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Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia.

Dietz UA, Wichelmann C, Wunder C, Kauczok J, Spor L, Strauß A, Wildenauer R, Jurowich C, Germer CT - Hernia (2012)

Bottom Line: Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days.No mesh-related hematomas, seromas, or intestinal fistulas were observed.Long-term course in a large number of patients must still confirm this result.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany. dietz_u@chirurgie.uni-wuerzburg.de

ABSTRACT

Purpose: Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall.

Methods: Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3-4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized.

Results: The abdominal wall gap in the 19 patients ranged in size from 240 cm(2) to more than 900 cm(2). An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60-100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed.

Conclusion: The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

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Typical planned giant ventral hernia following complicated course of a cholecystectomy in a 43-year-old female patient. The hernia begins in the medial subxiphoidal region at the costal arch and has an additional component right lateral. Length: 35 cm and width: 43 cm. BMI = 47; 40 pack-years
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Fig1: Typical planned giant ventral hernia following complicated course of a cholecystectomy in a 43-year-old female patient. The hernia begins in the medial subxiphoidal region at the costal arch and has an additional component right lateral. Length: 35 cm and width: 43 cm. BMI = 47; 40 pack-years

Mentions: The concept of open abdomen, also termed laparostomy, was introduced in the 1970s and is widely applied today [1, 2]. In the USA, it is most often used to treat abdominal trauma, and in Germany, for secondary peritonitis. A recent poll revealed that 94 % of German clinics employ open abdomen [3]. In patients treated over several days with open abdomen, anatomic abdominal wall closure poses a challenge. Often, the fascia edges are depleted due to inflammation and retracted laterally, preventing successful abdominal wall closure. If there is sufficient granulation of the intestinal convolutions, a skin mesh cover can follow with consecutive giant ventral hernia and all the challenges associated with further abdominal wall reconstruction (Fig. 1) [1, 4–10]. Although open abdomen is a proven therapy concept, patients so treated can only gradually be mobilized during hospitalization and are subject [upon release] to major social limitations due to the grossly deformed abdominal wall. Biological meshes for septic open abdomen have still not been sufficiently tested. Experience shows however that in some cases, they are dissolved by vacuum therapy or also lysed in part by germs and that they do not prevent incisional hernias during course [11].Fig. 1


Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia.

Dietz UA, Wichelmann C, Wunder C, Kauczok J, Spor L, Strauß A, Wildenauer R, Jurowich C, Germer CT - Hernia (2012)

Typical planned giant ventral hernia following complicated course of a cholecystectomy in a 43-year-old female patient. The hernia begins in the medial subxiphoidal region at the costal arch and has an additional component right lateral. Length: 35 cm and width: 43 cm. BMI = 47; 40 pack-years
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3412951&req=5

Fig1: Typical planned giant ventral hernia following complicated course of a cholecystectomy in a 43-year-old female patient. The hernia begins in the medial subxiphoidal region at the costal arch and has an additional component right lateral. Length: 35 cm and width: 43 cm. BMI = 47; 40 pack-years
Mentions: The concept of open abdomen, also termed laparostomy, was introduced in the 1970s and is widely applied today [1, 2]. In the USA, it is most often used to treat abdominal trauma, and in Germany, for secondary peritonitis. A recent poll revealed that 94 % of German clinics employ open abdomen [3]. In patients treated over several days with open abdomen, anatomic abdominal wall closure poses a challenge. Often, the fascia edges are depleted due to inflammation and retracted laterally, preventing successful abdominal wall closure. If there is sufficient granulation of the intestinal convolutions, a skin mesh cover can follow with consecutive giant ventral hernia and all the challenges associated with further abdominal wall reconstruction (Fig. 1) [1, 4–10]. Although open abdomen is a proven therapy concept, patients so treated can only gradually be mobilized during hospitalization and are subject [upon release] to major social limitations due to the grossly deformed abdominal wall. Biological meshes for septic open abdomen have still not been sufficiently tested. Experience shows however that in some cases, they are dissolved by vacuum therapy or also lysed in part by germs and that they do not prevent incisional hernias during course [11].Fig. 1

Bottom Line: Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days.No mesh-related hematomas, seromas, or intestinal fistulas were observed.Long-term course in a large number of patients must still confirm this result.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany. dietz_u@chirurgie.uni-wuerzburg.de

ABSTRACT

Purpose: Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall.

Methods: Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3-4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized.

Results: The abdominal wall gap in the 19 patients ranged in size from 240 cm(2) to more than 900 cm(2). An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60-100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed.

Conclusion: The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

Show MeSH
Related in: MedlinePlus