eMedicine Specialties > General Surgery > Abdomen

Temporary Abdominal Closure Techniques

Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Critical Care Units, Trinity Mother Francis Health System
Contributor Information and Disclosures

Updated: Aug 12, 2008

Basic Principles

Trauma Damage-Control Celiotomy: Context and Perspective

Over the past 2 decades, the way in which trauma surgeons approach a person with multiple severe injuries has undergone an evolution. Trauma surgeons no longer attempt to fix it all during the initial operation. Literature reflects the cumulative experience of trauma surgeons, confirming the following principles: conservative operative techniques and short operative times, even when all organ repairs have not been completed, increase survival in civilian and military patients with multiple trauma. These principles hold true for all affected regions of the body, including the abdominal cavity and its contents, which is the focus of this article.

Damage-control principles are typically applied to patients who have multiple severe injuries. These patients are commonly hypothermic, acidotic, and coagulopathic. Under these circumstances, a deliberate, staged, reoperative approach is optimal.

The 3 commonly recognized stages of damage-control celiotomy are as follows:

1. Limited operative intervention for control of hemorrhage and contamination and for prevention of further injury
2. Continuation of resuscitation in the surgical ICU setting
3. Reoperation for definitive repair, a second look for a possible missed injury or delayed manifestation of an organ injury, and formal closure of the incision if possible

Those who may require damage-control celiotomy are patients who are hypotensive (BP <90 mm Hg) with the following abdominal or pelvic traumatic injuries:

• Penetrating abdominal injury
• Blunt abdominal injury with intraperitoneal fluid noted on surgeon-performed focused abdominal sonography for trauma (FAST) or gross blood on surgeon-performed diagnostic peritoneal paracentesis (also known as DP tap)
• Closed pelvic fracture with intraperitoneal fluid noted on surgeon-performed FAST or gross blood on surgeon-performed DP tap
• Open pelvic fracture
• Penetrating or blunt abdominal injury with bowel edema, hypothermia, or acidosis
• Delayed injury with established severe intra-abdominal infection

Although the organ-specific operative techniques are beyond the scope of this article, patients who undergo damage-control celiotomy are at risk for the development of multiple, life-threatening complications in the early postoperative period. The chief complication in the postoperative period is abdominal compartment syndrome (ACS).

Abdominal Compartment Syndrome

Background

ACS is a condition that elevates intra-abdominal pressure (IAP), adversely affects end-organ physiology, and disrupts patient homeostasis. ACS was described as early as the 1800s; however, only in the last 10-15 years has ACS been consistently recognized in the surgical and medical patient population. The reported incidence of ACS is 10-15%, and, if left untreated, it is uniformly fatal. With diagnosis and treatment, the mortality rate is 46-66%.

Causes

ACS is most often encountered during the early postoperative course and commonly discovered in patients who have undergone damage-control celiotomy with primary fascial closure and intra-abdominal packing for coagulopathy.

ACS may be found in people with the following conditions:

• Massive ascites/massive intraperitoneal hemorrhage
• Ileus
• Hemorrhagic pancreatitis
• Pregnancy
• Ovarian cancer
• Ruptured abdominal aortic aneurysm
• Abdominal burns
• Liver transplantation
• Polytrauma

The aforementioned conditions may lead to decreased blood flow to the abdominal wall and organs. This derangement of cellular perfusion initiates cytokine release, destabilizing cell membranes and ultimately leading to cellular edema and cell death if not reversed. This process is clinically manifested by organ swelling, leading to secondary pressure effects on the respiratory, cardiovascular, and central nervous system when the IAP rises above a critical level. See Media files 2-3.

Additional causes of IAP include the following:

• Free intraperitoneal blood
• Capillary leak syndrome
• Visceral edema
• Ischemia-reperfusion injury
• Mesenteric venous ligation/thrombosis
• Positive pressure ventilation/positive end expiratory pressure
• Application of military antishock garment trousers

The aforementioned conditions either directly or indirectly increase IAP in patients who are critically ill with ACS.

Pathophysiologic Changes

Cerebral Changes

Elevated IAP results in elevated intrathoracic pressure, leading to elevated central venous pressure and causing an increase in intracerebral pressure. The Monroe-Kellie doctrine states that this increase in intracranial blood volume results in elevation of intracranial pressure. During resuscitation and vascular volume expansion, intracerebral pressure and cerebral perfusion pressure may increase transiently; however, these pressures will ultimately fall if abdominal pressure continues to increase. Due to a concomitant decrease in caval venous return, this will ultimately cause a fall in cardiac output that will negatively impact intracerebral perfusion pressure.

