Management of the patient with an open abdomen: Techniques in temporary and definitive closure
Section snippets
Temporary closure techniques
Towel clip closure is perhaps the most rapid of the temporary closure techniques. The towel clips are applied to the skin, approximately 1 cm apart. Orienting the handles toward the center (up from below and down from above) facilitates coverage of the towel clips and minimizes overlying artifact on subsequent radiographs (Fig 1). The towel clips are then covered with a towel and iodophor-impregnated adhesive plastic drape (Ioban, 3 mol/L; St. Paul, MN). The towel simplifies removal of the
Critical care management
Before the concept of damage control, seriously injured patients underwent major operations in which surgeons attempted to achieve hemostasis, control contamination, and repair all injuries definitively. Patients were subject to long operative times during which they would often develop or worsen existing acidosis, hypothermia, and coagulopathy. These 3 conditions make up the “triangle of death”54 and are directly attributable to persistent tissue hypoperfusion.55 An inability to reverse these
Complications
Because of the severity of physiologic and hemodynamic conditions necessitating the institution of damage control, it is not surprising that mortality and complication rates are high. In a large series of patients with multiple injuries requiring damage control, the mortality rate was 60%, with an associated abdominal complication rate of 43%.126 Patients are at risk for aspiration, pneumonia, intra-abdominal complications, line complications, thromboembolism, pressure ulcers, sepsis and
Primary closure
Primary closure, as long as it is performed without tension and does not lead to ACS, is the most preferable form of definitive closure. Although difficult to quantify, the risks of infection, enterocutaneous fistula, and recurrent wound problems appear to be lower if primary closure is possible (Table 5). As the patient’s overall status improves and edema lessens, primary closure can often be performed days to weeks after the original celiotomy. Many patients are extubated and discharged from
Summary
Although the commitment of resources and manpower to the care of these patients is significant, the improvement in outcome justifies the cost. The potential to develop the triangle of death must be anticipated and expeditious closure of body cavities pursued. The ideal temporary closure has yet to be developed, but Dexon mesh, followed by skin grafting and late components separation, has demonstrated satisfactory results. Whether use of the Bogotá bag and vacuum assisted closure will eliminate
Acknowledgment
The authors wish to gratefully acknowledge the help of Colin G. Thomas, Jr, MD, for his help in obtaining the original references and clarifying the historical facts presented in this monograph; Tamara S. Petty, for her help in obtaining samples of the various meshes; Preston B. Rich, MD, for his expertise and sharing figures; Michael C. Chang, MD, for providing expertise and figures regarding V.A.C. therapy; and Sumeet Teotia, MD, for his expertise in medical illustration.
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