Surgical perspective

Open Abdomen after Trauma and Abdominal Sepsis: A Strategy for Management

Indications for the open abdomen

The five recognized indications for leaving the abdomen open at the end of laparotomy are listed in Table 1. Open management of severe intraabdominal infection is indicated in cases in which a single laparotomy cannot effectively control the source of infection. Leaving the abdomen open enables repeated access to the peritoneal cavity and facilitates repeated debridement of nonviable tissue, peritoneal toilet, and effective drainage. It can be performed in the operating room or at the bedside

Early temporary wound coverage

The goals of early coverage of the open abdominal wound are atraumatic containment of the abdominal visceral content, protection of the bowel, and sparing the fascia to increase the likelihood of achieving delayed primary closure. Effective temporary closure also controls fluid losses and reduces the catabolic effects of the open abdomen. There is a range of technical options for coverage (Table 2). Choice of a specific option should be tailored to the clinical circumstances, but is also a

Considerations in placement of intestinal stomas

Five minutes of forethought before placement of an intestinal stoma during the initial operation can save hours of work during definitive abdominal closure. A poorly placed stoma can frustrate the best efforts to achieve progressive delayed primary abdominal closure and result in a large ventral hernia requiring a complex delayed reconstruction.³³

When possible, a loop stoma protecting a distal anastomosis is preferable to an end stoma with a remote mucous fistula or a Hartmann pouch, because

Physiology of the open abdominal wound

At the end of the initial damage control operation, the bowel is often edematous and massively distended. This edema often worsens during the immediate postoperative period, dissecting up between the leaves of the mesentery. Intraabdominal packs may be required to control hemorrhage, and the stapled ends of the bowel may be left in the abdomen. We strongly recommend oversewing the staple lines in this situation to prevent staple line dehiscence as the bowel continues to swell during the

Traditional approach to abdominal closure

The best option for definitive closure of the open abdomen is delayed primary closure at the end of the last reoperation. But this should never be done under tension. Tension-free closure is usually possible if the indication for open management was a planned “second look” (eg, for ischemic bowel) with minimal bowel distention and edema, or in trauma patients who underwent early damage control without massive fluid resuscitation. In this article, we are primarily concerned with patients in whom

A revolution in the management of the open abdomen

Four new concepts have recently converged to revolutionize management of the open abdomen: preservation of the peritoneal space, progressive abdominal closure, vacuum-assisted wound management, and use of biologic dressing.²⁸

An unintended fortuitous consequence of the introduction of the vacuum pack was the gradual realization that the inner layer of the vacuum pack delays adhesion formation between the visceral block and the anterolateral abdominal wall, preserving the peritoneal space and

Recommendations for open abdomen management

At the completion of the initial operation, leave the fascia open and close the skin over the viscera if you can. If skin closure is impossible, apply a vacuum pack.

Cover the bowel with a biologic dressing. Omentum is the best option if present. If omentum is not available, split-thickness skin homograft is a good option as a temporary dressing at this stage. Place a fenestrated plastic drape over the visceral block extending from the left gutter to the right gutter to ensure prevention of

Enteroatmospheric fistula: The nemesis of the open abdomen

An enterocutaneous fistula is a communication between the gastrointestinal tract and the skin. A hole in the exposed bowel in the middle of an open abdomen is a special problem—a so-called enteroatmospheric (or exposed) fistula.

The enteroatmospheric fistula is an especially challenging problem because there is no well-vascularized soft tissue overlying the fistula tract. In fact, there is no tract at all. This precludes any possibility of spontaneous healing. Continuous exposure of the

Principle 1: Prevention

Regardless of the method chosen for temporary abdominal closure, exposed abdominal viscera should be meticulously protected. Access to the wound should be limited to one or two experienced care providers who know the wound intimately. Free access to the wound for all members of the surgical and nursing team almost guarantees fistula formation.

Principle 2: Attempt to seal the fistula

Attempts to close a fistula in the midst of an open abdomen are usually unsuccessful, but may be worth a try in selected patients. Fibrin glue and acellular dermal matrix can occasionally seal a small enteroatmospheric fistula.⁵⁰ One of us (WS) has used this technique successfully in one patient.

Principle 3: Control fistula effluent

If the fistula occurs in an open abdomen that has not yet granulated into a “frozen” visceral block, source control and elimination of ongoing contamination of the peritoneal cavity are essential for survival. Exteriorization of the fistula and proximal diversion are obviously the best solutions, but are also often impossible because of massive edema and foreshortening of the mesentery. The “floating stoma” described by Subramanian and colleagues⁵¹ is an interesting solution to this problem.

Principle 4: Cover fistula with well-vascularized soft tissue

Occasionally, an open abdomen and fistula can be managed by soft-tissue cover with fascia or even skin as previously discussed, combined with fistula intubation to create a drainage tract. In this situation, intubation of a fistula at the time of soft tissue coverage is a good idea to establish an effective drainage tract. The fistula can then heal because it is covered by well-perfused soft tissue.⁵⁵

Principle 5: Resect chronic fistula when patient is fit and infection free

Patients with enteroatmospheric fistulas are so ill, and the abdomen so hostile, that definitive resection of the involved bowel segment must be delayed for many months (often a year or more). These procedures often require extensive planning and complex abdominal wall reconstruction in close collaboration with a plastic surgery team.

Principle 6: Daily attention by senior surgeon

Psychologic support of both the patient and the family is essential, because the management of an enteroatmospheric fistula is both time consuming and emotionally taxing. Failure to spend a small amount of time each day with the patient will result in a large expenditure of time later in the course of management because of psychologic “meltdown.” These patients are desperate and face a huge psychologic challenge, with grave concerns about body image, odor, and cleanliness when not focused on