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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Management of the difficult abdominal closure

, M.D.

Detroit Receiving Hospital, Surgery, St. Antoine, Detroit, U.S.A.

Abdominal injury with hemorrhagic shock or peritonitis due to intraabdominal sepsis requireses extensive resuscitation resulting in massive edema of the bowel, the retroperitoneum and the abdominal wall (fig. 1). The degree of edema appears to depend on the severity and duration of the insult. The abdominal wall loses compliance and primary closure under tension leads to the abdominal compartment syndrome, further tissue necrosis, necrotizing fasciitis and fascial dehiscence (1).

Figure 1. Severe visceral edema and loss of abdominal wall compliance precludes safe primary abdominal wall closure.

Figure 1

Severe visceral edema and loss of abdominal wall compliance precludes safe primary abdominal wall closure.

Types of wound closures

Retention sutures incorporating large portions of tissue tied under tension can forcibly contain the abdominal contents. Unfortunately, this exacerbates the abdominal compartment syndrome and has been implicated in the development of enterocutaneous fistula even when the sutures are placed extraperitoneally.

Polypropylene mesh can restore abdominal-wall integrity while permitting egress of fluid. It is associated with serious long-term complications (2). The mesh acts as a nidus of infection and is associated with enterocutaneous fistulas and mesh extrusion (3). The use of polytetrafluoroethylene (PTFE) may reduce the incidence of these problems, but this material is solid and prevents the egress of abdominal fluid which may contribute to increased intraabdominal pressure.

Absorbable mesh such as polyglycolic acid will provide a short term solution for closure of the abdominal wall. This material allows for egress of fluid and serves to maintain the viscera within the peritoneal cavity. Unfortunately late hernia formation will almost always occur (4). The use of plastic bags or silos sutured to the skin allow the viscera to extrude from the peritoneal cavity. This prevents the abdominal compartment syndrome, prevents egress of fluid unless openings are made in the silo and allows for inspection of the bowel. The bowel will become adherent in its new location and attempts at reducing the bowel into the peritoneal cavity is associated with increased bleeding. The viscera become attached to the wound margins and any increase in intraabdominal pressure by standing or coughing may lead to rupture of the bowel in the midportion of the wound. This technique requires bed rest and prolonged respiratory support until the wound can be skin grafted. The resulting giant hernia presents an additional challenge.

Abdominal wall pack technique

Frustrations with the previous methods of closure of the difficult abdominal wound led to the development of the abdominal wall pack technique (5). This technique maintains the viscera within the peritoneal cavity, allows for egress of fluid, can be rapidly placed as well as changed with a brief operation. This abdominal wall pack allows the patient to ambulate and facilitates weaning from the ventilator. The technique is inexpensive. Rayon cloth which can be purchased from the local department store or parachute silk is cut into large sheets (50 cm2) and sterilized. Nylon sutures (number 2) on large retention needles are passed 4 cm from the wound edge extraperitoneally (fig. 2). The exposed viscera are then covered with the rayon cloth which is tucked underneath the wound margins for at least 4 cm (fig. 3). Bulky fluff gauze is then placed over the rayon cloth and serves to hold the rayon cloth over the viscera while protecting the viscera from contact with the retention sutures. The retention sutures are tied with minimal tension and serve to simply maintain the viscera below the level of the peritoneum (fig. 4). Bulky gauze dressings are placed over the top of this wound pack and are changed as needed. A suction catheter can be placed in the wound to aspirate fluid.

Figure 2. The abdominal wall pack technique for temporary closure is initiated by placing number-2 nylon sutures on a large retention suture needle 4 cm from the wound edge at 2 cm intervals.

Figure 2

The abdominal wall pack technique for temporary closure is initiated by placing number-2 nylon sutures on a large retention suture needle 4 cm from the wound edge at 2 cm intervals. These sutures pass through the skin subcutaneous tissue and the muscle-fascia (more...)

Figure 3. Rayon cloth is placed over the viscera and tucked underneath the wound margins for at least 4 cm.

Figure 3

Rayon cloth is placed over the viscera and tucked underneath the wound margins for at least 4 cm. Bulky gauze dressings are then placed over the rayon cloth and beneath the retention sutures and serve to hold the rayon gauze in place and protect the viscera (more...)

Figure 4. The nylon sutures are then tied with sufficient tension to hold the pack in place without necrosing tissue.

Figure 4

The nylon sutures are then tied with sufficient tension to hold the pack in place without necrosing tissue. This pack maintains the viscera well below the level of the peritoneum. At subsequent dressing changes, the viscera and intestinal edema will have (more...)

