Scientific paper
Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control laparotomy

Presented at the 89th Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 8–9, 2002
https://doi.org/10.1016/S0002-9610(03)00059-XGet rights and content

Abstract

Background

The ability to massively transfuse and resuscitate critically ill surgical patients has resulted in unprecedented survival and a new set of complications including abdominal compartment syndrome (ACS) and the “unclosable” abdomen. Traditional methods of temporary abdominal closure have met with several limitations, not the least of which is a marked delay in achieving definitive fascial closure. Since 1991, we have consistently used reinforced silicone elastomer (Silastic) sheeting as a form of temporary abdominal closure in these settings. We report our results using this technique in a large cohort of critically ill surgical patients.

Methods

All patients undergoing silicone elastomer temporary abdominal closure since 1991 were identified and their charts abstracted for principal diagnosis and indication for temporary abdominal closure, fluid requirements, number of operations, and time to fascial closure. Time to definitive closure in the respective groups was analyzed using Kaplan-Meir survival curves and the Wilcoxon rank-sum test. Odds ratios for death were analyzed using logistic regression.

Results

One hundred thirty-four patients underwent temporary abdominal closure with silicone elastomer over this period and only 62% (83) survived their hospital admission. Trauma and ruptured abdominal aortic aneurysm were the most frequent diagnoses. The most frequent indication was edema precluding abdominal closure. The mean crystalloid and blood requirements in the 24 hours preceding temporary abdominal closure were 21 ± 16 L and 15 ± 11 U, respectively. Of survivors, 75% (63 of 83) achieved fascial closure during their index admission. The median time to fascial closure in patients ultimately closed was 5 days. The median time to closure and the proportion of patients ultimately closed varied with the indication for closure with an earlier and greater chance of success in patients who could not tolerate closure (ACS) or could not be closed primarily (edema). Age-adjusted mortality was 5 times (95% confidence interval: 2 to 13) higher in patients developing ACS.

Conclusions

Nylon reinforced silicone elastomer is a safe, reliable material for temporary abdominal closure in severely ill patients. Primary fascial closure can be obtained in a timely fashion in the majority of patients. The success of obtaining definitive fascial closure depends on the indication for temporary abdominal closure, with visceral edema and ACS having the highest likeliest of early success.

Section snippets

Patients and methods

We performed a retrospective review of all patients admitted to Harborview Medical Center (HMC) requiring temporary abdominal closure with nylon reinforced silicone elastomer sheet from 1991 to 2000. During the study period, there were 21,414 admissions to our general/trauma, vascular, and thoracic surgery services and 39,517 total trauma admissions. The material was initially manufactured and supplied by Dow Corning (Silastic; Toledo, Ohio) and since 1995 by Bentec Medical (Sacramento,

Results

All patients requiring temporary abdominal closure with nylon reinforced silicone elastomer membrane from 1991 to 1999 were identified. There were 134 patients who underwent closure with silicone elastomer. Application of silicone elastomer for closure increased with time (Fig. 1). The principal diagnoses and primary indications for temporary abdominal closure are demonstrated in Table 1. Trauma was the most frequent primary diagnosis with blunt mechanism in 62 (46%) and a penetrating

Comments

The open abdomen, although reported decades earlier, is in part a “disease of technology” resulting from more aggressive fluid administration, damage control laparotomy, and modern critical care advances. Often life-saving, decompressive laparotomy carries with it the responsibility of restoring anatomic continuity of the abdominal wall. The surgeon should choose the method most likely to result in fascial closure. Numerous options have coevolved in the last decade as surgeons sought solutions

References (12)

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