Vacuum and Mesh-mediated Fascial Traction for Closure of the Open Abdomen after Abdominal Aortic Aneurysm Repair

Abstract

The management of the open abdomen (OA) is a controversial and challenging topic. The OA has been used in lifethreatening intra-abdominal conditions as hemorrhage, hypertension and severe sepsis. 1 Although this technique has been proved as an important tool in the initial management of the physiologically unstable patient, feared complications such as enteroatmospheric fistulas, hernias, secondary infections, hypercatabolic state, loss of bowel function and excessive fluid loss may also occur and lead to prolonged hospitalization and eventually to increased morbidity, mortality and hospital cost. 1 Toward this direction, many different methods for temporary abdominal wall closure have been implemented. Among them, the “Bogota Bag” has been partly abandoned due to ineffectiveness in removal of cytokine-rich intra-abdominal fluid and synthetic meshes cannot be used in a septic abdominal environment. Other surgical techniques, such as Witmann patch, dynamic retention sutures, locking system, loose packing and zipper have also failed to clearly evidence their superiority. 2 The study by Sorelius et al. 3 provided evidence that vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) may help the abdominal wall closure in a selected subgroup of patients with open abdomen after abdominal aortic aneurysm (AAA) repair. Interestingly, the authors found that primary delayed fascial closure rate was achieved in all survivors. These results may be indirectly compared to the results of VAWC treatment alone without mesh-mediated traction, which showed 70% fascial closure rate among trauma patients. However, in the current study a patient selection bias might have occurred and concern may be raised by the late OA-related complications which occurred in 17% of the VAWCM patients (2 enteroatmospheric fistulas, 2 graft infections and 1 aortoenteric fistula), all of whom developed intestinal ischemia. In the absence of large prospective randomized trials, smaller case series like the study by Sorelius et al. 3 may provide helpful information regarding the clinical implications of VAWCM. High potential for graft infection from exposure to the environment remains a concern for patients with OA after AAA repair. Dressing changes should be performed in the operating room under sterilized conditions and conscious sedation. It is essential to vigorously monitor intra-abdominal pressure and to individualize pressure settings in order to optimize the time of the abdominal wall closure. The promising results of VAWCM should be evaluated in the context of a prospective randomized clinical trial.