A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

Summary

Closure of catastrophic open abdominal wounds presents a challenge to the surgeon. We present a surgical technique utilizing a combination of mechanical and biologic xenograft closure systems in closing complex open abdominal wounds. This technique offers another option to the surgeon for definitive fascial closure and accelerated wound healing.

Abstract

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

Introduction

The increasing prevalence of abdominal compartment syndrome (ACS) has led to an emergence of various temporary abdominal closure (TAC) techniques¹. TAC is performed to prevent evisceration, assist in the removal of unwanted intraperitoneal fluid, minimize intra-abdominal complications, and expedite the closure of the abdominal cavity². Closure of an open abdomen facilitates restoration of normal physiology in the patient³. Prolonged duration of an open abdomen results in complications such as fistula formation and an inability to close the abdomen⁴. There are several methods to achieve final closure of an open abdomen.

The simplest way to temporarily close an abdomen is by using towel clips to close the skin⁵. One of the most commonly used and studied abdominal closure techniques is negative pressure wound therapy (NPWT)⁵. For the NPWT, a nonadherent barrier to protect the intraabdominal contents is applied followed by a moisture-absorbing sponge-like material, an outermost adhesive layer to sure the dressing in place, and a negative pressure mechanism⁶. A Bogota bag can also be used for temporary closure of an open abdomen. A Bogota bag is an empty intravenous fluid bag cut in half and sutured to skin edges⁷. NPWT and the Bogota bag closure are two temporizing measures that facilitate delayed primary closure of the abdominal cavity⁷.

Once the abdomen is deemed ready for closure, different closure methods can be utilized. The simplest way is to apply a split-thickness graft over the omentum once it has formed healthy granulation tissue. If the wound is not contaminated, a nonabsorbable synthetic sheet may be used to bridge the fascial edges⁸. If the fascial gap is less than 14-20 cm in maximal diameter, component separation of the rectus sheath can be performed⁹.

Some abdominal closure techniques allow for gradual reapproximation of the fascial edges and eventual primary closure¹⁰. A Wittmann patch consists of two opposing Velcro sheets that are sutured to each fascial edge¹¹. The opposing sheets are then fastened together in the midline. This mechanism allows easy re-entry into the abdomen and adjustment for abdominal compartment pressures. Additionally, this can provide midline traction on the fascial edges that can prevent retraction of the fascial edges and also facilitate primary closure of the fascia.

Alternatively, a DTS is available and is part of the technique described in this paper. The described DTS is composed to a silicone viscera protector that is applied over abdominal contents to prevent adhesions and adherence of viscera to the abdominal wall. Adjustable elastomers then penetrate the full abdominal wall thickness on each side and provide medializing dynamic tension, allowing relaxation of the flat muscles (obliques and transversus abdominus). This allows medialization of the rectus myofascial units (Figure 1). A product composed of porcine urinary bladder extracellular matrix can be placed in the subcutaneous space once primary myofascial closure is achieved (Figure 2). Porcine xenograft placement in the subcutaneous space augments and expedites wound healing through angiogenesis, innervation, modulation of the inflammatory response, and resistance to infection¹².

In this study, we describe a novel technique of primary abdominal closure following abdominal compartment syndrome utilizing a dynamic closure system and a biologic xenograft. At our level 1 trauma and acute care center, abdominal compartment syndrome is a common diagnosis. Prior to utilization of this novel method, most catastrophic open abdomens were not amenable to primary closure and a skin graft was placed over the viscera or bridging mesh. Since the adoption of this method in May of 2016, we have closed 100% of open abdomens due to abdominal compartment syndrome in a high-risk population (average BMI 40.45, SD 9.83) (Table 1).

Protocol

1. Installation of Dynamic Tissue System

1. Exclude if there is hemodynamic instability, a need for further abdominal washouts, or a concern for intraabdominal sepsis.
   1. If an ostomy exists, trim the ostomy wafer to make as narrow as possible and outline on abdominal skin. Cover ostomy with 4x4 and secure in place with adhesive transparent film dressing.
   2. Apply antimicrobial betadine impregnated adhesive drape to the skin of the abdomen widely, covering the operating field.
   3. Wash the abdomen out with at least 2 L of 40.5° C normal saline.
   4. Measure and record the myofascial gap (MFG), visceral extrusion (VE), and the length of incision in centimeters for documentation of progress on the operative note.
   5. Mark the skin of the anterior abdominal wall 5 cm laterally from medial fascial edge to create an ellipse around the midline wound.
   6. Place the elastomer buttons side by side on the ellipse created in step 1.1.5. with the “U” of the elastomer at the 5 cm ellipse demarcation around the midline wound. This will assure 3 cm spacing as recommended.
   7. Create superficial thickness dermotomies with an 11 blade.
   8. Pull the elastomer through the abdominal wall using the cannulator.
   9. Repeat the same steps on the opposite side. This time pull the elastomer across the myofascial gap and secure both ends with a hemostat.
   10. Loosely attach the elastomer bands to the elastomer buttons. Do not tighten elastomer bands.
   11. Attach elastomer adhesion stickers on the button tails.
   12. Perform osteopathic maneuvers throughout installation. This is performed with two people standing on either side of the patient. Apply bimanual forces in the flank area, gently massaging towards the midline and create circular motions synchronized with the other operator first towards the head and then creating circular motions towards the feet.

