There is no such thing as an "Open
Abdomen"
September 2011 note: A recent RCT was completed showing the type of temporary abdominal closure technique chosen makes a huge difference in outcome and cost of care. Despite the cheaper option of a Bogota bag, it does not mobilize cytokine rich fluids as well, has a markedly increased rate of fistula formation (50%) a longer delay to closure (29 days), fewer successful closures (70%) and higher mortality (27%) than commercially available negative pressure dressings (0-4%; 4.3 -6.4 days, 94%, 16% respectively).[18] Cost associated with varying closure techniques were also markedly different - Failure to close requiring split thickness skin grafts $598,000; Progressive closure over a few weeks $378,000; Primary closure in 4-5 days $227,000. [19]
Introduction
A term commonly used by surgeons for the treatment of major trauma cases and situations where there is significant swelling within the abdominal viscera such that they cannot close the fascia at the end of a case is “open abdomen.” This term means that the surgeon operated on a patient’s abdomen and did not close the fascia or skin because the patient either already had IAH or ACS and needed to be decompressed, they had so much swelling in their abdomen that they could not tuck the intestinal contents back in, or they were afraid that if they did tuck the intestinal contents back in and sew them shut, the patient would develop abdominal hypertension and possibly abdominal compartment syndrome.[1, 2] However, the surgeons do not actually leave the abdomen “open” outside of the sterile operating room environment – instead they cover the intestines with a temporary dressing. The actual term in the literature for “open abdomen” intervention outside the operating suite is “temporary abdominal closure” (TAC) – note the term CLOSURE.[3] This is an important distinction because there is a common belief is that because the abdomen is left “open”, the patient cannot develop IAH or ACS. In fact – they are temporarily closed and most certainly can re-accumulate fluid and edematous bowel and progress to IAH and ACS despite this expanded temporary dressing.[4, 5]
Figure 1: This patient has an IAP of 33 mm Hg – he is suffering from organ dysfunction due to abdominal compartment syndrome and needs a decompressive laparotomy.[6]
Figure 2:
This is the patient from figure 1 after his decompressive
laparotomy. Note how
dramatically the swollen intestines have bulged out of the abdominal
incision. You can
imagine how this swelling led to a dramatic increase in the IAP when
the abdominal wall confined it.
Now that it has been decompressed, the patient’s IAP has
dropped to 15 mm Hg.
The result of a decompressive laparotomy or of “temporary closure” after a surgical case is that the volume of space available for the abdomens contents is much larger – probably half again as large. Once the abdomen is opened, the patient’s intestines are not left out in the open air because this would result in them drying out and dying as well as becoming infected by the external environment. For this reason, every “open abdomen” is closed with a dressing.
Temporary abdominal dressing closures are done in a variety of ways: Bogota bag, Ioban dressing, Wittman patch, KCI Vac-pac, AbThera etc.[7-12] One of the more common methods is using a “Bogota bag” because it costs almost nothing.[7]
A Bogota bag is simply a 3 liter IV plastic bag with 3 of the edges cut off so it lies flat (It is put in a sterilizer in the operating room, then given to the surgeon who stitches it over the guts to the sides of the abdominal incision. This allows the clinician to be able to look through the clear window of the plastic bag and see if the guts are healthy. Sometimes they pack gauze under the bag to absorb fluid.
Bogota Bags - homemade dressings created from an IV saline bag then stitched over the bowel to create a clear window
The other methods are variations on the same theme though much more sophisticated and likely resulting in far better results in terms of time to closure and management of free fluids. Some devices include suction that allows re-accumulated fluid to be suctioned out of the abdominal cavity which enhances the removal of pro-inflammatory cytokines and may reduce edema more rapidly.[11-13]
Wittman Patch photos - a method for closing the fascia once edema is controlled
Vac-Pac photos - Another way of controlling fluids then using soe form of facial tension to eventually close the abdomen
The point of all the above discussion is this: There is no such thing as an open abdomen outside the operating theatre. To leave it open would lead to desiccation (drying- mummification) and death of the bowel, massive fluid losses, a messy wound and a huge risk of infection. ALL open abdomens are closed with an airtight dressing for protection. The result is an expanded but closed abdomen that has a larger volume that the previous abdomen so the internal pressure is reduced.
