Staged abdominal repair: Development and current practice of an advanced operative technique for diffuse suppurative peritonitis

Abstract

Background: To improve mortality of intraabdominal infections, since 1975, many surgeons worldwide have been extending the classical single-stage operative approach for the sickest 10 % of patients. A variety of names have been introduced for similar operative strategies. All procedures contributed to the development of Staged Abdominal Repair (STAR). Methods: STAR is defined as one operation performed in multiple steps at 24 hours intervals to 1) reverse or prevent the physiological derangement of increased intra-abdominal pressure from peritoneal edema and ileus and to 2) combine damage control in non-stable patients with delayed definitive repair including formation of anastomoses, and ultimate formal fascial closure. The abdomen is temporarily closed using the artificial burr that has been approved for clinical use by the European and US health authorities (www.starsurgical.com). The wound above the artificial burr is sealed with a Hypobaric Wound Shield (HBS) that acts as a barrier against exogenous contamination in the ICU and allows for collection of toxic peritoneal fluid for diagnostic purposes to provide a basis for meaningful protein substitution. Results: Our recent series from 1988 to 1999 includes 128 patients with an Apache II score of 19±7. We entered the abdominal cavity 5.9±3.5 times during 6.8±4.1 days per patient and performed STAR because we were unable to close the abdomen without undo tension in 83 % of our patients. The viability of the bowel was a concern in 17% of the cases. Patients required an average of 22±19 (median 18) days of care in the intensive care unit and they were discharged a median of 30 (2–252) days after the Index STAR. We were able to close the fascia in 93 % of the cases. The 30 day, 60 day and hospital mortality was 11 %, 15 %, and 19 % respectively. Post STAR we saw 3 intestinal fistulae that closed spontaneously and 12 % of the patients developed abdominal wall hernias. Conclusions: The observed mortality compares favorably to the expected mortality of 47 % for patients with similar risk factors, and there are fewer complications when compared with other open techniques.