Abdomen That Will Not Close

Question 1

How can the viscera be contained and protected in cases where domain is maintained, but the abdomen is left open?

Answer 1

A slush basin drape or an x-ray cassette drape can be used to cover and protect the viscera, ensuring all viscera are included to prevent adhesion to the peritoneum.

Question 2

What additional materials may be used to manage abdominal fluid effluent in an open abdomen?

Answer 2

A folded radiopaque towel or laparotomy pad can be placed around a nasogastric tube to manage fluid effluent, creating negative pressure under an occlusive dressing.

Question 3

How is the Bogotá bag used in abdominal closure?

Answer 3

The sterile IV fluid bag is placed in an inlay position and affixed to the fascia or skin to temporarily cover and protect the viscera after laparotomy.

Question 4

What are the downsides of using the Bogotá bag technique?

Answer 4

need to fix the bag to the fascia or skin, which may require subsequent debridement, potentially creating a larger defect for closure later. Additionally, it does not prevent visceral adhesion to the peritoneum, making closure in future operations more difficult.

Question 5

What are some causes of visceral edema that can lead to a loss of domain?

Answer 5

Causes of visceral edema include mesenteric venous thrombosis, aortic aneurysm rupture, resuscitation techniques, pancreatitis, or other conditions.

Question 6

What is recommended for managing cases with visceral edema and loss of domain?

Answer 6

The use of a negative pressure system is recommended

Question 7

When is the FASTAC technique or plastic patch particularly effective?

Answer 7

effective in cases where multiple takebacks are anticipated due to the patient’s condition and loss of domain.

Question 8

How is the plastic patch applied in the FASTAC technique?

Answer 8

A thick plastic drape is cut into two pieces, folded into multiple layers, and sewn to the fascia bilaterally with enough intraperitoneal plastic to reach the gutters. The medial edges of the plastic sheets are sewn together in the midline to retain the viscera without causing compartment syndrome.

Question 9

How does the clear plastic drape benefit the management of the peritoneal cavity?

Answer 9

The clear plastic drape allows for daily inspection of the peritoneal cavity, repetitive entry if needed, and sequential bedside tensioning for staged reduction of the defect size over time.

Question 10

What is the purpose of using an abdominal silo in patients with loss of domain?

Answer 10

The abdominal silo promotes the reduction of bowel edema and may facilitate closure in patients with severe abdominal compartment syndrome by enclosing and elevating the viscera above the abdominal wall

Question 11

In what medical conditions has the silo closure technique been traditionally used?

Answer 11

The silo closure technique has been traditionally used in pediatric surgery for treating gastroschisis and omphalocele.

Question 12

What are the benefits of using a wound protector for silo creation?

Answer 12

The benefits include the absence of needing suture fixation to the fascia or skin, ease of sequential tightening by twisting the plastic, and versatility due to various available sizes.

Question 13

What is the Wittmann patch, and how is it used for abdominal closure?

Answer 13

The Wittmann patch is a plastic visceral adhesion barrier with hook-and-loop fasteners (like Velcro) sewn to the fascial edges, allowing for easy opening and closure. It can be used for sequential and progressive closure during multiple returns to the operating room

Question 14

What is the transabdominal wall traction (TAWT) system, and how does it differ from the Wittmann patch

Answer 14

The TAWT system, developed at Cook County Hospital, secures the Wittmann patch with transfascial sutures anchored to the lateral rectus sheath, distributing tension to the oblique muscles. This reduces the risk of tissue destruction at the fascial edge and achieves primary closure in up to 100% of cases.

Question 15

How does the risk of complications relate to the duration of an open abdomen?

Answer 15

The risk of complications increases linearly with the time the abdomen remains open. Efforts should focus on limiting the duration of the open abdomen to achieve definitive closure as soon as possible

Question 16

Why is it important to prevent direct contact between viscera and the abdominal wall during temporary closure?

Answer 16

Direct contact between viscera and the abdominal wall can prevent successful delayed closure by causing adhesions, which significantly limit the ability to achieve primary closure

Question 17

How does judicious use of hypertonic saline aid in the management of an open abdomen?

Answer 17

Hypertonic saline increases serum osmolarity, reducing interstitial edema and improving microvascular circulation, which decreases the overall volume of fluid administered while maintaining organ perfusion, leading to quicker resolution of acidosis and earlier return to surgery.

