Primary Fascial Closure Rate Research Articles

Early placement of a non-invasive, pressure-regulated, fascial reapproximation device improves reduction of the fascial gap in open abdomens: a retrospective cohort study

BackgroundSince current fascial traction methods involve invasive procedures, they are generally employed late in the management of the open abdomen (OA). This study aimed to evaluate early versus late placement...

The Safety and Efficacy of Hypertonic Saline in Achieving Primary Fascial Closure Following Damage Control Laparotomy: A Systematic Review and Meta-Analysis.

Effective fluid management is critical in patients undergoing damage control laparotomy (DCL) for trauma and sepsis. Hypertonic saline (HTS) has been proposed as an alternative to isotonic fluids to enhance primary fascial closure rates and optimize fluid balance. This systematic review and meta-analysis aimsto evaluate the efficacy and safety of HTS compared to isotonic fluids in patients undergoing DCL. A comprehensive literature search was conducted across multiple databases up to the 14thof June 2024, identifying studies that compared HTS to isotonic fluids in adult patients undergoing DCL for trauma or sepsis. Eligible studies included randomized controlled trials and observational studies reporting outcomes such as early primary fascial closure (EPFC) rates, time to fascial closure, fluid requirements, electrolyte imbalances, renal function, and mortality. Data extraction and quality assessment were performed independently by two reviewers, and pooled analyses were conducted using fixed-effectmodels where appropriate. Four studies encompassing 375 patients met the inclusion criteria, with 100 patients receiving HTS and 275 receiving isotonic fluids. HTS administration was associated with a significantly higher EPFC rate compared to isotonic fluids (odds ratio (OR): 0.314; 95% confidence interval (CI): 0.142-0.696; p=0.004). The mean time to fascial closure was also significantly reduced in the HTS group by approximately eight hours (mean difference (MD): 8.007 hours; 95% CI: 5.558-10.596; p<0.001). Patients receiving HTS required significantly less total fluid over 48 hours (MD: 1.055 liters; 95% CI: 0.713-1.398; p<0.001). While HTS use led to higher peak sodium levels (MD: -4.318 mEq/L; 95% CI: -4.702 to -3.934; p<0.001), there were no significant differences in peak creatinine levels, need for inpatient renal replacement therapy, or 28-day mortality between the groups. HTS appears to be effective in improving EPFC rates and reducing both time to closure and overall fluid requirements in patients undergoing DCL for trauma and sepsis. Although associated with higher serum sodium levels, HTS did not increase the risk of renal dysfunction or mortality. These findings suggest that HTS is a safe and efficacious alternative to isotonic fluids in the management of critically ill patients requiring DCL. Further large-scale, randomized controlled trials are warranted to confirm these results and inform clinical guidelines.

Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management.

To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM). Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25). VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004). VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

A descriptive analysis of skin-only closure and Bogota bag techniques for achieving complete fascial closure in damage control abdominal surgery

