Early Abdominal Closure Research Articles

Predictors of exploration in patients at high risk of abdominal compartment syndrome

Context Abdominal compartment syndrome (ACS) is caused when an acute increase in intra-abdominal pressure (IAP) occurs sufficient to impair vascular inflow and thereby compromising the viability of the tissues and organs within the abdomen. Familiarity with the presentation of ACS is mandatory for all clinicians who care for critically ill patients to avoid its high mortality if not recognized and treated. The measurement of IAP is a vital part of clinical management of ACS. Early recognition is important, and the need for surgical decompression may be urgent. Aim The aim was to evaluate the cases at high risk for development of ACS trying to prevent its fatal adverse effects by defining its predictors. Patients and methods This prospective, interventional, non-randomized clinical trial was conducted at Mansoura University and emergency hospitals over the period from February 2016 to February 2019. This study was conducted on patients at high risk of intra-abdominal hypertension. Two groups were included. The first group was managed conservatively, and the second one received decompressive laparotomy depending on clinical parameters, including IAP, and general status. Data were analyzed using SPSS v-24. Results A total of 40 patients who had an increased IAP greater than or equal to 20 cmH2O with several clinical presentations were included. These patients had respiratory distress (90%) and distended tense abdomen, whereas abdominal pain and oliguria were only present in ∼25% of cases. Overall, 20 (50%) patients underwent conservative management, and all these cases passed normally. Moreover, 20 (50%) patients underwent decompressive laparotomy. Univariate and multivariate analyses showed central venous pressure, BMI, urinary bladder pressure, and postoperative organ failure were found to be significant independent risk factors that increased the rate of mortality. The complications of the first group were owing to the primary operation and those of the second of group were owing to the primary operation as well as owing to operative decompression procedure. The mortality of the studied groups was 25% in the second one only, and there was a significant difference between both groups in the hospital stay. Conclusion These results had suggested that early detection of cases with ACS and proper management may be curative, and they could decrease multiorgan dysfunction and mortality in such cases. The avoidance of early abdominal closure, which may be distressing to the patients, could be mandatory in such conditions.

Early Abdominal Closure Achieved through Retroperitoneal Hematoma Evacuation after Endovascular Aneurysm Repair and Open Abdominal Management for a Ruptured Aortic Aneurysm

Early Abdominal Closure Achieved through Retroperitoneal Hematoma Evacuation after Endovascular Aneurysm Repair and Open Abdominal Management for a Ruptured Aortic Aneurysm

Abdominal compartment syndrome and the open abdomen: any unresolved issues?

This article reviews the key principles of abdominal compartment syndrome and the open abdomen, exploring some of the unresolved issues. It reviews new concepts in care. Recent use of peritoneal resuscitation, and benefits of mesh-mediated traction are discussed. Abdominal compartment syndrome remains a result of complex interaction between general haemorrhage, sepsis and fluid resuscitation. Improved resuscitation and sepsis control has decreased but not abolished the need for the open abdomen and progression for abdominal compartment syndrome. Fourth-generation abdominal wall dressings need to be combined with a dynamic closure system; currently, negative pressure wound therapy at the index open abdomen coupled with mesh-mediated tractions offers the best outcome. The key to optimizing outcome is early abdominal closure within 7 days because failure to do so will increase morbidity, mortality and fistulae formation. Novel techniques complementing existing de-resuscitation techniques are discussed.

Early abdominal closure using component separation in patients with an open abdomen after trauma: a pilot study

Early abdominal closure using component separation in patients with an open abdomen after trauma: a pilot study Karan Chopra,1 Kashyap Komarraju Tadisina,1 Jamil A Matthews,1 Jennifer Sabino,1 Devinder P Singh,1 Wassim Habre2 1University of Maryland Medical Center, Baltimore, MD, 2Crozer-Chester Medical Center, Upland, PA, USA Background: Permanent abdominal wall closure in patients undergoing damage-control laparotomy is achieved using techniques involving separation and advancement of abdominal wall components along with surgical mesh. However, these techniques are costly, morbid, and time-consuming. We compared outcomes following permanent abdominal closure using component separation (CS) with non-cross-linked porcine acellular dermal matrix (PADM) versus temporizing split-thickness skin graft (STSG) closure. Materials and methods: A retrospective review identified eleven patients who underwent damage-control laparotomies from January 2010 to June 2011. Outcomes assessed included hospital length of stay (LOS), days on ventilator, size of defect and tissue matrix, and postoperative functionality. Results: Of the eleven patients identified, primary closure was achieved in five, CS/PADM closure in four, and STSG closure in two. Those with primary closure were excluded from the study. In the CS/PADM group, large defects (>24×20 cm) were successfully closed using CS with PADM. Patients in the CS/PADM group had reduced third-space fluid loss, less difficulty in managing the open abdominal wound, and decreased risks for potential enterocutaneous fistulae, and intra-abdominal abscess formation. Total hospital LOS and days on the ventilator were also significantly reduced in the CS/PADM group compared with the STSG group. Conclusion: Early abdominal closure using CS/PADM was safe and effective in these patients, and may be cost-effective because only one operation is required. The shorter hospital LOS and days on the ventilator observed versus STSG closure appear promising, although further study is required. Keywords: acellular dermal matrix, laparotomy, abdominal wall closure, split-thickness skin graft, Strattice