This fall in ICP may be transient as well if intrathoracic pressure increases due to increased IAP. This can cause increased intracerebral pressure due to increased internal jugular/superior caval venous pressure.

In a porcine model, Bloomfield et al have demonstrated significant effects of elevated IAP upon the central nervous system (CNS); elevated IAP resulted in increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP).¹ The mechanism is a functional obstruction of jugular venous drainage due to the elevated pleural pressures and CVP. As previously mentioned, the increase in intracranial blood volume results in elevation of the ICP (the Monroe-Kellie doctrine). Abdominal decompression has resulted in a return toward baseline for ICP and an improvement in the CPP. Head injury and concomitant abdominal injury is a frequently encountered clinical scenario. This observation (confirmed clinically) is important. Decompressive celiotomy in patients such as these has resulted in a dramatic reduction in ICP. Abdominal decompression in these patients has resulted in a return toward baseline for ICP and an improvement in CPP.

Ophthalmologic Changes

Increased IAP can cause the rupture of retinal capillaries, resulting in the sudden onset of decreased central vision (Valsalva retinopathy). Valsalva retinopathy has been described in a number of settings in which a sudden increase in IAP or intrathoracic pressure has occurred. The retinal hemorrhage usually resolves within days to months, and no specific treatment is necessary. If a patient with ACS develops visual changes, Valsalva retinopathy should be considered and an appropriate ophthalmic examination should be performed.

Cardiovascular Changes

Increased IAP may cause the following problems:

• Compression of splanchnic capacitance vessels (When IAP is at least or between 10-15 mm Hg, compression of splanchnic capacitance vessels may occur, causing temporary auto transfusion [approximately 250-500 mL].)
• Decreased cardiac output
• Increased heart rate
• Unchanged mean arterial pressure
• Artificial elevation of capillary wedge pressures and central venous pressure

An increase of IAP to greater than 15 mm Hg results in the following:

• Increased systemic vascular resistance
• Decreased venous return
• Decreased stroke volume
• Decreased cardiac output
• Decreased BP
• Compensatory tachycardia

Pulmonary Changes

ACS may lead to pulmonary complications.

• Diaphragm is forced cephalad.
• Chest wall expansion is restricted.
• Dynamic and static compliance decrease.
• Peak and plateau pressures increase.
• Physiologic dead space and intrapulmonary shunting increase.
• Combined respiratory/metabolic acidosis is a common finding.

Renal Changes

ACS can lead to acute renal failure.

• Oliguria occurs when IAP is greater than 20 mm Hg.
• Anuria occurs when IAP is greater than 30 mm Hg.

Increased IAP causes the following:

• Increased renal parenchymal pressure
• Direct pressure on renal veins
• Shunting of blood from renal cortex to the medulla
• Decreased renal blood flow/glomerular filtration rate

Ureteral obstruction does not occur with increased IAP.

Increased IAP up-regulates the juxtaglomerular apparatus, causing the following:

• Rennin, angiotensin (I and II)
• Aldosterone, vasopressin

Abdominal Wall/Viscera Changes

Increased IAP results in the following:

• Markedly reduced blood flow to the abdominal wall (IAP >40 mm Hg = blood flow 20% of normal. IAP of 30-40 mm Hg causes blood flow in celiac, hepatic, and mesenteric arteries and in portal and mesenteric veins.)
• Decreased perfusion of every intra-abdominal organ, except the adrenal gland
• Severely decreased splanchnic flow with concomitant decreased cardiac output
• Ischemia in the gastric, duodenal, and intestinal mucosa

Monitoring and Measuring IAP

The most direct and accurate measurements of IAP are via a cannula placed percutaneously into the peritoneum.

Indirect IAP is monitored through transfemoraly placed inferior-caval venous lines, nasogastric tubes, rectal tubes, and, most commonly, Foley catheters. The most accurate and simple way to determine the IAP is indirectly by measurement of the bladder pressure using a Foley catheter. The bladder pressure is essentially equivalent to the IAP.