However, the same processes that led to the
accumulation of fluid and increase in IAP in the first place are
still present. A patient that has a temporary abdominal closure is
actually at very high risk for capillary leak and ACS or they would
never have been left “open” – in other words they are the worst
cases for capillary permeability and have a high chance of
progressing. Furthermore, the fact they went to the operating room
and had this aggressive procedure performed means that very
significant resources have already been committed to the care of
this patient and they should be carefully monitored for recurrent
IAH and abdominal compartment syndrome since the treatment
is now as simple as expanding their dressing. If they
continue to leak fluid and further edema develops, the pressure
within the abdomen can easily begin rising again and ACS can recur.
This is called “recurrent abdominal compartment syndrome” and is one
of the core definitions of this syndrome.[5, 14] This has been
described in many reports.[5] The largest series, by Gracias
demonstrated that ¼ of all patients who had their abdomen left open
to prevent IAH / ACS and had
a vacuum pack placed to suction out excess fluid, still
developed ACS (defined as IAP > 25 mmHg plus organ dysfunction).[4]
The mortality in those who developed ACS was 60% while it was only
7% in the others. The
authors recommend that “treatment of IAH can be achieved by incising
the external antimicrobial drape to allow for further expansion of
the abdominal wall ….
Prior to placement of a new sterile drape.”[4] Their conclusion:
“ Management of the open
abdomen with the vacuum-pack closure technique does not obviate
against the development of ACS.
…Ongoing vigilant monitoring of IAP is mandatory in this
patient population to recognize IAH and treat it expediently.”
Our ICU keeps a cart available specifically to address this issue. The cart has all the surgical supplies to score open and redress a temporary closure wound dressing. If the patient with temporary abdominal closure begins to develop increasing IAP’s, the cart is taken into the room, the surgical resident or staff (or ICU attending) get into surgical scrub, the patient is prepped, the dressing is cut open and expanded and a new dressing is placed over the top. This prevents the patient from developing ischemic gut, improves their urinary, pulmonary and hemodynamic status and reduces the need to return to the operating room. Dr. Cheatham, from Orlando Florida, has a slightly different approach. He places a silo dressing over the wound that allows for significant bowel expansion without the risk of developing recurrent ACS. He also very aggressively measures IAP in all “open abdomens” and intervenes with medical therapy and recurrent surgery for all cases that re-accumulate fluid and pressure.[15] By monitoring all these patients and intervening aggressively with medical therapy and reopening of the dressing, he has demonstrated the ability to close twice as many abdomens during the initial stay, reduce death rates by 20%, reduce fistula rates, ventilator day and ICU length of stay and reduce hospital length of stay by 10 days – an obviously cost effective strategy. He and others are now investigating newer therapies aimed at actively removing free fluid and cytokine using negative pressure therapy which may further enhance outcomes.[12, 13]
In summary, there is no such thing as an open
abdomen outside the operating suite. Instead we create expanded
abdomens with temporary abdominal closure devices.
Patients who undergo this procedure are self selected as very
high risk for recurrent ACS and need to be carefully monitored so
interventions can be done in a timely fashion to prevent further
ischemic complications.[4, 5, 15] These patients consume a huge
amount of health care resources with estimates coming out of
Vanderbilt University of $150,000 or more to care for these patients
(double to triple that if they failed to close the abdomen in the initial
stay).[16, 19] Protocol
driven monitoring and interventions applied specifically to patients
with “open abdomens” clearly demonstrate better outcomes, reduced
hospital length of stay, earlier abdominal closure and less resource
consumption.[15, 17] “Open abdomens” are not really open and often
progress to recurrent ACS. All open abdomens patients should have
frequent IAP measurements taken and protocol driven interventions
applied should the IAP begin to increase.
