Limits...
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.

Show MeSH

Related in: MedlinePlus

Intraoperative presentation of stage 1: a Insulation bag used to protect the bowels and prevent adhesion to the abdominal wall. b Vacuum dressing over the insulation bag, with suction drain
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC3412951&req=5

Fig2: Intraoperative presentation of stage 1: a Insulation bag used to protect the bowels and prevent adhesion to the abdominal wall. b Vacuum dressing over the insulation bag, with suction drain

Mentions: The goal of stage 1 is damage control, that is, control of intra-abdominal infection and pressure (Table 2). All patients underwent stage 1 treatment. During stage 1, special attention was also paid to conditioning of the abdominal wall for subsequent abdominal wall closure; any adhesions between the intestinal loops and the abdominal wall were prevented or lysed early. If a firmly adhesive intestinal convolution already existed (e.g., in patients transferred from other facilities), it was mobilized if possible in stages from the abdominal wall during revisions. As a rule, the abdominal wall should be kept free for a circumference of at least 6 cm to allow for later—during stage 2—anatomic abdominal wall closure or suture mesh fixation. To protect abdominal organs, a bandage was applied according to the technique of Barker et al. [13], using the foil-lined side of an insulation bag (Vi-Drape®, MCD St. Paul, MN, USA) (Fig. 2). The purpose was to prevent adhesions between the abdominal wall and the intestinal convolution and to protect the intestinal loops from excessive vacuum pressure. Macroscopic cleansing of the intra-abdominal cavity was confirmed by swabs for microbiological investigation; in the classification of Björck et al., the finding was grade 1A, 2A, or 4 [14]. The primary aim was to achieve fascial closure after stage 1. If anatomical abdominal wall closure was not possible at the end of stage 1, the patient was enrolled to abdominal wall closure through stages 2–4. This was the case in patients with rectus diastasis > 15 cm, with adhesive intestinal convolutions, and with pronounced intestinal edema.Table 2


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)

Intraoperative presentation of stage 1: a Insulation bag used to protect the bowels and prevent adhesion to the abdominal wall. b Vacuum dressing over the insulation bag, with suction drain
© Copyright Policy
Related In: Results  -  Collection

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

Fig2: Intraoperative presentation of stage 1: a Insulation bag used to protect the bowels and prevent adhesion to the abdominal wall. b Vacuum dressing over the insulation bag, with suction drain
Mentions: The goal of stage 1 is damage control, that is, control of intra-abdominal infection and pressure (Table 2). All patients underwent stage 1 treatment. During stage 1, special attention was also paid to conditioning of the abdominal wall for subsequent abdominal wall closure; any adhesions between the intestinal loops and the abdominal wall were prevented or lysed early. If a firmly adhesive intestinal convolution already existed (e.g., in patients transferred from other facilities), it was mobilized if possible in stages from the abdominal wall during revisions. As a rule, the abdominal wall should be kept free for a circumference of at least 6 cm to allow for later—during stage 2—anatomic abdominal wall closure or suture mesh fixation. To protect abdominal organs, a bandage was applied according to the technique of Barker et al. [13], using the foil-lined side of an insulation bag (Vi-Drape®, MCD St. Paul, MN, USA) (Fig. 2). The purpose was to prevent adhesions between the abdominal wall and the intestinal convolution and to protect the intestinal loops from excessive vacuum pressure. Macroscopic cleansing of the intra-abdominal cavity was confirmed by swabs for microbiological investigation; in the classification of Björck et al., the finding was grade 1A, 2A, or 4 [14]. The primary aim was to achieve fascial closure after stage 1. If anatomical abdominal wall closure was not possible at the end of stage 1, the patient was enrolled to abdominal wall closure through stages 2–4. This was the case in patients with rectus diastasis > 15 cm, with adhesive intestinal convolutions, and with pronounced intestinal edema.Table 2

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