Abdominal Reapproximation Anchor Research Articles

Successful Multimodal Approach to Megacolon, Enterocutaneous Fistula, and Chronic Incisional Hernia with Loss of Domain: A Case Report

Our case highlights a 41-year-old male with a past medical history of severe diverticular disease since age 30, diabetes mellitus type 2, hypertension, protein calorie malnourishment, and body mass index of 50 kg/m2 who presented for a large bowel obstruction. Active surgical issues included: chronic incisional hernia, enterocutaneous fistulae, and a megacolon secondary to a recto-sigmoid anastomotic stricture. In collaboration with a colorectal surgeon and by using a multimodal approach, we successfully addressed the patient’s gastrointestinal issues and incisional hernia. The multimodal approach included botulinum toxin A (BTA) injections to the abdominal wall flat muscles (external oblique, internal oblique, and transverse abdominus), installation of an abdominal reapproximation anchor (ABRA) dynamic tissue system (DTS), and porcine urinary bladder matrix (PUBM) xenografts. The patient received BTA injections prior to the index operation, which lasted over 12 hours. The ABRA DTS assisted in achieving primary fascial closures. Definitive closure of this class 4 wound was facilitated by the antimicrobial and accelerated wound healing properties of PUBM as well as a unique multimodal approach to achieve exemplary results in a patient with multiple complex surgical issues.

The Abdominal Re-Approximation Anchor device (ABRA®) has the potential to be useful in both emergency and elective dynamic temporary fascial closure.

The management of an open abdomen (OA) remains an evolving field because of its relative rarity. Many techniques to achieve temporary abdominal closure exist, but often require multiple returns to the operating theatre and usually do not address the issue of lateral fascial retraction and do not achieve primary fascial closure (PFC). The ensuing incisional hernias result in a significant surgical challenge affecting both the physical and mental health of the patient. We describe our experience with the Abdominal Re-approximation Anchor (ABRA) device, which addresses some of these issues. The records of patients with an OA managed by a single surgeon using the ABRA device at Princess Alexandra Hospital, Queensland, Australia, between December 2014 and April 2020 were analysed retrospectively. Six patients with OA were managed with the ABRA. All patients required an OA for the ramification of intraabdominal sepsis. Three patients were managed with the ABRA device electively and three in the acute setting. 100% of patients achieved PFC. Average follow-up was 40 months with three developing incisional hernias that were subsequently repaired. The OA in critically ill surgical patients remains one of the most challenging problems in general surgery. The ABRA device is simple to use and has shown positive outcomes in both the acute and elective setting. Our use has resulted in 100% PFC, which demonstrates that the ABRA device is an important tool for the general surgeon in managing these complex cases.

Use of an abdominal reapproximation anchor system in the closure of large, open myelomeningoceles.

Open neural tube defects are complex congenital abnormalities of the nervous system in which nervous tissue is exposed on the patient's back at the time of delivery. These malformations require surgical correction, and although replacement of the neural placode internally is fairly standard, providing skin closure can be very challenging especially in large defects. An abdominal reapproximation anchor (ABRA) device may be of value in attaining skin closure in these large, open myelomeningocele defects in which primary closure cannot be accomplished surgically. In a study period during which 65 patients underwent surgical closure of open myelomeningocele defects, 5 of them underwent ABRA-assisted closure.The average surgical intervention for myelomeningocele repair occurred on day 2.2 of life (range 2-3 days). The average defect size was 37 cm2 (range 16-56 cm2), and the average time to formal closure was 30.8 days (range 8-63 days). One of the patients had natural closure with just ABRA approximation. The remaining 4 patients underwent formal delayed primary closure when the skin edges became approximated. Use of the ABRA system in the closure of a large, open myelomeningocele may be valuable in select patients but requires further follow-up and comparison to identify truly significant differences with traditional techniques.

Management of a Septic Open Abdomen Patient with Spontaneous Jejunal Perforation after Emergent C/S with Confounding Factor of Mild Acute Pancreatitis.

Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.

Delayed Closure of 61 Open Abdomen Patients Based on an Algorithm.