To measure the bladder pressure, the following steps must be completed:

• Inject 50-100 mL of sterile saline into the Foley catheter via the aspiration port.
• Cross-clamp the sterile tubing of the urinary drainage bag just distal to the culture aspiration port.
• Connect the end of the drainage bag tubing to the indwelling Foley catheter.
• Release the clamp just enough to allow the tubing proximal to the clamp to fill with fluid from the bladder.
• Reapply the clamp.
• Y-connect a pressure transducer to the drainage bag via the culture aspiration port of the tubing using a 16-gauge needle.
• Determine the IAP from the transducer using the top of the symphysis pubis bone as the zero point with the patient in the supine position. (A handheld manometer connected to the Foley catheter via the column of fluid in the tubing may be used instead of a transducer.) See Media file 4.

Release of ACS

Morris et al and other investigators have noted that the sudden release of ACS may lead to an ischemia-reperfusion injury, causing acidosis, vasodilatation, cardiac dysfunction, and cardiac arrest.² Morris et al have also recommended that, prior to the release of the abdominal cavity, the patient should be preloaded with 2 L of 0.45% normal saline, 50 g/L of mannitol, and 100 mEq of sodium bicarbonate crystalloid solution.² Vasodilators, such as dobutamine or phosphodiesterase inhibitors, may also be beneficial.

Prevention and Treatment of ACS

Leaving the abdominal incision open during surgery prevents ACS. ACS more commonly presents in the early postoperative period (24-72 h); however, it can present later than this time frame.

Temporary Abdominal Closure

The techniques of temporary abdominal closure (TAC) are varied, each with its own advantages and disadvantages. All techniques face a similar challenge: the management of the open abdomen. No prospective randomized studies are available to compare the effectiveness of these various techniques or to validate the concept of the open abdomen protocol. However, retrospective data in the form of case and cohort studies do exist. These data consistently show that maintaining the open abdomen protocol in high-risk groups has been effective in reducing mortality in a clinical setting.

The benefits of TAC include the following:

• Allows viscera to expand and prevent abdominal hypertension
• Allows the patient to return to the critical care setting for further resuscitation and restoration of physiologic reserve, tissue perfusion, normothermia, correction of acid base balance, and normalization of coagulation
• Allows the trauma team to further assess the patient and to define other potential life- or limb-threatening injuries

Strategy Pearls

• Damage-control celiotomy: The trauma surgeon must decide to convert to a limited procedure within 5 minutes of starting the operative procedure. This decision is based on the initial physiological state of the patient and a rapid initial assessment of the internal injuries. The surgeon must not wait for evidence of metabolic failure to manifest. This decision is imperative to the patient's survival. The intent of damage-control surgery is to accomplish the following:
  • Control hemorrhage
  • Prevent contamination
  • Avoid further injury
• TAC: The trauma surgeon should be familiar with different TAC techniques, including their indications, their advantages, and their disadvantages.
• Reevaluate in 24-36 hours: The trauma surgeon must maintain a low index of suspicion for delayed or occult injuries, particularly in patients with blunt polytrauma.
• Spare the fascia: Repeated attempts at TAC that use the aponeurotic fascia cause recurrent direct and indirect (ischemic) tissue damage. This damage degrades the native tissue, decreasing its tensile and elastic capacity, and increases the potential for delayed incisional hernia.
• Attempt definitive closure within 7-10 days: Loss of abdominal domain and lateral retraction of the recti and aponeurotic edges tend to be maximal after this time frame.

Types of Temporary Abdominal Closures

Towel Clipping the Skin Edges

One of the simplest and fastest forms of temporary closure of the abdomen is towel clipping the skin edges. Towel clips are placed 1 cm apart and 1 cm away from each side of the skin edge. Up to 30 standard perforating towel clips may be required to close an incision. The incision may then be covered with an adherent plastic drape (eg, Vi-Drape, Steri-Drape). Covering the incision decreases manipulation of the towel clips while transferring the patient. This technique may be used in the rapid temporary closure of thoracic or groin incisions in patients with trauma injuries who are in unstable condition and in patients undergoing general surgery. See Media files 5-6.