Question 18

How does early enteral feeding benefit patients with an open abdomen who are not in discontinuity?

Answer 18

Early enteral feeding improves osmotic pressure, promotes fluid mobilization, and helps reduce visceral edema, aiding in the achievement of primary fascial closure

Question 19

What are the limitations of nasogastric decompression in bowel discontinuity cases?

Answer 19

Nasogastric decompression is limited in its ability to decompress the entire proximal bowel.
Postpyloric decompression may be more effective in preventing bowel distension and reducing intraperitoneal volume

Question 20

When should intestinal continuity be reestablished in open abdomen cases?

Answer 20

intestinal continuity should be reestablished within 48 hours of the initial operation. If this is not possible, early ostomy formation may be considered.

Question 21

Why should an ostomy be placed laterally in patients with an open abdomen following damage control surgery?

Answer 21

Placing the ostomy laterally avoids interfering with tissue advancement techniques that may be necessary later for abdominal wall reconstruction, which is contrary to the standard practice of placing the ostomy within the rectus fascia

Question 22

What should be avoided when placing an ostomy in an open abdomen, and why?

Answer 22

The semilunar line should be avoided, as placing the ostomy there can lead to large hernias.

Question 23

How can an ostomy be accommodated in temporary or sequential closure methods?

Answer 23

The ostomy can be placed laterally, swept above the plastic visceral protection drape that is inserted into the colonic gutters, which helps prevent intestinal adhesion to the abdominal wall

Question 24

Where should drains be placed when managing an open abdomen, and why?

Answer 24

Drains should be placed laterally through the oblique muscles to avoid potential complications with tissue advancement during future abdominal wall reconstruction.

Question 25

Why are transabdominal feeding tubes avoided in the early stages of an open abdomen?

Answer 25

Transabdominal feeding tubes can interfere with tissue advancement and closure. Nasoenteral methods are preferred until definitive closure is achieved

Question 26

What feeding method is recommended for patients with an open abdomen until definitive closure?

Answer 26

Nasoenteral feeding methods are recommended to provide enteral nutrition without disrupting the abdominal closure process.

Question 27

When should patients with an open abdomen typically return to the operating room after the initial operation?

Answer 27

Patients should typically return to the operating room within 48 hours of the initial operation. If the patient is not physiologically corrected at that time, reoperation should be considered to assess for ongoing issues like ischemia.

Question 28

What is the goal of reoperation if a patient is not ready for primary closure after 48 hours?

Answer 28

The goal is not closure, but to assess for any causes of continued physiological derangement, such as ongoing ischemia, enterotomy, or other complications.

Question 29

What parameters indicate a patient may be ready for primary fascial closure?

Answer 29

Parameters include a normalized base deficit, lack of vasopressor requirements, and a net negative fluid balance

Question 30

What options exist if primary fascial closure is not possible after returning to the operating room?

Answer 30

Options include returning to the ICU to achieve a net negative fluid balance and planning another attempt at closure in 48 hours, or utilizing techniques like subcutaneous flap creation to reduce tension.

Question 31

How can subcutaneous flap creation aid in abdominal closure?

Answer 31

In thin patients, releasing the skin from the anterior rectus fascia for 2 to 3 cm can reduce tension and gain up to 2 cm of domain, facilitating fascial closure. However, it has limited utility for larger wounds.

Question 32

What secondary options are available if primary closure is not possible?

Answer 32

Secondary options include skin-only closure (with a planned hernia repair later), biologic mesh if the skin can be closed over it, or absorbable synthetic mesh (e.g., polyglactin) with or without negative pressure dressings.

Question 33

Why is permanent mesh not recommended for use in an open abdomen?

Answer 33

Permanent mesh is likely to result in chronic infection and fistula formation when used in the open abdomen scenario

Question 34

When should major abdominal wall reconstruction techniques, such as component separation, be performed?

Answer 34

Major abdominal wall reconstruction should be delayed for at least 6 months after wound closure by secondary intention or skin grafting, allowing the inflammatory process to subside and visceral adhesions to release

Question 35

How can the readiness for definitive abdominal reconstruction be assessed?

Answer 35

Readiness can be assessed by lifting or pinching the skin away from the underlying viscera. If the skin can be physically separated from the viscera, definitive reconstruction can be considered.