BackgroundTemporary abdominal closure (TAC) techniques are essential in managing open abdomen cases, particularly in damage control surgery. Skin-only closure (SC) and Bogota bag closure (BBC) are commonly used methods for TAC, but their comparative effectiveness in achieving primary fascial closure (PFC) remains unclear. The objective of this study was to evaluate the rates of PFC between patients undergoing SC and BBC techniques for TAC in peritonitis or abdominal trauma cases at a tertiary care hospital.MethodsA retrospective cross-sectional study was conducted at the Surgical A Unit of Hayatabad Medical Complex, Peshawar, from January 2022 to July 2023. Approval was obtained from the institutional review board, and patient consent was secured for data use. Patients undergoing temporary abdominal closure using either skin-only or Bogota bag techniques were included. Exclusions comprised patients younger than 15 or older than 75 years, those with multiple abdominal wall incisions, and those with prior abdominal surgeries. Data analysis utilized SPSS version 25. The study aimed to assess outcomes following damage control surgery, focusing on primary fascial closure rates and associated factors. Closure techniques (skin-only and Bogota bag) were chosen based on institutional protocols and clinical context. Indications for damage control surgery (DCS) included traumatic and non-traumatic emergencies. Intra-abdominal pressure (IAP) was measured using standardized methods. Patients were divided into SC and BBC groups for comparison. Criteria for reoperation and primary fascial closure were established, with timing and technique determined based on clinical assessment and multidisciplinary team collaboration. The decision to leave patients open during the index operation followed damage control surgery principles.ResultsA total of 193 patients were included in this study, with 59.0% undergoing skin-only closure (SC) and 41.0% receiving Bogota bag closure (BBC). Patients exhibited similar demographic characteristics across cohorts, with a majority being male (73.1%) and experiencing acute abdomen of non-traumatic origin (58.0%). Among the reasons for leaving the abdomen open, severe intra-abdominal sepsis affected 51.3% of patients, while 42.0% experienced hemodynamic instability. Patients who received SC had significantly higher rates of primary fascial closure (PFC) compared to BBC (85.1% vs. 65.8%, p = 0.04), with lower rates of fascial dehiscence (1.7% vs. 7.6%, p = 0.052) and wound infections (p = 0.010). Multivariate regression analysis showed SC was associated with a higher likelihood of achieving PFC compared to BBC (adjusted OR = 1.7, 95% CI: 1.3–3.8, p < 0.05).ConclusionIn patients with peritonitis or abdominal trauma, SC demonstrated higher rates of PFC compared to BBC for TAC in our study population. However, further studies are warranted to validate these results and explore the long-term outcomes associated with different TAC techniques.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center.

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed(60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Open abdomen: a comprehensive review

When the abdominal viscera are visible due to a defect in the abdominal wall, which is usually caused intentionally or as a result of abdominal compartment syndrome, it is referred to as an open abdomen. As a protracted open abdomen can result in problems including fluid and protein losses, intestinal fistulization, and loss of abdominal dominance, the main goals of temporal abdominal closure techniques are to prevent fluid losses and loss of dominance. There are several techniques for short-term abdominal closure, each having advantages and disadvantages. These techniques include patch closure, silo closure, and negative pressure systems based on towels and sponges. After temporary abdominal closure, the patient is monitored in the critical care unit while any required adjustments are made to the abdominal dressings. Observational studies have shown that the Wittmann Patch has the highest average rate of primary fascial closure when compared to other operations. Yet, a temporary closure of this sort might not be adequate to stop fluid loss on its own. To monitor fluid loss, a negative pressure device (sponge- or towel-based) is advised. It can be used either on its own or in combination with other techniques for closing the temporal abdominal cavity. When the sign of an open abdomen has been removed, the abdomen is closed, ideally using a major fascial closure. If primary fascial closure cannot be achieved, functional closure may be accomplished using a biological mesh inlay method. While there is a good probability of developing a posterior hernia, this treatment adds new fascial tissue where the natural fascial limits are located. The fascia defect may be filled in with primary skin closure or skin grafts once a layer of granulation tissue has developed over the consolidated visceral mass if the space between the fascia's borders is too large for functional closure. Effective abdominal closure and the prevention of issues ultimately depend on proper management and supervision of temporary abdominal closure.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

Hypertonic saline infusion does not improve the chance of primary fascial closure after damage control laparotomy: a randomized controlled trial