Open Packing of the Abdomen

Open packing of the abdomen, a form of TAC, has been used for more than 2 decades at the Detroit Receiving Hospital. The abdominal wall defect and the exposed viscera are covered with rayon cloth. This rayon cloth is then covered with gauze dressing. Widely spaced, retention-type sutures are placed, encompassing all layers of the abdominal wall, and tied above the gauze packing. As bowel edema diminishes, the gauze dressing is removed and the retention sutures are gradually tightened until the incision can be closed. Bender et al reported successful fascial closure in 15 of 17 patients who survived beyond the initial 24 hours.³

Zipper Closures

First described by Leguit in 1982, zipper closures were popularized by Stone et al in their open abdomen approach for pancreatic abscess.^4,5 See Media file 7.

Wittmann Patch

The approach using the Wittmann Patch (STARSURGICAL, Inc, Burlington, Wis) was first reported by Teichman et al, Wittmann et al, and Aprahamian et al.^6,7,8 As bowel edema resolves, the excess Velcro-biocompatible patch material is removed and the fascial edges are approximated. Tension closure is accomplished by the adherence of the overlapping Velcro-like sheets.

The major advantage of this approach is the ease of access for repeated surgical interventions and the capacity to apply tension to the midline fascia, which helps prevent lateral retraction of the aponeurotic edges, allowing for definitive delayed primary closure in most cases (see Media files 8-10).

Synthetic Mesh Closure

Polytetrafluoroethylene Closure

The polytetrafluoroethylene (PTFE) 2-mm biocompatible prosthetic abdominal wall graft is strong and watertight and creates a bed for granulation tissue, which may be covered with a split-thickness skin graft when the prosthesis is removed. PTFE is expensive, and similar outcomes may be achieved with less costly absorbable mesh or silastic (silo) dressing changes. See Media file 11.

Marlex Mesh (Polypropylene)

Several authors have reported the use of marlex mesh in the setting of a contaminated wound (eg, fasciitis, intra-abdominal sepsis). Healing has been reported, even in wounds where frank purulent discharge is present. Although short-term successes have occurred, numerous long-term complications have been reported with marlex mesh. These complications include increased incidence of postoperative wound sepsis, increased incidence of enteric fistulas, and significant decreased survivability of split-thickness skin grafts. The experience recorded by Voyles et al, Stone et al, and Jones et al strongly suggests that permanent rigid-type prosthetic mesh should not be inserted in the setting of abdominal wall defects with associated contamination from the gastrointestinal tract secondary to trauma, intra-abdominal sepsis, or necrotizing infections involving the abdominal wall.^9,5,10 See Media file 12.

Absorbable Mesh

Synthetic absorbable mesh has been used extensively in TACs. Polyglactin (Vicryl) and polyglycolic acid (Dexon) have been in the surgical armamentarium for approximately 25 years. This type of prosthetic mesh implant has been used in the repair of traumatic liver, splenic, and renal injuries and in pelvic floor repair in the setting of abdominal peroneal resection of the rectum. Although early burst strength (at 8 wk) is comparable to that of permanent mesh, as the mesh is absorbed (at 10-12 wk), hernias inevitably develop in most patients.

As described by Bender et al, the mesh is applied loosely over the abdominal contents and then covered with fine mesh gauze packing, maintaining the bowel below the absorbable mesh and within the abdominal contents.³ This may decrease bowel wall distention, thinning, and subsequent desiccation, which may decrease the incidence of enterocutaneous fistula.

The choice between the use of either Vicryl mesh or Dexon mesh is primarily determined by the surgeon's preference. However, Brasel et al have reported some advantage in the use of Dexon mesh.¹¹ This mesh has wider interstices that Brasel et al believe may allow for more efficient drainage of intra-abdominal fluid and, thus, may decrease potential delayed complications (eg, abdominal distention, ileus, abscess).¹¹ See Media files 13-14.

Silastic (Plastic) Closures

A presterilized (gas), soft 3-L plastic cystoscopy fluid irrigation bag is cut and shaped to cover the abdominal incision and extruded viscera. This bag is either stapled or sutured to the skin edges of the wound with a standard (wide) skin stapling device or monofilament, nonabsorbable suture, thus preserving the fascia. Sterile, antibiotic-soaked towels (using Kantrex) may be applied over the silo, which is then covered with an iodine-impregnated adhesive plastic drape.

