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

Good day, I'd Dr.Catharine Ronaghan, attending surgeon at Texas Tech University Health Science Center in Lubbock, Texas. This is my chief resident, Dr.Yana Puckett. Today we would like to introduce the ABRA Dynamic Tissue System.

This system allows for successful closure of the catastrophic open abdomen. The reestablished linea alba restores a biomechanically functional abdominal wall. The main advantage of this technique is the avoidance of a massive incisional hernia.

Even the most complex open abdomens are closed with superb long-term results. This video series will demonstrate the ABRA Dynamic Tissue System installation technique, adjustment procedure, and deinstallation with primary myofascial closure in a series of three installments. The patient is widely prepped from the nipple area to the upper thighs.

From the entire anterior and lateral abdominal area to where the body meets the bed. Notice the plastic visceral protector is left in place for the prep. Only the outer blue sponge and vacuum drape tape are removed.

Also notice the wide towel draping with clips, followed by a narrow four-towel drape around the incision. This is to ensure the iodine-impregnated adhesive barrier is applied on the skin. The goal is to have every element of the Dynamic Tissue System on the adhesive barrier and not directly on the patient's skin.

Initially, do not remove the adhesive backing from the laparotomy drape. Remove the plastic visceral protector. Proceed with thorough exploration and large volume paracentesis with heated 0.9%normal saline.

Be very respectful of the visceral mass. If the visceral mass is fused to itself, as seen in this video, do not attempt to separate bowel loops. It is important to be sure the visceral mass is not fused to the posterior fascia.

Otherwise, there is a risk of injury from the silicone visceral protector. If the patient is deemed an abdominal wall Dynamic Tissue System candidate, obtain baseline measurements:the MFG, or myofascial gap, which is the distance in centimeters between the medial edges of the rectus muscles;the VE, or visceral extrusion, the protrusion of viscera in centimeters above the posterior fascia;and L, the length of the incision in centimeters. Cut the drapes to widely expose the anterior and lateral abdomen.

The goal is to apply the iodine-impregnated adhesive barrier widely such that every element of the Dynamic Tissue System is on the barrier and not directly on patient skin. Protect the visceral mass with a laparotomy sponge, which should not directly contact the skin. Always double-glove and change as needed throughout the procedure.

Generously spritz the skin with medical adhesive spray to ensure durable adhesion of the iodine-impregnated adhesive barrier to the skin for the duration of installation. This sheet will remain in place until the device is de-installed and primary myofascial closure is achieved. The application of the adhesive barrier should start on the side of the operative surgeon.

The assistant across from the surgeon holds the opposite end of the adhesive barrier and follows the operative surgeon's lead for placement. A third person removes the backing at the direction of the operative surgeon. Notice the large area of skin covered by the adhesive barrier.

It is important to apply it slowly and smoothly. Also, note that there was no excessive tension as the adhesive barrier is applied to avoid skin shear injury. The iodine-impregnated adhesive barrier is cut around the laparotomy sponge, which is removed from the field.

Notice how adherent the adhesive barrier is to the skin edge, in some areas, actually overlapping, which can be trimmed later as needed. The important point is that the barrier is densely adherent to the skin edge, which prevents fluid from tracking between the adhesive barrier and skin thus causing a maceration skin injury. Elements of the Dynamic Tissue System are shown.

These are the main components of the Dynamic Tissue System. Measure five centimeters lateral to each myofascial edge. To ensure the distance is actually five centimeters from the myofascial edge and not the skin edge, it is recommended that the operative surgeon graph the myofascial unit and measure from the deep myofascial edge.

The operative surgeon places a 15-centimeter ruler at the end of the middle finger and palpates through the abdominal wall. The area is marked, ultimately creating the ellipse seen here. The elastomers should be positioned every three centimeters along the myofascial gap.

Do not place elastomers under the intact abdominal wall. So be aware of the cephalad and caudal aspects of the myofascial gap. Fortuitously, the button is three centimeters in width.

So if no ostomies are present, place the buttons side-by-side and mark the base of the U-shaped slit intersecting the ellipse. Mash the side opposite to the elastomer insertion sites by initially placing an elastomer across the myofascial gap at the cephalad most mark. Then proceed with side-by-side button placement to symmetrize the elastomer insertion sites on the contralateral side.

This is the cannulator. It is the device meant to bluntly dissect through the abdominal wall but could definitely injure viscera so use caution. Use a Number 11 knife blade to make superficial but full thickness dermotomies on one side only.

Be sure the dermotomy is large enough for the cannulator. Bleeding is minimized if deep stab incision are avoided. It is easily controlled with bimanual pressure if encountered.

Note the parallel position of the blade to the skin. The cannulator is placed through the abdominal wall at an absolute 90-degree angle. Protect the visceral mass with the viscera retainer.

Apply a lot of countertraction with the other hand. This allows for a safe and controlled cannulation. Insert the elastomer and slide it toward the end of the cannulator to secure the elastomer as the cannulator is withdrawn through the abdominal wall.

