Management of open abdominal wounds with a dynamic fascial closure system.(Trauma and Critical Care)(Report)

Publication: Canadian Journal of Surgery

Publication Date: 01-JUN-08

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Background: In damage-control surgery, definitive abdominal closure may not be possible for several days or weeks after laparotomy until the patient has stabilized. Methods: We present 23 patients treated with the Canica ABRA[R] dynamic wound closure system that re-approximated open abdomens with silicone elastomers placed transfascially across the wound. This study aimed to assess the results of using this system and to identify risk factors for unsuccessful closure. The system maintains a medially directed force across the wound. A traditional regimen of wound dressing changes was performed. Results: The dynamic closure system remained in place an average of 48 days and was applied an average of 18 days after the beginning of treatment for the open abdominal wound. Delayed primary fascial closure was achieved in 14 of 23 patients (61%) without further surgery. Six patients (26%) healed with ventral hernias but with a smaller abdominal defect. Two patients (9%) developed enterocutaneous fistulae through the wound that required further surgery. An overall reduction in wound area of 95% was achieved. Conclusion: This dynamic wound closure technique permitted the delayed primary closure of open abdomens in 61% of cases when treatment was instituted an average of 18 days after initial laparotomy.

Contexte : Au cours d'une intervention chirurgicale visant a limiter les degats, il arrive qu'on ne puisse pas refermer definitivement l'abdomen pendant plusieurs jours ou semaines apres une laparotomie, jusqu'a ce que le patient se soit stabilise. Methodes : Nous presentons le cas de 23 patients traites au moyen du systeme de fermeture dynamique de plaie Canica ABRAMD qui rapproche les levres de plaies abdominales ouvertes au moyen d'elastomeres en silicone disposes perpendiculairement a la plaie. Cette etude visait a evaluer les resultats de l'utilisation du systeme et a determiner les facteurs de risque d'une fermeture non reussie. Le systeme exerce une force perpendiculaire sur la plaie. On a applique un regime traditionnel de changements de pansements. Resultats : Le systeme de fermeture dynamique est demeure en place en moyenne 48 jours et a ete applique en moyenne 18 jours apres le debut du traitement de la plaie abdominale ouverte. On a reussi a retarder la fermeture fasciale primaire chez 14 des 23 patients (61 %) sans autre intervention chirurgicale. Six patients (26 %) ont gueri avec une hernie ventrale mais avaient un defaut abdominal moindre. Deux patients (9 %) ont eu des fistules enterocutanees dans la plaie qui ont oblige a pratiquer une autre intervention chirurgicale. On a reussi a reduire de 95 % la superficie de la plaie. Conclusion : Cette technique de fermeture dynamique de la plaie a permis de retarder la fermeture primaire d'abdomens ouverts dans 61 % des cas lorsqu'on a commence le traitement en moyenne 18 jours apres la laparotomie initiale.

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Damage-control surgery is abbreviated surgery performed to control a patient's life-threatening illness. It minimizes the time during which the patient is exposed to coagulopathic stimuli, hypothermia and acidosis in the operating room in favour of returning the patient to the intensive care unit as expeditiously as possible for a full resuscitation. It is typically performed for treatment of trauma, abdominal sepsis and abdominal compartment syndrome. Bowel and retroperitoneal edema resulting from hypoperfusion and resuscitative efforts frequently prevent reapproximation of the abdominal fascia. The patient is returned to the operating room 24-48 hours later for definitive treatment of the injuries should he or she survive. (1) Definitive abdominal closure may not be possible for several days or weeks, until the patient has stabilized.

Damage-control laparotomy has increased the number of patients surviving to require treatment for an open abdomen. Temporary abdominal wall closure can be achieved by placing an absorbable mesh or plastic visceral retainer and packing the resultant wound with gauze with or without retention sutures. The fascia then retracts laterally, and loss of abdominal domain begins. This may permanently prevent fascial closure and require treatment through a planned ventral hernia repair in which...

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