Links of interest for open abdomen management:
Dr. Cheathams case of the "open abdomen" that developed recurrent abdominal compartment syndrome
Woundsite.info lecture regarding "open abdomen" management
References:
1.
Campbell, A., et al.,
Management of the open abdomen: from initial operation to definitive
closure. Am Surg, 2009. 75(11 Suppl): p. S1-22.
2.
Diaz, J.J., Jr., et al.,
The management of the open
abdomen in trauma and emergency general surgery: part 1-damage
control. J Trauma, 2010.
68(6): p. 1425-38.
3.
Bee, T.K., et al., Temporary abdominal closure techniques: a prospective randomized trial
comparing polyglactin 910 mesh and vacuum-assisted closure. J
Trauma, 2008. 65(2): p.
337-42; discussion 342-4.
4.
Gracias, V.H., et al.,
Abdominal compartment syndrome in the open abdomen. Arch Surg,
2002. 137(11): p.
1298-300.
5.
Kirkpatrick, A.W., et al.,
The secondary and recurrent
abdominal compartment syndrome. Acta Clin Belg Suppl, 2007(1):
p. 60-5.
6.
Balogh, Z. and F.A. Moore,
Recent advances in the
characterisation of post-injury abdominal compartment syndrome.
International J Intensive Care, 2004.
11(1): p. 30-42.
7.
Joglar, F., et al.,
Dynamic retention suture closure: modified Bogota bag approach.
J Surg Res, 2010. 162(2):
p. 274-8.
8.
Tieu, B.H., et al., The
use of the Wittmann Patch facilitates a high rate of fascial closure
in severely injured trauma patients and critically ill emergency
surgery patients. J Trauma, 2008.
65(4): p. 865-70.
9.
Keramati, M., et al.,
The Wittmann Patch s a temporary abdominal closure device after
decompressive celiotomy for abdominal compartment syndrome following
burn. Burns, 2008. 34(4):
p. 493-7.
10.
Hadeed, J.G., et al.,
Delayed primary closure in damage control laparotomy: the value of
the Wittmann patch. Am Surg, 2007.
73(1): p. 10-2.
11.
Perez, D., et al., Prospective evaluation of vacuum-assisted closure in abdominal
compartment syndrome and severe abdominal sepsis. J Am Coll Surg,
2007. 205(4): p. 586-92.
12.
Batacchi, S., et al.,
Vacuum-assisted closure device enhances recovery of critically ill
patients following emergency surgical procedures. Crit Care,
2009. 13(6): p. R194.
13.
Kubiak, B.D., et al.,
Peritoneal Negative Pressure Therapy Prevents Multiple Organ Injury
in a Chronic Porcine Sepsis and Ischemia/Reperfusion Model.
Shock, 2010.
14.
Malbrain, M.L., I. De laet, and M. Cheatham,
Consensus conference
definitions and recommendations on intra-abdominal hypertension
(IAH) and the abdominal compartment syndrome (ACS)--the long road to
the final publications, how did we get there? Acta Clin Belg
Suppl, 2007(1): p. 44-59.
15.
Cheatham, M.L. and K. Safcsak,
Is the evolving management of
intra-abdominal hypertension and abdominal compartment syndrome
improving survival? Crit Care Med, 2010.
38(2): p. 402-7.
16.
Collier, B., et al.,
Feeding the open abdomen is associated with earlier abdominal
closure and less fistulae. Acta Clin Belg Suppl, 2007.
62-supplement 1: p. O65
Abstract.
18. Kaplan, M.J., et al., Does the method of temporary abdominal closure affect outcomes in trauma patients managed with an open abdomen? Am Surg, 2011. 77(7): p. S112.
19. Cheatham, M., K. Safcsak, and M. Sugrue,
Long-term implications of Intra-abdominal hypertension and abdominal
compartment syndrome: Physical, Mental and financial. Am Surg,
2011. 77(7): p. S78-S82.
20. Ouellet, J.F. and C.G. Ball, Recurrent abdominal compartment syndrome induced by high negative pressure abdominal closure dressing. J Trauma, 2011. 71(3): p. 785-6.