Early abdominal closure improves long-term outcomes after damage-control laparotomy

The impact of initial clinical decisions on the long-term quality of life and functional outcome of patients who undergo damage-control laparotomy (DCL) is unknown. We hypothesized that early abdominal closure after DCL improves long-term outcomes. Patients (2005-2011) who underwent DCL (n = 140) at our Level I trauma center were identified. A total of 108 patients survived their hospitalization, and 15 died following discharge. Of the remaining 93 survivors, 59 were unreachable and not present in the social security death index. Our final study population of 34 survivors prospectively completed a standardized study questionnaire, the SF-36 health survey, and inpatient and outpatient records were reviewed. Survivors were compared on the basis of time with final abdominal closure (early, <7 days vs. late, >7 days; either primary closure or Vicryl mesh), and study variables were analyzed. A p < 0.05 was considered significant. Our study population was primarily male (82%) of varying age (36 [13]) and mechanism (blunt 56%, penetrating 44%) with severe injuries (mean [SD] Injury Severity Score [ISS], 17 [8]). Despite no differences in age, sex, mechanism, ISS, admission Glasgow Coma Scale (GCS) score, or admission systolic blood pressure, early-closure patients (n = 13) had shorter hospital (25 days vs. 57 days) and intensive care unit (12 days vs. 20 days) stays and, upon long-term follow-up, higher physical (54 vs. 18), emotional (86 vs. 44), and general health (66 vs. 50) SF-36 scores than late-closure patients (n = 21) (all p < 0.05). Early-closure patients had less daily pain (38% vs. 95%), had higher overall SF-36 scores (66 vs. 46), and were more likely to return to work (54% vs. 10%) than late-closure patients (all p < 0.05). Early clinical decisions impact the lives of critically injured patients. Abdominal closure within 7 days of DCL improves long-term quality of life and functional outcome. Therapeutic study, level IV.

Damage-control laparotomy in nontrauma patients

The principle of damage-control laparotomy (DCL) in trauma is well established. The DCL concept can be applied in emergency general surgery when an abbreviated laparotomy is performed at the initial stage. Subsequent definitive management and abdominal closure are achieved when the patient is stabilized. In this study, we report our experience with DCL in acute general surgical nontrauma patients. A retrospective review was performed of all nontrauma patients who underwent DCL at Auckland City Hospital from January 2008 to December 2010. Data including indications and outcome were collected and analyzed. Forty-two nontrauma patients underwent DCL in the 3-year period. The median age was 66 years. There were 22 males and 20 females. The most common primary indications for DCL were bowel ischemia (13 patients), bleeding (13 patients), and peritonitis (10 patients). Majority of patients had an American Society of Anesthesiologists score of 3 or 4. Overall, 24 patients (57%) underwent closure of the fascia within 7 days, 7 patients were closed after more than 7 days, and 11 patients could not undergo primary closure at all. The main complications after DCL were sepsis (14 patients) and intra-abdominal collections (10 patients). There were significantly fewer postoperative complications in patients undergoing early closure. The medium length of stay in intensive care as well as in hospital was significantly less in the early closure group. However, postoperative respiratory failure was more common in those with early closure (5 vs. 0). The mortality rate overall was 19%, with no significant difference regarding timing of abdominal closure. The DCL principle is often applied to the critically ill surgical patients in the nontrauma setting. This group of critical surgical patients has a high morbidity and mortality. However, early abdominal closure should be performed where possible to prevent complications. It is unclear whether patients with early closure were going to have a better outcome regardless, and prospective studies are needed to address. Therapeutic/care management, level V.