An alternative is to apply sterile towels over the silo and to secure them with a Montgomery abdominal wound binder, being careful not to create increased abdominal pressure while securing the dressing. The wound is inspected and the dressing is changed every 24 hours (or as needed). Intravenous (IV)/cystoscopy bag silos may be replaced in the ICU setting using standard sterile surgical technique and equipment. This technique is a variation of the silon (silo) closure used for the repair of gastroschisis and omphalocele. In hospitals in Colombia, South America, IV bag closure (also known as the Bogotá Bag) has been used extensively and successfully. See Media files 15-18.

Silastic closures are fast and effective temporary closure modes and have some significant cost benefits, as reported by Fernandez, Norwood, and Roettger, et al.¹² See Media files 19-21.

Methods of Definitive Abdominal Wall Reconstruction

Primary Delayed Fascial Closure

Primary delayed facial closure (between 5-10 d) may be attempted if the abdominal cavity can be closed without significant elevation of IAP. A high index of suspicion for recurrent ACS must be maintained. Elevated peak airway pressure or plateau pressures (>30 mm Hg), increased urinary catheter bladder pressures (>25 mm Hg), and accompanying deteriorating clinical parameters (eg, abdominal distension, decreased urine output) should prompt a careful reevaluation of the patient and consideration for decompressive celiotomy.

Fabian Protocol

Fabian et al have published their experience with their eponymous protocol.¹³ The patients are subsequently brought back for definitive reconstruction, usually within 6-12 months.

• Stage I - Prosthesis placement (polyglactin 910 [Vicryl] or polyglycolic acid [Dexon])
• Stage II - Mesh removal or allowance of granulation tissue to cover the mesh
• Stage III - Split-thickness skin graft applied when granulation tissue is adequate
• Stage IV - Definitive abdominal wall reconstruction (6 mo to 1 y)

See Media files 22-23.

Closure of Abdominal Wall (Creation of Ventral Hernia)

Sure-Closure System

The Sure-Closure Skin Stretching System is a patented, disposable, molded device made of stainless steel and plastic parts and used to provide sufficient skin in advance of closures for fasciotomies and trauma repairs of various types, including closure of the open abdomen. Use of the Sure-Closure Skin Stretching System can minimize the need for more extensive secondary wound closure techniques. The device is attached intraoperatively by first inserting needles parallel to the wound edges. These needles serve to distribute tension forces over the length of the incision. Gauges on the device monitor the applied forces, ensuring a safe and permanent skin stretching. The device allows the surgeon to take advantage of the inherent viscoelastic properties of the skin by mechanically stretching the skin and allowing it to relax under tension; the surgeon then has sufficient skin to affect a suitable closure.

The device comes in sizes of 50 mm and 75 mm. The 50-mm device is designed for smaller skin defects with uneven surfaces, while the 75-mm device is designed for larger skin defects with relatively flat, even surfaces.

The Sure-Closure Skin Stretching System was first described by Hirshowitz et al and has been used extensively in the plastic, orthopedic, cancer, general surgical, and trauma patient population.¹⁴

In a comparative clinical study of the Sure-Closure Skin Stretching System with more conventional wound closure techniques, Narayanan et al found that, in their study cohort, they were able to demonstrate a cost reduction trend (P <.05).¹⁵ In their cost analysis, they included the costs of the following: operating room time, operating room supplies, anesthesia, monitoring, recovery room time, wound care supplies, pharmacy charges, and hospital room and board.¹⁵ They also noted above average healing of the wounds at 1 month and 3 months, with better cosmesis than comparable conventionally closed wounds.¹⁵ This experience has been confirmed by other reported clinical studies.

Using the Sure-Closure device potentially offers the following:

• Relatively fast closure, usually in 30-60 minutes, with healthy skin and subcutaneous tissue
• Cosmetically superior appearance when compared with that of split-thickness skin grafts
• Decreased need for future scar reduction
• Shorter hospital stay
• Bedside application
• Reduced overall cost

By using the Sure-Closure Skin Stretching System, the surgeon is able to close most cases of skin defects that would more commonly require secondary wound closure techniques, such as myocutaneous flaps or skin grafts.

Sure-Closure System Application

The Sure-Closure device accomplishes skin stretching by using 2 intradermal needles in conjunction with a tension rod that connects 2 self-aligning U-arms. The device contains a graduated tension indicator that registers after 1 kg of force is applied. The Sure-Closure system has a built-in safety clutch mechanism that prevents excessive tension by limiting the total force to 3 kg. The device is used in the setting of the following:

• Fasciotomy closures
• Skin cancer resections
• Scar revisions
• Closure of traumatic wounds (including open abdomen)
• Delayed primary closures

See Media files 24-27.

