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

a Schematic presentation of stage 3; (1) The polyurethane sponge is trimmed under the detached subcutis but still covers the entire area of the two-component mesh; (2) The skin suture is optimized on the two wound poles. a–c the two-component mesh is incrementally incorporated by granulation tissue, the wound healing is uneventful (3); b 30 % granulation after 2 weeks; c 90 % granulation after 4 weeks
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC3412951&req=5

Fig4: a Schematic presentation of stage 3; (1) The polyurethane sponge is trimmed under the detached subcutis but still covers the entire area of the two-component mesh; (2) The skin suture is optimized on the two wound poles. a–c the two-component mesh is incrementally incorporated by granulation tissue, the wound healing is uneventful (3); b 30 % granulation after 2 weeks; c 90 % granulation after 4 weeks

Mentions: Stage 3 lasted from 2 to 4 weeks and serves for wound conditioning. Its goal is to achieve granulation tissue formation in at least 50–80 % of the two-component mesh area (Table 2). The vacuum delivery volume was noted and the vacuum dressing changed every 5–6 days. At every vacuum dressing change, the skin at the proximal and distal wound poles was closed a little more and the polyurethane sponge trimmed in order to diminish the subcutaneous wound surface (Fig. 4). During stage 3, some patients could be weaned from the respirator, extubated, and mobilized to a bedside chair. Stage 3 was ended when the mesh was visibly incorporated by the granulation tissue, and the secondary skin suture of the final stage (stage 4) could be performed. Two to three suction drains running parallel to each other were placed on the granulated two-component mesh at 5-cm intervals (Table 2). To prevent dislocation of the drains, these could be attached with a 5-0 USP rapid-absorbable suture to the PP component (e.g., Safil Quick® or Vicryl Rapid®). The four-stage procedure was concluded with subcutaneous suture and Donati skin suture with Prolene 2-0 USP (Fig. 5). The drains were left in place for prophylaxis against seroma for at least 7–10 days and removed when the delivery volume was reduced to 10 ml/24 h. Before pulling the drain, sonography of the abdominal wall was performed to exclude epifascial seroma.Fig. 4


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 3; (1) The polyurethane sponge is trimmed under the detached subcutis but still covers the entire area of the two-component mesh; (2) The skin suture is optimized on the two wound poles. a–c the two-component mesh is incrementally incorporated by granulation tissue, the wound healing is uneventful (3); b 30 % granulation after 2 weeks; c 90 % granulation after 4 weeks
© Copyright Policy
Related In: Results  -  Collection

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

Fig4: a Schematic presentation of stage 3; (1) The polyurethane sponge is trimmed under the detached subcutis but still covers the entire area of the two-component mesh; (2) The skin suture is optimized on the two wound poles. a–c the two-component mesh is incrementally incorporated by granulation tissue, the wound healing is uneventful (3); b 30 % granulation after 2 weeks; c 90 % granulation after 4 weeks
Mentions: Stage 3 lasted from 2 to 4 weeks and serves for wound conditioning. Its goal is to achieve granulation tissue formation in at least 50–80 % of the two-component mesh area (Table 2). The vacuum delivery volume was noted and the vacuum dressing changed every 5–6 days. At every vacuum dressing change, the skin at the proximal and distal wound poles was closed a little more and the polyurethane sponge trimmed in order to diminish the subcutaneous wound surface (Fig. 4). During stage 3, some patients could be weaned from the respirator, extubated, and mobilized to a bedside chair. Stage 3 was ended when the mesh was visibly incorporated by the granulation tissue, and the secondary skin suture of the final stage (stage 4) could be performed. Two to three suction drains running parallel to each other were placed on the granulated two-component mesh at 5-cm intervals (Table 2). To prevent dislocation of the drains, these could be attached with a 5-0 USP rapid-absorbable suture to the PP component (e.g., Safil Quick® or Vicryl Rapid®). The four-stage procedure was concluded with subcutaneous suture and Donati skin suture with Prolene 2-0 USP (Fig. 5). The drains were left in place for prophylaxis against seroma for at least 7–10 days and removed when the delivery volume was reduced to 10 ml/24 h. Before pulling the drain, sonography of the abdominal wall was performed to exclude epifascial seroma.Fig. 4

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