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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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a Schematic presentation of stage 2; b the two-component mesh (1) with PGA hem seam (1′); c Operation site of the two-component mesh in IPOM position (1) as well as transfascial suture fixation with pledget (2′). (1) and (1′) = two-component mesh in IPOM position with the PGA layer underneath; (2) and (2′) = transfascial suture with pledget; (3) = Vacuum packing with polyurethane sponge tucked laterally between the fascia and subcutaneous tissue; (4) = Donati suture of the skin wound ending
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Fig3: a Schematic presentation of stage 2; b the two-component mesh (1) with PGA hem seam (1′); c Operation site of the two-component mesh in IPOM position (1) as well as transfascial suture fixation with pledget (2′). (1) and (1′) = two-component mesh in IPOM position with the PGA layer underneath; (2) and (2′) = transfascial suture with pledget; (3) = Vacuum packing with polyurethane sponge tucked laterally between the fascia and subcutaneous tissue; (4) = Donati suture of the skin wound ending

Mentions: In stage 2, a two-component mesh was fixed by suture in IPOM position and a conditioning vacuum bandage applied (Table 2). To start, subcutaneous tissue was detached from the fascia ca. 6 cm in a lateral direction. The abdominal wall defect was measured to determine the form and size of the mesh. The gap was reduced by concentric traction to ensure that the mesh would fit, the goal being to cover the facial defect with the mesh allowing a 5–6 cm overlap. The mesh was tailor-made from two different commercially available meshes: a woven PGA mesh (Dexon® Style #8, Covidien, USA) attached by absorbable sutures beneath a large-pore PP mesh (Optilene® Mesh Elastic, 3 mm pore size, B.Braun-Aesculap, Germany). The PGA layer is made larger in area so as to allow suture fixation around the margin of the PP mesh. To finish, PP 1 USP sutures for later transfascial fixation of the two-component mesh are placed at 5-cm intervals on the abdominal wall (Fig. 3). The two-component mesh was positioned with the PGA mesh in the IPOM position on the intestinal convolution, extended under the facial defect, and attached transfascially; if possible, the suture holes were made lateral to the rectus abdominis. To avoid tear-out, the epifascial knots were tied over a pledget (Ethisorb®, Ethicon, USA). For vacuum conditioning, a polyurethane sponge (KCI-Medical, USA) was tucked laterally beneath the subcutaneous tissue. The skin of the proximal and distal wound poles was closed with strong Donati sutures (e.g., with PP 2-0 USP) [15, 16]. The wound was sealed over the polyurethane sponge with adhesive foil, the “suction cup” affixed and continual vacuum therapy begun at 125 mmHg (Fig. 3).Fig. 3


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)

a Schematic presentation of stage 2; b the two-component mesh (1) with PGA hem seam (1′); c Operation site of the two-component mesh in IPOM position (1) as well as transfascial suture fixation with pledget (2′). (1) and (1′) = two-component mesh in IPOM position with the PGA layer underneath; (2) and (2′) = transfascial suture with pledget; (3) = Vacuum packing with polyurethane sponge tucked laterally between the fascia and subcutaneous tissue; (4) = Donati suture of the skin wound ending
© Copyright Policy
Related In: Results  -  Collection

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

Fig3: a Schematic presentation of stage 2; b the two-component mesh (1) with PGA hem seam (1′); c Operation site of the two-component mesh in IPOM position (1) as well as transfascial suture fixation with pledget (2′). (1) and (1′) = two-component mesh in IPOM position with the PGA layer underneath; (2) and (2′) = transfascial suture with pledget; (3) = Vacuum packing with polyurethane sponge tucked laterally between the fascia and subcutaneous tissue; (4) = Donati suture of the skin wound ending
Mentions: In stage 2, a two-component mesh was fixed by suture in IPOM position and a conditioning vacuum bandage applied (Table 2). To start, subcutaneous tissue was detached from the fascia ca. 6 cm in a lateral direction. The abdominal wall defect was measured to determine the form and size of the mesh. The gap was reduced by concentric traction to ensure that the mesh would fit, the goal being to cover the facial defect with the mesh allowing a 5–6 cm overlap. The mesh was tailor-made from two different commercially available meshes: a woven PGA mesh (Dexon® Style #8, Covidien, USA) attached by absorbable sutures beneath a large-pore PP mesh (Optilene® Mesh Elastic, 3 mm pore size, B.Braun-Aesculap, Germany). The PGA layer is made larger in area so as to allow suture fixation around the margin of the PP mesh. To finish, PP 1 USP sutures for later transfascial fixation of the two-component mesh are placed at 5-cm intervals on the abdominal wall (Fig. 3). The two-component mesh was positioned with the PGA mesh in the IPOM position on the intestinal convolution, extended under the facial defect, and attached transfascially; if possible, the suture holes were made lateral to the rectus abdominis. To avoid tear-out, the epifascial knots were tied over a pledget (Ethisorb®, Ethicon, USA). For vacuum conditioning, a polyurethane sponge (KCI-Medical, USA) was tucked laterally beneath the subcutaneous tissue. The skin of the proximal and distal wound poles was closed with strong Donati sutures (e.g., with PP 2-0 USP) [15, 16]. The wound was sealed over the polyurethane sponge with adhesive foil, the “suction cup” affixed and continual vacuum therapy begun at 125 mmHg (Fig. 3).Fig. 3

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