Hemodynamic resuscitation, source control, and delayed abdominal closure are the three fundamental steps for open abdomen (OA) management. When to start delayed abdominal closure and how to determine which delayed closure method should be applied to each OA patient are not clarified in the literature. We evaluated an algorithm that was developed to address these two questions. A retrospective chart review was conducted for OA patients treated for according to the algorithm. When hemodynamic stabilization and source control using negative pressure therapy resulted in regression of sepsis and decreased procalcitonin levels, patients were assigned to either the skin-only or fascial closure groups according to their Björck scores and open abdominal fascial closure (OAFC) scores. The novel OAFC scoring system was created by adding age and malignancy to the sequential organ failure assessment (SOFA) score. For skin-only closure, skin flaps and skin grafts were used; for fascial closure, an abdominal re-approximation anchor system (ABRA) or ABRA plus biologic mesh was applied. From January 2008 through September 2014, 108 OA patients were managed based on the algorithm; 61 were included in this study. Abdominal closure rate was 90.2% (55/61). Overall hospital mortality rate was 11.4% (7/61). Small hernias developed in only 12.5% (4/32) of the fascial closure group. In this retrospective study, the algorithm with the novel OAFC score provided practical and valid guidance to clarify when to start delayed abdominal closure and which delayed closure method to use for each OA patient.

Management of Septic Open Abdomen in a Morbid Obese Patient with Enteroatmospheric Fistula by Using Standard Abdominal Negative Pressure Therapy in Conjunction with Intrarectal One.

Introduction. Management of open abdomen (OA) with enteroatmospheric fistula (EAF) in morbid obese patient with comorbid disease is challenging. We would like to report the management of septic OA in morbid obese patient with EAF which developed after strangulated recurrent giant incisional hernia repair. We would also like to emphasize, in this case, the conversion of EAF to ileostomy by the help of second Negative Pressure Therapy (NPT) on ostomy side, and the chance of new EAF occurrence was reduced with intrarectal NPT. Case Presentation. 62-year-old morbid obese woman became an OA patient with EAF after strangulated recurrent giant hernia. EAF was converted to ostomy with pezzer drain by the help of second NPT on ostomy. Colonic distention was reduced with the third NPT application via rectum. Abdominal reapproximation anchor (ABRA) system was used for delayed abdominal closure. Conclusions. Using the 2nd NPT on ostomy side may help in the maturation of the ostomy created in a difficult condition in an open abdomen. Using the 3rd NPT through rectum may decrease the chance of EAF formation by reducing the pressure difference between intraluminal pressure and extraluminal pressure in hollow viscera.

Management of the open abdomen using combination therapy with ABRA and ABThera systems.

The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen. We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia. Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%). We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjuction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.

A Prospective, Controlled Evaluation of the Abdominal Reapproximation Anchor Abdominal Wall Closure System in Combination with VAC Therapy Compared with VAC Alone in the Management of an Open Abdomen

Dramatic increases in damage control and decompressive laparotomies and a significant increase in patients with open abdominal cavities have resulted in numerous techniques to facilitate fascial closure. We hypothesized addition of the abdominal reapproximation anchor system (ABRA) to the KCI Abdominal Wound Vac™ (VAC) or KCI ABThera™ would increase successful primary closure rates and reduce operative costs. Fourteen patients with open abdomens were prospectively randomized into a control group using VAC alone (control) or a study group using VAC plus ABRA (VAC-ABRA). All patients underwent regular VAC changes; patients receiving VAC-ABRA also underwent concomitant daily elastomer adjustment of the ABRA system. Primary end points included abdominal closure, number of operating room (OR) visits, and OR time use. Eight patients were included in the VAC-ABRA group and six patients in the control group. Primary closure rates between groups were not statistically different; however, the number of trips to the OR and OR time use were different. Despite higher Acute Physiology and Chronic Health Evaluation II scores, larger starting wound size, and higher rates of abdominal compartment syndrome, closure rates in the VAC-ABRA group were similar to VAC alone. Importantly, however, fewer OR trips and less OR time were required for the VAC-ABRA group.