BackgroundPrevious observational studies showed higher rates of abdominal wall closure with the use of hypertonic saline in trauma patients with abdominal injuries. However, no randomized controlled trials have been performed on this matter. This double-blind randomized clinical trial assessed the effect of 3% hypertonic saline (HS) solution on primary fascial closure and the timing of abdominal wall closure among patients who underwent damage control laparotomy for bleeding control.MethodsDouble-blind randomized clinical trial. Patients with abdominal injuries requiring damage control laparotomy (DCL) were randomly allocated to receive a 72-h infusion (rate: 50 mL/h) of 3% HS or 0.9 N isotonic saline (NS) after the index DCL. The primary endpoint was the proportion of patients with abdominal wall closure in the first seven days after the index DCL.ResultsThe study was suspended in the first interim analysis because of futility. A total of 52 patients were included. Of these, 27 and 25 were randomly allocated to NS and HS, respectively. There were no significant differences in the rates of abdominal wall closure between groups (HS: 19 [79.2%] vs. NS: 17 [70.8%]; p = 0.71). In contrast, significantly higher hypernatremia rates were observed in the HS group (HS: 11 [44%] vs. NS: 1 [3.7%]; p < 0.001).ConclusionThis double-blind randomized clinical trial showed no benefit of HS solution in primary fascial closure rates. Patients randomized to HS had higher sodium concentrations after the first day and were more likely to present hypernatremia. We do not recommend using HS in patients undergoing damage control laparotomy.Trial registration The trial protocol was registered in clinicaltrials.gov (identifier: NCT02542241).

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

P109 MANAGEMENT OF THE OPEN ABDOMEN WITH COMBINED THERAPIES. HOW TO AVOID VENTRAL HERNIAS AND BE ABLE TO PERFORM THE REPAIR OF THE ABDOMINAL WALL IN A DEFINITIVE WAY

Abstract Aim To demonstrate that in patients with abdominal sepsis, delayed primary fascial closure and definitive abdominal wall repair can be achieved, in the same hospitalization, using combined therapies, which reduces the percentage of ventral hernias. Material and Methods Medical records, tomography images and outpatient controls of 9 patients were reviewed, which required open abdomen management for abdominal sepsis using negative pressure therapy combined with a dynamic fascial mesh traction, from February 2020 until May 2021. Results 9 patients (2 men and 7 women), all Grade 2C open abdomen according to Björck clasification, with a median age of 43 years (25-71). The median time therapy was 29±3 days. The primary fascial closure rate was 100% (n = 9), 77.8% (n = 7) underwent a definitive repair of the abdominal wall with absorbable synthetic mesh in the same hospitalization, while 22.2% (n = 2) did not, due to being cancer patients. The mortality rate was 11.1% (n = 1) due to pneumonia and the fistula rate was 11.1% (n = 1). None developed an incisional hernia at the one-year follow-up. Conclusions The combination of negative pressure therapy with dynamic fascial mesh traction, in the management of the open abdomen, allows us to achieve a 100% delayed primary fascial closure, avoiding ventral hernia. In the same hospitalization, while the patient leaves the critical stage, we can achieve a definitive repair of the abdominal wall using absorbable synthetic meshes returning the biomechanics to the abdominal wall, improving the quality of life of these patients.

P110 MANAGEMENT OF THE OPEN ABDOMEN WITH COMBINED THERAPIES. HOW TO AVOID THE VENTRAL HERNIA AND BE ABLE TO PERFORM THE REPAIR OF THE ABDOMINAL WALL IN A DEFINITIVE WAY

Abstract Aim To demonstrate that in patients with abdominal sepsis, delayed primary fascial closure and definitive abdominal wall repair can be achieved, in the same hospitalization, using combined therapies, which reduces the percentage of ventral hernias. Material and Methods Medical records, tomography images and outpatient controls of 9 patients were reviewed, which required open abdomen management for abdominal sepsis using negative pressure therapy combined with a dynamic fascial mesh traction, from February 2020 until May 2021. Results 9 patients (2 men and 7 women), all Grade 2C open abdomen according to Björck clasification, with a median age of 43 years (25-71). The median time therapy was 29±3 days. The primary fascial closure rate was 100% (n = 9), 77.8% (n = 7) underwent a definitive repair of the abdominal wall with absorbable synthetic mesh in the same hospitalization, while 22.2% (n = 2) did not, due to being cancer patients. The mortality rate was 11.1% (n = 1) due to pneumonia and the fistula rate was 11.1% (n = 1). None developed an incisional hernia at the one-year follow-up. Conclusions The combination of negative pressure therapy with dynamic fascial mesh traction, in the management of the open abdomen, allows us to achieve a 100% delayed primary fascial closure, avoiding ventral hernia. In the same hospitalization, while the patient leaves the critical stage, we can achieve a definitive repair of the abdominal wall using absorbable synthetic meshes returning the biomechanics to the abdominal wall, improving the quality of life of these patients.

