intes-
tinal fistulae and graft infections increase [26]. The duration of open abdomen
treatment seems to be a crucial factor, since most severe complications usually
develop after 2 weeks [27].
9.3 Open Abdomen Following Management of Acute
Mesenteric Ischemia
The increasing use of revascularization of the mesenteric arterial circulation in
acute mesenteric ischemia has created an increased demand of second- or third-
look laparotomies for assessing bowel viability and definitive reconstructions of
the bowel [28]. In patients that develop peritonitis, a damage control strategy is
sensible [29]. The frequency of patients with acute mesenteric ischemia in series
reporting damage control laparotomy in non-trauma patients varies between 13
and 31% [10, 11, 30, 31] (Table 9.1), which means that acute mesenteric ischemia
is a rather common cause when performing damage control laparotomies. Survival
rate was reported to be 62% in 16 actively treated patients in one series [29].
Collaboration between vascular and general surgeons may improve outcome. In
Fig. 9.1 Vacuum-assisted
wound closure and
mesh-mediated fascial
traction technique: 1,
bowel; 2, visceral protective
layer; 3, abdominal wall; 4,
abdominal wall fascia; 5,
polypropylene mesh; 6, two
pieces of polyurethane
foam placed on top of the
mesh and subcutaneously
between the wound edges;
7, tubing set with an
interface pad attached to an
opening in the self-adhesive
drapes and connected to the
vacuum source
S. Acosta et al.
113
the recently developed European Society of Vascular Surgery Guidelines on the
management of diseases of the mesenteric arteries and veins, damage control
surgery and second- look laparotomy are recommended when bowel infarction has
developed in patients undergoing intestinal revascularization [32]. This strategy is
less well studied in non-occlusive mesenteric ischemia and mesenteric venous
gangrene [33], but liberal use of second-look laparotomy seems to be a rational
approach in these entities of acute mesenteric ischemia as well.
9.3.1 Treatment of Acute Superior Mesenteric Artery Occlusion
Optimal treatment may include both open and endovascular surgery, and patients
are best treated in a vascular center with a hybrid operating room, if available within
a reasonable distance. From preoperative clinical and CT angiography evaluation, it
can be determined whether the patient has peritonitis or not and whether the occlu-
sion is embolic or thrombotic. Laparotomy is indicated if there is peritonitis to
evaluate the extent and severity of intestinal ischemia by inspection of color of the
intestines, dilatation and peristaltic motion of the bowel, visible pulsations in the
mesenteric arcade arteries, and bleeding from cut surfaces. Acute mesenteric arte-
rial revascularization, open, hybrid, or endovascular, is done preferably before any
bowel surgery (Fig. 9.2). There is rarely any indication for revascularization of both
the SMA and the coeliac trunk, of which SMA revascularization seems to be more
important and durable. In an acute thrombotic occlusion, retrograde open mesen-
teric stenting [34] may be a very useful hybrid approach where SMA is exposed at
laparotomy, followed by retrograde recanalization of the thrombotic and atheroscle-
rotic occluded SMA, and stented in retrograde or antegrade manner (Fig. 9.3). All
initial emergency vascular and necessary visceral surgery should be performed dur-
ing the same operation.
9.3.2 Temporary Abdominal Closure in Acute Mesenteric
Ischemia
Even a low grade of intra-abdominal hypertension may become fatal when a large
portion of the intestinal tract is gangrenous [27]. In this situation it is important to
optimize the perfusion of the remaining bowel, which often requires open abdo-
men treatment [35]. In the event of bowel perforation, the affected intestinal seg-
ment is rapidly resected, followed by mesenteric revascularization, leaving the
reconstruction of the intestinal tract until second-look laparotomy after 18–36 h.
The optimal TAC method in patients with acute mesenteric ischemia is not clear.
While temporary skin-only closure may be a good option in some patients, full
open abdomen to optimize visceral circulation may be necessary in others. In some
reports, long-term NPWT in open abdomen due to secondary peritonitis [36] or
intestinal ischemia requiring bowel resection and anastomosis [25] were factors
9 The Open Abdomen in Non-traumatic Vascular Emergencies