Management of the open abdomen with the Abdominal Reapproximation Anchor dynamic fascial closure system

BackgroundWith the increased use of damage control surgery and open abdomens, there are growing challenges in achieving primary fascial closure. The purpose of this study was to retrospectively review our experience using the Abdominal Reapproximation Anchor (ABRA; Canica Design Inc, Almonte, Ontario, Canada), a dynamic fascial closure system, to gain fascial apposition in complex abdominal surgical patients. MethodsA retrospective review of patients who underwent placement of the ABRA device to aid in abdominal closure was undertaken. Details including age, sex, the reason for an open abdomen, the number of operations, the time to primary closure, the success rate of primary closure, and complications related to the use of the ABRA were analyzed. ResultsBetween January 2006 and July 2011, 36 patient charts were identified. The average Acute Physiology and Chronic Health Evaluation II score was 21.9 ± 6.9. There was a mean of 3.1 ± 1.8 laparotomies before ABRA placement for each patient, and the duration of ABRA placement until removal was 10.4 ± 6.1 days. Complete fascial apposition was achieved in 83% of the patients across the entire study and in 91% of the patients in the final 2 years. Component separation was used in 17% of cases. The incisional hernia rate was 13% at 6 months and 11% at 12 months. ConclusionsOur use of the ABRA system resulted in an 83% fascial apposition rate, which further improved when experience was taken into account. The incisional hernia rate was acceptable in this complicated patient group. This technique is an excellent addition to a surgeon’s armamentarium for complicated abdominal cases that require an open abdomen. Further prospective studies are planned to identify ideal candidates for this technique.

Use of an abdominal reapproximation anchor (ABRA) system in a patient with abdominal compartment syndrome after severe burns: A case report

Jessica Heimes *, Elizabeth Carlton , Jessica McDonnell , Tracy Rogers , Khadi Udobi , Michael Moncure a Department of Surgery, The University of Kansas Medical Center, United States The University of Kansas Medical Center, Department of Surgery, Division of Trauma, United States University of Kansas Hospital, Department of Surgery, Division of Trauma, United States b u r n s 3 9 ( 2 0 1 3 ) e 2 9 – e 3 3

Use of dynamic wound closure system in conjunction with vacuum-assisted closure therapy in delayed closure of open abdomen

Definitive abdominal closure may not be possible for several days or weeks after laparotomy in damage-control surgery, abdominal compartment syndrome and intraabdominal sepsis, until the patient has stabilized. Vacuum-assisted closure (VAC therapy(®), KCI, San Antonio, TX, USA) and abdominal re-approximation anchor system (ABRA, Canica, Almonte, Ontario, Canada) are novel techniques in delayed closure of open abdomen. Our aim is to present the use of these strategies in the management of 7 patients with open abdomen. Between August 2010 and December 2011, 7 patients with severe peritonitis were stabilized by laparotomy and treated with either ABRA system or ABRA system in conjunction with VAC dressing. VAC dressing applied to 4 patients initially and followed by ABRA. ABRA was applied alone to remaining 3 patients. Demographic data and patient characteristics, timing of VAC dressing and ABRA system were recorded. ICU and hospital stay and development of incisional hernia were also recorded. Stage of open abdomen, width of abdominal defect, extent to damage to fascia, and pressure sores were staged. The mean duration with VAC dressing before ABRA application was 18 days. The mean duration of ABRA application was 53 days. The average width of the abdominal defect was 18 cm. The average length of defect was 20.8 cm. Delayed primary abdominal closure was accomplished in 6 patients without further surgery. Incisional hernia with a small abdominal defect developed in 2 patients. Abdominal re-approximation anchor system and VAC dressing can be used separately or in conjunction with each other for closure of delayed open abdomen successfully.

Delayed Primary Closure of the Septic Open Abdomen with a Dynamic Closure System

BackgroundThe major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall.MethodsEighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck.ResultsIn this severely ill population the mean time before ABRA system application was 12 days (range: 2–39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7–30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia.ConclusionsDelayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen.Electronic supplementary materialThe online version of this article (doi:10.1007/s00268-011-1210-8) contains supplementary material, which is available to authorized users.

Comment On “Closure of Massive Abdominal Wall Defects: A Case Report Using the Abdominal Reapproximation Anchor (ABRA) System”

Comment On “Closure of Massive Abdominal Wall Defects: A Case Report Using the Abdominal Reapproximation Anchor (ABRA) System”

Comment On “Closure of Massive Abdominal Wall Defects: A Case Report Using the Abdominal Reapproximation Anchor (ABRA) System”

Comment On “Closure of Massive Abdominal Wall Defects: A Case Report Using the Abdominal Reapproximation Anchor (ABRA) System”