The patient is taken back to the operating room in 72–96 hours and the sutures and pack are removed. The exposed viscera are irrigated with warm saline, but there are no attempts to expose or explore areas of the abdomen. If the patient has undergone a brisk diuresis, the abdominal wall may be compliant enough to allow a fascial closure. If not, new retention sutures and a new pack are placed. Often the retention sutures can be tightened allowing for progressive closure of the abdomen. Following changing of the pack the patient will experience fever and tachycardia for the first 24 hours. Diuresis usually continues. The majority of patients will have closure of their abdominal wall fascia without tension by the fourth dressing change or by three weeks.

Occasionally there is loss of abdominal wall and the wound cannot be approximated by three weeks. In these instances the wound is allowed to granulate (6). It is crucial that the retention sutures continue to be placed to prevent the granulating surface from bulging, causing thinning of the granulation tissue, blister formation and bowel fistula. The retention sutures are removed once the split-thickness skin graft has been applied. This healed wound allows the patient to fully recover from the prior traumatic or septic insult. The abdominal hernia can then be addressed (7).

Bilateral advancement muscle flap technique

Repair of this giant hernia can be accomplished with a bilateral advancement muscle flap technique (8). Initially the split-thickness skin graft is excised from the skin borders and is easily dissected from its attachment to the underlying intestines after 6–9 months. The subcutaneous tissue is then dissected from the underlying anterior rectus sheath and external oblique fascia from the wound border to the midaxillary line (fig. 5). This plane is dissected from the xiphoid to the pubis and is performed bilaterally. The linea alba should be intact and is dissected from any scar tissue. The advancement flap is developed by excising the external oblique fascia and muscle in the anterior axillary line. The inferior portion of this incision should stay 1.5 cm above the anterior superior spine and the inguinal ligament and extend to within 3 cm of the midline. The superior extension of this external oblique incision extends over the short ribs to within 2 cm of the sternum (fig. 6). This allows the medial portion of the external oblique and the adjacent rectus muscle to be advanced about 6–10 cm thus closing a defect that previously measured 20 cm in width (fig. 7). If the defect is larger than 20 cm, the anterior rectus sheath can be incised laterally and rotated medially to produce an additional 2–4 cm of length. Bilateral suction drains are used beneath the subcutaneous tissue and the skin is closed primarily. The use of this technique in multiple patients has been successful with return to full activity. Complications include wound seroma which is treated with repeated aspirations.

Figure 5. The split-thickness skin graft has been excised.

Figure 5

The split-thickness skin graft has been excised. The plane between the subcutaneous fat and the underlying anterior rectus sheath and external oblique fascia is dissected from the midline to the midaxillary line.

Figure 6. The dissection of the subcutaneous fat plane extends superiorly over the short ribs and inferiorly down to and including the anterior superior spine and inguinal ligament.

Figure 6

The dissection of the subcutaneous fat plane extends superiorly over the short ribs and inferiorly down to and including the anterior superior spine and inguinal ligament. An excision has been made in the external oblique fascia and muscle in the anterior (more...)

Figure 7. The medial portion of the external oblique and adjacent rectus muscle can be advanced about 6–10 cm.

Figure 7

The medial portion of the external oblique and adjacent rectus muscle can be advanced about 6–10 cm. Excess skin and subcutaneous tissue is excised and the skin is closed primarily.

References

1.
Ledgerwood A M, Lucas C E. Postoperative complications of abdominal trauma. Surg Clin North Am. (1990);70:715–731. [PubMed: 2190344]
2.
Stone H H, Fabian T C, Turkles M L. et al. Management of acute full-thickness losses of the abdominal wall. Ann Surg. (1981);193:612–616. [PMC free article: PMC1345130] [PubMed: 6263197]
3.
Voyles C R, Richardson J D, Bland K L. et al. Emergency abdominal wall reconstruction with polypropylene mesh. Short-term benefits versus long-term complications. Ann Surg. (1981);194:219. [PMC free article: PMC1345243] [PubMed: 6455099]
4.
Tyrell J, Silberman H, Chandrasoma P. et al. Absorbable versus permanent mesh in abdominal operations. Surg Gynecol Obstet. (1989);168:227. [PubMed: 2537535]
5.
Saxe J M, Ledgerwood A M, Lucas C E. Management of the difficult abdominal closure. Surg Clin North Am. (1993);73:243–251. [PubMed: 8456355]
6.
Ledgerwood A M, Lucas C E. Management of massive abdominal wall defects: Role of porcine skin grafts. J Trauma. (1976);16:85–88. [PubMed: 130498]
7.
Fabian T C, Croce M A, Pritchard E. et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg. (1994);219:643. [PMC free article: PMC1243212] [PubMed: 8203973]
8.
Lucas C E, Ledgerwood A M. Autologous closure of giant abdominal wall defects. Am Surg. (1998);64(7):607–610. [PubMed: 9655268]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6962

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