Vacuum Assisted Closure^®

Fascial Vacuum Assisted Closure^® (V.A.C.^®) therapy (Kinetic Concepts, Inc, San Antonio, Tex) is a relatively new concept in the management of the open abdomen that allows for fascial closure as long as 1 month after the initial laparotomy. This avoids the need and attendant operative risks incurred with abdominal wall reconstruction in the future.

The main functional component of V.A.C.^® is the use of a nonadherent, polyethylene sheet to cover the exposed viscera and the placement of a polyurethane sponge under controlled negative pressure. The polyethylene sheet helps prevent visceral-abdominal wall adhesions that inhibit movement of the abdominal wall. The polyurethane sponge, when placed under negative pressure (suction), provides the countertraction required to inhibit abdominal wall retraction and creates an environment where approximation of the abdominal wall may occur.

Miller et al reported excellent results in the use of this system.¹⁶ They reviewed 646 patients with trauma injuries who underwent laparotomies, of which 148 patients required management of an open abdomen over a 5-year period (1996-2001). Of these 148 patients, 85 survived to closure. Patients treated with the open abdomen technique who were unable to undergo fascial closure by early postoperative period (POD 9) were treated with a fascial V.A.C.^® technique. Patients treated with planned hernia (HERNIA group, Fabian protocol) were compared with those undergoing fascial closure 9 or more days after the initial laparotomy (LATE group). All of the patients in the LATE group underwent fascial V.A.C.^® therapy.

Fifty-nine patients underwent fascial closure, 37 patients before postoperative day 9 and 22 patients on or after postoperative day 9. Mean time to fascial closure in the LATE group was 21 days (range, 9-49 d). Injury severity scores, admissions base deficit, number of fistulas, number of operations, and mortality were similar between the HERNIA group and the LATE group. The incidence of abscess, wound dehiscence, and fistula in the LATE group and the HERNIA group were nearly identical. In both groups, the differences were not significant with respect to time in the intensive care unit, total hospital stay, incidence of acute respiratory distress syndrome, multiple organ failure, and death. The fascial closure rate (71.08%) reported compares favorably with the results previously published by Barker et al in their large review of fascial closure rates using the standard vacuum pack technique; the fascial closure rate in the previous study was 70%.¹⁷

Case Study

In the following case study, Dennis E. Weiland, MD, and John M. Stein, MD (Scottsdale Health Care-Osborn, Scottsdale, Arizona), illustrate the abdominal V.A.C.^® capabilities.

A 25-year-old man was admitted with 2 gunshot wounds to the abdomen. Repair of liver laceration with abdominal washout was accomplished (see Media file 28). Postoperatively, the patient developed severe abdominal distention and respiratory distress. He required a decompression laparotomy for ACS. He was placed on suction drainage for 2 days. V.A.C.^® therapy was initiated on day 3. The wound was closed by delayed primary closure 12 days after the initial decompression laparotomy.

The diagnosis was ACS secondary to a gunshot wound to the abdomen.

The prognosis was excellent once the skin was closed over the fascia.

V.A.C.^® therapy was as follows:

• 8/25/01 - Laparotomy, cholecystectomy, and repair of liver laceration with drainage
• 8/28/01 - Laparotomy, abdominal decompression with drainage tubes and plastic abdominal dressings, and release of abdominal adhesions
• 8/30/01 - Removal of decompressive dressings and application of V.A.C.^® therapy (see Media files 29-30)
• 9/05/01 - Removal of V.A.C.^® system, partial closure of the wound, and reapplication of V.A.C.^® therapy
• 9/09/01 - Removal of V.A.C.^® system and delayed primary closure of the abdominal wound

After discharge, the patient continued to have follow-up visits in the wound clinic.

The open skin over the fascia will be closed either by contraction or by secondary closure. The original wound measured 30 cm X 15 cm at the time of the decompression laparotomy. The wound now measures 20 cm X 3-4 cm. See Media file 31.