Open Abdomen after Two Trauma Laparotomies: Do Diuretics Help?

Data are lacking regarding the use of diuretics in facilitating closure of the open abdomen (OA). For patients with an OA after 2 laparotomies, we hypothesized that diuretic use was associated with a higher rate of primary fascial closure than no diuretic use. A retrospective review of patients with trauma laparotomies over 7years was performed. Primary fascial closure (PFC) was defined as apposition of fascial edges without interposition mesh. Of 321 patients, 30 (9%) remained with an OA after 2 laparotomies. Prior to the third laparotomy, median cumulative fluid balance was +12.6 L. Thirteen (43%) received diuretics. Primary fascial closure rates were similar for diuretic use vs no diuretic (38% vs 59%, P = .46). Primary fascial closure was not associated with age (P = .2), gender (P = 0.7), cumulative fluid balance (P = .3), or units of packed cells (P = .4). Diuretic use in trauma patients with an OA after 2 laparotomies was not associated with successful PFC.

EP.FRI.337 Active management of the open abdomen in non-trauma catastrophes, including use of negative pressure wound therapy, is associated with high primary fascial closure rates

Abstract Aims Deliberate use of the open abdomen (OA) following emergency laparotomy (EL) may be life-saving in the non-trauma abdominal catastrophe (NTAC) and damage control surgery (DCS) can reduce the risk of abdominal compartment syndrome in compromised patients. Controversy exists over optimum management of the abdominal wall. An audit was undertaken of negative pressure wound therapy (NPWT) in OA patients. Methods All patients who underwent OA management of NTAC from 1st Jan 2019 to 31st Dec 2020 were identified. Data on patient demographics, indication for OA and clinical outcomes were analysed. Results Eighteen patients (median age 65.5 years; M:F9 each) underwent OA following EL. The indications were: bowel ischaemia (8), intra-abdominal sepsis (5), grossly distended bowel (3) and intra-abdominal haemorrhage (2). In all cases, ABTHERATM dressings (KCI/Acelity) were used. Mean ICU stay was 7.4 days (range 1-15) and mean hospital stay 33 days (range 2-61). Four patients died, 3 within 24 hours of initial EL. Relook laparotomy was performed within 48 hours in the remaining 15 patients; 3 patients required 2 relooks and 1 patient had three. Primary fascial closure (PFC) was achieved within five days in 13/14 (93%) survivors. Eight patients had SSIs with 2 intra-abdominal collections and all were treated conservatively. One patient developed an enterocutaneous fistula. Conclusions The use of commercially-available NPWT dressings in OA management is associated with high PFC rates within one week of initial EL. This practice is consistent with World Society of Emergency Surgery guidance recommending planned re-look laparotomy within 48 hours.

Correlation between surgical site infection and obesity after exploratory laparotomy in trauma patients