After the Storm: Early Abdominal Closure Affects Long Term Outcomes of Damage Control Survivors

After the Storm: Early Abdominal Closure Affects Long Term Outcomes of Damage Control Survivors

Hyperacute Abdominal Compartment Syndrome: An Unrecognized Complication of Massive Intraoperative Resuscitation for Extra-abdominal Injuries

Primary and secondary abdominal compartment syndrome (ACS) are well-recognized entities after trauma. The current study describes a "hyperacute" form of secondary ACS (HACS) that develops intraoperatively while repair of extra-abdominal injuries is being carried out simultaneous with massive resuscitation for shock caused by those injuries. The charts of patients requiring abdominal decompression (AD) for HACS at time of extra-abdominal surgery at our level I trauma center were reviewed. The following data was gathered: age, Injury Severity Score (ISS), mechanism, resuscitation details, time to AD, time to abdominal closure, and outcome. All continuous data are presented as mean +/- standard error of mean. Hemodynamic and ventilatory data pre- and post-AD was compared using paired t test with significance set at P < 0.05. Five (0.13%) of 3,750 trauma admissions developed HACS during the 15-month study period ending February 2004. Mean age was 32 +/- 7 years, and mean ISS was 19 +/- 2. Four of five patients arrived in hemorrhagic shock (blunt subclavian artery injury, 1; chest gunshot, 1; gunshot to brachial artery, 1; stab transection of femoral vessels, 1) and were immediately operated upon. One of five patients (70% burn) developed HACS during burn wound excision on day 2. HACS developed after massive crystalloid (15 +/- 1.7 L) and blood (11 +/- 0.4 units) resuscitation during prolonged surgery (4.8 +/- 0.8 hours). Pre- versus post-AD comparisons revealed significant (P < 0.05) improvements in mean arterial pressure (55 +/- 6 vs 88 +/- 3 mm Hg), peak airway pressure (44 +/- 5 vs 31 +/- 2 mm Hg), tidal volume (432 +/- 96 vs 758 +/- 93 mL), arterial pH (7.16 +/- 0.0 vs 7.26 +/- 0.04), and PaCO2 (52 +/- 6 vs 45 +/- 6 mm Hg). There was no mortality among the group, and all patients underwent abdominal closure by fascial reapproximation in 2-5 days. Two (40%) of the five patients required extremity fasciotomy for compartment syndrome. HACS is a rare complication of massive resuscitation for extra-abdominal injuries. It should be considered in such patients in the face of unexplained hemodynamic and/or ventilatory decompensation. Prompt AD is life saving. Early abdominal closure is usually possible. Vigilance for compartment syndromes elsewhere in the body is warranted in any patient with HACS.)

Early abdominal closure with mesh reduces multiple organ failure after ruptured abdominal aortic aneurysm repair: Guidelines from a 10-year case-control study

Objective: The objectives of this study were the comparison of patients who needed mesh closure of the abdomen with patients who underwent standard abdominal closure after ruptured abdominal aortic aneurysm repair and the determination of the impact of timing of mesh closure on multiple organ failure (MOF) and mortality. Methods: We performed a case-control study of patients who needed mesh-based abdominal closure (n = 45) as compared with patients who underwent primary closure (n = 90) after ruptured abdominal aortic aneurysm repair. Results: Before surgery, the patients who needed mesh abdominal closure had more blood loss (8 g versus 12 g of hemoglobin; P <.05), had prolonged hypotension (18 minutes versus 3 minutes; P <.01), and more frequently needed cardiopulmonary resuscitation (31% versus 2%; P <.01) than did the patients who underwent primary closure. During surgery, the patients who needed mesh closure also had more severe acidosis (base deficit, 14 versus 7; P <.01), had profound hypothermia (32°C versus 35°C; P <.01), and needed more fluid resuscitation (4.0 L/h versus 2.7 L/h; P <.01). With this adverse clinical profile, the patients who needed mesh closure had a higher mortality rate than did the patients who underwent primary closure (56% versus 9%; P <.01). However, the patients who underwent mesh closure at the initial operation (n = 35) had lower MOF scores (P <.05), a lower mortality rate (51% versus 70%), and were less likely to die from MOF (11% versus 70%; P <.05) than the patients who underwent mesh closure after a second operation in the postoperative period for abdominal compartment syndrome (n = 10). Conclusion: This study reports the largest experience of mesh-based abdominal closure after ruptured abdominal aortic aneurysm repair and defines clinical predictors for patients who need to undergo this technique. Recognition of these predictors and initial use of mesh closure minimize abdominal compartment syndrome and reduce the rate of mortality as the result of MOF. (J Vasc Surg 2002;35:246-53.)