ACS and Abdominal Hypertension Not Present, Patient Requires Reoperation

Intraperitoneal Silo

Among the trauma patient population, the more common indications for reoperations include bleeding, infection, presence of ACS, and reassessment of the abdomen for bowel viability or possible missed or delayed injury. The management of the severely contaminated abdomen, severe peritonitis, and intra-abdominal sepsis by an open approach has been discussed in the literature. First proposed by Steinberg, the intraperitoneal silo approach has been applied in several settings and surgical patient groups.¹⁸

Fernandez et al described a technique that evolved from their experience with the use of the silastic silo closure for patients with ACS.¹⁹ They used the extraperitoneal silo in the intraperitoneal (IP) position in selected patients who did not have ACS and whose injuries would benefit from a second look procedure. Their patient population was summarized (see Media file 32). The approximate total hospital cost of the silo was $15.94 with an approximate patient cost of $57 (see Media file 33). Fernandez et al reported one death in the group (patient 3).¹⁹ They also reported one IP silo failure (patient 1) that developed a small bowel dehiscence. This patient underwent IP silo replacement in the ICU.

Placement of IP Silo

The technique of IP silo placement is simple and straightforward.

• A presterilized (gas), soft, 3-L, plastic, cystoscopy fluid irrigation bag is commonly used.
• A small epigastric slit incision is made at the cephalad portion of the silo. This incision allows placement of the IP silo around the falciform ligament and round ligament of the liver (if still present after initial damage-control celiotomy) without causing injury.
• The inferior corners and lateral edges of the silo are gently tucked into the right and left lower abdominal quadrants and the lateral pericolic gutters, respectively.
• Finally, the skin is approximated with skin clips, and a sterile dressing is applied.

See Media files 34-42.

Conclusion

Several techniques in the surgical armamentarium are available to affect temporary closure of the open abdomen. One of the least expensive and rapid is the gas sterilized, 3-L, plastic, cystoscopy irrigation bag. This bag is commonly available, and its application is straightforward. In the author's opinion, it is the preferred initial method of temporary closure, particularly in patients who may require multiple reoperative interventions.

Of the techniques described within this article, the Sure-Closure Skin Stretching System has the potential to obviate split-thickness skin grafting in the setting of the open abdomen, particularly if approximation of the skin can be achieved within the first 7-10 days. This Sure-Closure device facilitates the creation of a ventral hernia that may be repaired at a later date in an elective fashion.

The Wittmann Patch and the abdominal V.A.C.^® are inherently designed to affect not only a temporary closure but also a permanent fascial closure in most patients. The relative cost of these devices is small in comparison to the potentially decreased associated cost and morbidity of a second, planned abdominal wall reconstructive procedure commonly required in this patient population. The Wittmann Patch and the abdominal V.A.C.^® system represent major advancements in surgical theory and are a welcome addition to the extant surgical doctrine.

Multimedia

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Media file 1: Damage-control celiotomy in progress.

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Media file 2: Edematous eviscerated bowel in a patient with blunt trauma.

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Media file 3: Close-up view of edematous bowel.

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Media file 4: Grading abdominal pressure. Courtesy of Saggi BH, Sugerman HJ, Ivatury RR, et al. Abdominal compartment syndrome. J Trauma 1998; 45: 597-609.

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Media file 5: Left lateral thoracotomy with towel clip closure of damage-control celiotomy. Courtesy of Pedro Gustavo R. Teixeira, Trauma Surgeon, Brazil, The Trauma Imagebank.

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Media file 6: Evisceration of the bowel (as illustrated) may occur if towel clips are not placed properly (1 cm from skin edge X 1 cm apart). This temporizing measure may not decompress the abdomen adequately. Intra-abdominal pressures as high as 50 mm Hg have been obtained with this type of closure technique.

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Media file 7: Either a conventional zipper or a commercial zipper is sewn to the skin or fascia with a continuous suture of 0 or 2-0 nylon or polypropylene. By using the skin, the fascia is spared and the incidence of postoperative fascial dehiscence may be diminished.

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Media file 8: Artificial burr attaching the loop sheet to the right fascia. Courtesy of Wittmann, et al.

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Media file 9: Artificial burr attaching the hook sheet to the left fascia. Courtesy of Wittmann, et al.

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Media file 10: Two sheets of Velcro-like biocompatible material are sewn to the midline fascia. The Velcro-like material can be adjusted to accommodate increased intra-abdominal pressure (IAP), or, as the IAP decreases, it may be trimmed and the incision approximated accordingly. Courtesy of Wittmann, et al.

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Media file 11: Gore-Tex 2-mm mesh is sewn to itself and to the skin or fascia (as in this case) to achieve temporary closure.