Abstract Background Obesity has become a major contributor to the global burden of chronic disease and disability. Understanding the effect of obesity on the incidence of wound infections and other wound complications remains incomplete despite considerable attention to both the growing ‘‘epidemic’’ of obesity and the frequent occurrence of surgical site infection (SSI) after surgical procedures. Damage-control laparotomy specifically has been associated with a higher rate of infectious complications and a lower rate of primary fascial closure in obese patients. Aim of the work The aim of the study is to evaluate the correlation between obesity and surgical site infection (SSI) in patients undergoing exploratory laparotomy after abdominal trauma. Patients and methods A retrospective study performed on obese patients of both genders aged between 18 and 60 years old undergoing exploratory laparotomy after abdominal trauma at the surgery departments of Ain Shams University Hospitals, Al-Bank Al-Ahly Hospital, Al-Mataria Hospital and Al-Salam Hospital, Cairo, Egypt for two years (1st of January 2018 to 1st of January 2020). Patients with infected wounds, receiving antibiotic therapy at the time of injury, those with a known immunodeficiency, who died within 48 hours after injury, who had sustained burn injuries, who underwent surgery at another institution before admission to our hospital were excluded. The rate of 30-day SSI post-operatively among obese and non-obese patients were compared. Statistical analysis was also done. Results Out of 782 patients, only 480 of those patients for whom BMI data were available, 360 (75%) were males and 120 (25%) were females. Out of the 480 patients: 168 patients had BMI more than 30; 114 patients (67.8%) had SSI (P &amp;lt; 0.05), 312 patients had BMI less than 30; 61 patients (19.5%) had SSI. All of the included patients were fulfilling the inclusion and the exclusion criteria. On multivariate analysis, obesity was the strongest predictor of SSI (odds ratio = 1.59; 95% confidence interval, 1.32-1.91) after adjustment for sex and age. Obese patients with SSI compared with the non-obese had longer hospital stays (mean, 9.5 vs 8.1 days, respectively; P &amp;lt; .001) and markedly higher rates of hospital readmission (27.1% vs 6.5%, respectively; P &amp;lt; .001). Conclusion Obesity is considered as one of the risk factors in causing surgical site infection. Thus, this study showed the relation of BMI and obesity with surgical site infection in case of exploratory laparotomy after abdominal trauma.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial

BackgroundFluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.MethodsA pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan–Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built.ResultsA total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications.ConclusionAmong postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

Closing Difficult Laparostomies With the Aid of Botulinum Toxin A: An Audit of 12 Cases.

BackgroundObtaining primary fascial closure following laparostomy can be difficult; especially with fascial retraction or large pre-existing fascial defects. Various techniques have been described in the literature which attempt to improve reapproximation rates. Most techniques described comprise the use of adjuncts including Bogota Bags, negative pressure dressings, anchor devices and various types of mesh. While most techniques achieve primary closure, less achieve primary fascial closure. Botulinum toxin A (BTA) has proven a beneficial adjunct in repairing large ventral herniae. While there is limited research in the use of BTA in the acute setting of laparostomy closure its benefits in elective repair may prove transferrable with the appropriate protocols.MethodThis retrospective study reviewed 12 cases where BTA was used as an adjunct to close laparostomy. It compared primary fascial closure rates to historical controls at the same institution. ResultsSeven males and five females. Median age 63.5 years. Median BMI 32.95. Median days from BTA injection to primary fascial closure 9.5. Median 18 days from primary operation to primary fascial closure. 83% of patients achieved primary fascial closure with the rest achieving partial closure with the residual defect bridged with biological mesh. At the time of review, there was only one resulting ventral hernia in a patient with a BMI of 51.7 at the time of surgery.ConclusionWhile BTA does not guarantee primary fascial closure in laparostomy this study would indicate it improves primary fascial closure rates and can be added to any other existing method for managing the open abdomen. As BTA can be injected via the open abdomen or with ultrasound guidance it can be performed by any appropriately trained surgeon, anaesthetist or radiologist making its use widely achievable. Retrospectively registered.

New non-invasive device to promote primary closure of the fascia and prevent loss of domain in the open abdomen: a pilot study

BackgroundPrimary closure of the fascia at the conclusion of a stage laparotomy can be a challenging task. Current techniques to medialize the fascial edges in open abdomens entail several trips...

Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure.

The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. Therapeutic study, level IV.

Vacuum-Assisted Wound Closure with Mesh-Mediated Fascial Traction Achieves Better Outcomes than Vacuum-Assisted Wound Closure Alone: A Comparative Study

BackgroundOpen abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur.MethodsNon-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta “modified” technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction.ResultsNinety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the “other reasons” group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002).ConclusionsThe survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.