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 m....

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 th....

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