Protocol Improves Open Abdominal Closure

CHICAGO – A standardized sequential closure protocol significantly increased fascial closure rates in a prospective, observational study of 51 consecutive patients with open abdomens after damage-control surgery.

Primary fascial closure was achieved in all 29 patients in whom the protocol was followed versus 55% of 22 patients in whom it was not followed, Dr. Clay C. Burlew said at the annual meeting of the Western Surgical Association.

The average time to fascial closure in the protocol group was 7 days (range, 3-19 days) vs. 4.3 days (range, 2-9 days) among the 12 nonprotocol patients in whom fascial closure was obtained. The average number of laparotomies to closure was five vs. three, respectively. In the 10 nonprotocol patients who could not attain fascial closure, coverage of the viscera was obtained at day 10 (range, 7-16) following six (range, four to eight) operative procedures.

"Preventing fascial retraction appears to be a critical component of abdominal closure," she said. "Moreover, one of the keys to obtaining fascial closure is returning to the operating room every other day, regardless of how hectic the OR schedule becomes."

In all, 73% of protocol violations were due to failure to return to the OR within 48 hours, said Dr. Burlew, director of the surgical ICU at Denver Health Medical Center.

The protocol has been in place since 2005, and is based in part on the vacuum-assisted closure (VAC) technique developed to avoid a ventral hernia, with later reconstruction in open-abdomen patients unable to undergo fascial closure after initial laparotomy (J. Trauma 2002;53:843-9). Instead of using the VAC itself to provide constant fascial tension, Dr. Burlew’s team placed direct sutures through the fascia to provide graded tension and used two layers of VAC sponges. They also implemented a stringent protocol for return to the OR every other day.

The sequential closure technique begins by placing VAC white sponges over the bowel and stapling them together before placing the sponges under the midline fascia. The fascial edges are then placed under moderate tension using interrupted No. 1 polydioxanone sutures placed about 5 cm apart in full-thickness fascial bites of at least 1.5 cm, she said.

Clear, sticky plastic VAC covering is placed over the patchwork of white sponges and the adjacent 5-10 cm of skin. This is then trimmed along the skin edge and the center removed to provide skin protection. The black VAC sponge is placed across the wound and adjacent protected skin, and affixed with an occlusive dressing. A standard suction tube is tunneled into the black sponge.

Patients are returned to the OR every 2 days where the superior and inferior fascia are closed several centimeters and the "sponge sandwich" replaced until the number of white sponges under the closed fascia diminishes, Dr. Burlew said. The team does not routinely reexplore the abdomen, investigate the integrity of the suture lines, or eviscerate the bowel at each repeat operation.

"We currently use this closure technique in all patients with an open abdomen," she said.

The team’s first experience with the protocol resulted in 100% fascial closure in an average of 7.5 days in 14 patients requiring postinjury damage-control surgery or decompressive laparotomy for abdominal compartment syndrome (Am. J. Surg. 2006;192:238-42).

In the current series, 57% of patients experienced blunt trauma, 80% were male, and their average age was 35 years. There were no differences between groups in patient demographics or mean injury severity score (37), abdominal trauma index (26), base deficit (16), or 24-hour red blood cell transfusions (20 U), Dr. Burlew said.

The overall abdominal complication rate was 41%, with nine abscesses and one anastomotic leak in the protocol group and eight abscesses and three enterocutaneous fistulas in the nonprotocol group, she said. There was one death in each group.

Invited discussant Dr. Peter Lopez of Wayne State University in Detroit commended the authors on their overall fascial closure rate of 90% and said their technique enhances the success of open-abdomen closure by burying the suture and staple lines within the abdomen, preventing the abdominal contents from freezing to the fascia and peritoneal side walls to avoid the contents becoming vapor locked, and keeping the fascia from tracking down and away from the midline.

He asked why the protocol stresses returning to the OR within 48 hours and whether it has been modified since the investigators’ initial experience.

Dr. Burlew said that the protocol has remained unchanged and that she pursued the study in part because some of her colleagues were not convinced that adherence to each element in the protocol would make a difference.