2. Silicone Visceral Protector Inserted

1. Insert silicone visceral protector midline over abdominal viscera, taking care to protect any ostomies (Figure 3).
2. Envelop the abdominal viscera with silicone visceral protector down to each paracolic gutter.
3. Create necessary cut outs in the visceral protector with scissors to protect the ostomies.
4. Place elastomer retainer in the midline on top of visceral protector and evenly space elastomer bands into the retainer (trim to size).
5. Adjust elastomer bands slowly in between osteopathic maneuvers.
6. Stop elastomer adjustments when tension hashmarks across the MFG is 1.5 – 2x stretch.
7. Record the MFG and VE with a ruler in centimeters at the start, install, and completion (Figure 4).

3. Installation of Negative Pressure Wound Therapy Device

1. Make NPWT device sponge as thing as possible and place in the midline above the elastomer retainer (Figure 5).
2. Cover with vacuum drape tape and apply the negative pressure device with continuous suction at -100 mmHg.
3. Perform osteopathic maneuver a few more times.

4. Elastomer Adjustment

1. Bring the patient back to operating room, or if your facility has the capability to perform in ICU, periodically. First elastomer adjustment can be 2 – 5 days after installation.
2. Remove the NPWT device overlying the midline wound with scissors, taking care to leave the adhesive iodine drape on the skin intact.
3. Prep the abdomen widely including the elastomers in place with 4% chlorhexidine gluconate.
4. Perform osteopathic maneuvers intermittently throughout procedure. See step 1.1.12. for details.
5. Record the MFG and myofascial apposition (Figure 6).
6. Irrigate the midline wound with at least 2 L of 40.5° C normal saline, taking care not to spill water on the DTS or the antimicrobial iodine impregnated adhesive drape.
7. Adjust elastomers by releasing the elastomer from the anchor and pulling each elastomer laterally, away from the midline.
8. Reapply the black sponge NPWT device.

5. Fascial Closure

1. Bring the patient back to the operating room. Prep widely.
2. Remove the elastomer retainer.
3. Remove the visceral protector and irrigate the abdominal cavity with at least 2 L of normal saline.
4. Close the fascia in a bi-directional fashion utilizing a Smead-Jones technique and a #2 vicryl suture on a TP1 needle.
5. Irrigate and dry the midline wound.
6. Apply PUBM micromatrix powder to the midline wound and evenly distribute the powder so that the newly created linea alba is covered in PUBM micromatrix.
7. Hydrate a two-layer, 10x15 cm, PUBM wound sheet and delaminate so there are 2 single sheets. Apply the sheets on top of the powder to cover the entire midline wound surface (Figure 7).
8. Appose skin edge with strips of vac drape tape (Figure 8).

Results

We have analyzed a total of 11 patients so far with catastrophic open abdomens. Primary myofascial closure was achieved at a mean of 9.36 days. We had 0% surgical site infections (SSI) and achieved 100% primary myofascial closure. No enteroatmospheric fistula resulted in this technique, unless present prior to this DTS and xenograft approach. Since May 2016, zero open abdomens were left open or covered with a skin graft (Figure 9).

Discussion

The most critical step of the protocol for closing a complex abdominal wound is performing osteopathic maneuvers before elastomer placement, after elastomer placement, and before and after elastomer adjustments. In addition, we perform osteopathic maneuvers on these patients after surgery three times a day, for at least five days. Our approach describes the use of osteopathic maneuver prior and after elastomer adjustments. The anecdotal observation has been that these maneuvers aid in fascial approximation, by facilitati...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
ABRA Abdominal Wall Closure Set	Southmedic	CWK08 Abdominal
3M Ioban 2 Antimicrobial Incise Drape	3M	6651EZ
MicroMatrix Micronized Particles 200 mg	ACell	MM0200
Cytal Wound Matrix 2-Layer 10 x 15 cm	ACell	WSM1015
Negative Pressure Therapy System	KCI	09-03-193.ABT.IE