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Media file 12: Marlex mesh is sewn to itself and to the fascia.

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Media file 13: Dexon absorbable mesh is sewn to the fascia.

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Media file 14: Close-up view of Dexon mesh.

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Media file 15: Presterilized (gas), 3-L, cystoscopy irrigation bag.

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Media file 16: Opened, gas sterilized, 3-L, cystoscopy irrigation bag.

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Media file 17: Example of massive edema of the bowel and liver in a patient who experienced blunt trauma and developed abdominal compartment syndrome (ACS).

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Media file 18: Same patient as in Media file 17. Note the distended small bowel loops.

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Media file 19: Demographic data for 15 patients requiring temporary abdominal IV bag closure. Courtesy of Fernandez L, Norwood S, Roettger R, et al. Temporary intravenous bag silo closure in severe abdominal trauma. J Trauma 1996; 40: 258-260.

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Media file 20: Cost comparison for abdominal closure materials. Courtesy of Fernandez L, Norwood S, Roettger R, et al. Temporary intravenous bag silo closure in severe abdominal trauma. J Trauma 1996; 40: 258-260.

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Media file 21: Comparison of materials considered for use in temporary abdominal closure. Courtesy of Fox V, Miller J, Nix M. Temporary abdominal closure using an IV bag silo for severe trauma. AORN J 1999 Mar; 69(3): 530-5, 537, 539-41.

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Media file 22: Placement of absorbable mesh.

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Media file 23: Split-thickness skin graft on a patient with multiple gunshot wounds and enteric fistulae.

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Media file 24: Approximation of the abdominal skin edges using the Sure-Closure device. Note that the abdominal silo resides in a partial intraperitoneal position.

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Media file 25: The Sure-Closure device in place.

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Media file 26: Approximation of the abdominal skin, creating a ventral hernia.

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Media file 27: Patient with blunt trauma with nearly healed ventral hernia (subcutaneous flap advancement technique with the Sure-Closure device).

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Media file 28: CT scan of a 25-year-old man who presented with 2 gunshot wounds to the abdomen. CT scan shows liver injury and abdominal distension, 8/30/01.

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Media file 29: Open abdominal wound before placement of Vacuum Assisted Closure® (V.A.C.®) system, 8/30/01.

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Media file 30: Vacuum-assisted closure (VAC) dressing applied, 8/30/01.

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Media file 31: First wound clinic follow-up, 9/18/01.

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Media file 32: Demographic data for 15 patients requiring intraperitoneal silo procedures. Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

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Media file 33: Comparison of materials considered for use in temporary abdominal closure. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept: 467-478.

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Media file 34: Presterilized, 3-L, cystoscopy irrigation bag. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept: 467-478.

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Media file 35: Epigastric slit. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

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Media file 36: Silo in place within the peritoneal cavity. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

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Media file 37: The surgeon removes the intraperitoneal silo.

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Media file 38: Appearance of the intraperitoneal silo after removal from the peritoneal cavity.

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Media file 39: Appearance of the bowel after removal of the intraperitoneal silo.

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Media file 40: Diagram of silo placement within the abdominal cavity. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

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Media file 41: Cross-section of the abdomen with the intraperitoneal silo in place. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

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Media file 42: Beginning the skin closure. Courtesy of Fernandez L, Norwood S, Wilkins H, et al. Intraperitoneal silo: a form of temporary abdominal closure. Surg Rounds 1999 Sept; 467-478.

Keywords

temporary abdominal closure, TAC, trauma damage-control celiotomy, damage control, damage-control celiotomy, damage-control surgery, damage control celiotomy, trauma damage control celiotomy, damage control surgery, abdominal compartment syndrome, ACS, intra-abdominal pressure, IAP, positive pressure ventilation, positive end expiratory pressure, intrathoracic pressure, central venous pressure, intracerebral pressure, intracranial pressure, abdominal wall, viscera, fascia, zipper closure, Wittmann Patch, synthetic mesh closure, polytetrafluoroethylene closure, marlex mesh, absorbable mesh, silastic closure, primary delayed fascial closure, Fabian protocol, Sure-Closure system, Sure-Closure Skin Stretching System, vacuum-assisted closure, VAC, vacuum-assisted fascial closure, VAFC, intraperitoneal silo, IP silo

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