Secure both ends of the elastomer with a small hemostat. On the opposite side, repeat each step, starting with superficial dermotomies. Remember to apply the hemostat to the other end of the elastomer once it is positioned across the myofascial gap.

Always orient the silicone visceral protector in the long axis of the abdomen as demonstrated. Scroll it. Place it under the elastomers.

Carefully unroll it, and cover the visceral mass. It is rarely necessary to trim the silicone visceral protector. Instead, fold it on itself as needed in the paracolic gutters and pelvic brim.

Secure the elastomers with the buttons and remove the hemostats. Do not tension the elastomers across the myofascial gap yet. Pinch the elastomer at the button base.

Stretch the elastomer distillate to lock into the cleat. Orient the elastomer so that the black tension markings are visible. At this point, begin two region osteopathic maneuvers and continue intermittently for the remainder of the case.

Each move should last about 60 seconds. You can not do too many moves. Notice the lateral position of the hands lateral to all elements of the Dynamic Tissue System.

Continue this move at least three times per day while the device is in place and at least five days after deinstallation. Trim the elastomer retainer to slightly less than the length of the incision. Place the elastomers into the appropriate slot.

It is perfectly acceptable to have two elastomers in one slot if needed. Begin elastomer adjustments interspersed with osteopathic maneuvers until proper dynamic tension is achieved across the myofascial gap. That is defined as 1.5 to two times stretch of the black tension markings across the myofascial gap.

Record the progress for operative note documentation. Spray the iodine-impregnated adhesive barrier with medical adhesive spray. Gently lift the back of the button.

Fold the backing of the button tail exposing the metal hanger. Place the metal hanger at a right angle to the button tail lock, and be sure the hanger is placed within the narrow slot to lock. Once all button tails are in place, trim the excess elastomer length.

Note the elastomer trim mark on the button tail. Cut the black sponge into a long thin piece, and apply it as shown. Generously apply additional adhesive spray to the iodine-impregnated adhesive barrier medial to the buttons.

Cut vacuum drape tape sheets into strips. Apply overlapping the vacuum drape tape strips lateral to medial as the goal is medialization of all elements of the abdominal wall. Apply the track pad in the standard fashion.

Set the negative pressure to between 20 and 75 millimeter mercury with continuous high intensity. Use as low a negative pressure as possible to control drainage. Excess vacuum drape tape should be rolled under the buttons.

Apply a double layer of moisture-wicking fabric with antimicrobial silver as demonstrated such that the button completely sits on the fabric and completely surrounds the elastomer as it exits the skin. This will capture any moisture from within the abdominal cavity tracking along the elastomer. Leave the patient on the hospital bed.

Do not move the patient to the OR table. The operative surgeon should carefully remove the black sponge. Notice that a minimal amount of vacuum drape tape is removed.

If the iodine-impregnated adhesive barrier is adherent to the medial skin edges, do not disrupt it. Only trim the barrier in areas where it has separated from the medial skin edges. Any exposed skin will be covered at the end of the procedure with vacuum drape tape.

It is common to have layers of vacuum drape tape over the intact iodine-impregnated adhesive barrier. Obtain new baseline measurements. Typically the cephalad and caudal myofascial edges move to the midline first so document the length of the MFA as well.

The operative surgeon should prep the patient using chlorhexidine gluconate. Avoid a sloppy wet prep. Throughout the adjustment procedure, perform at least two region osteopathic maneuvers.

You cannot perform too many. Complete a thorough re-exploration with a large volume paracentesis. There is no need to remove the silicone visceral protector or release the elastomers.

Be sure the visceral protector hasn't slipped or impinged on hollow or solid viscera. Most importantly, be sure that the elastomers are never in direct contact with the viscera once the device is completely installed and the elastomers are tensioned. Once these steps are completed, if appropriate adjust the elastomers based on the elastomer tension markings across the myofascial gap.

Do so in a bidirectional fashion such that the middle elastomers are always tensioned last. Do not over tension. Typically adjustments are made when tension markings are at 1.5 times stretch.

Be very sensitive to the feel of the elastomer and terminate the adjustment as soon as resistance is felt, regardless of the tension markings across the myofascial gap. Typically, micro adjustments interspersed with osteopathic maneuvers work best. Never adjust elastomers with the negative pressure wound therapy device in place.

You cannot see the tension markings across the myofascial gap. Obtain measurements at the completion of the adjustment procedure and record them in an operative note. Apply the black sponge device as demonstrated.

The patient is moved to the OR table with risers to accommodate an X-ray cassette. Again, the operative surgeon should remove the negative pressure wound therapy device sponge and complete the skin prep with chlorhexidine gluconate. This should be a non-sloppy wide prep.

The wide and narrow four-towel drape configuration described for installation is used here as well. It is important to raise subcutaneous flaps at least two centimeters back from the myofascial edges to completely and precisely delineate the myofascia. Obtain a baseline peak inspiratory pressure reading.

This should be monitored throughout the primary myofascial closure. The device is removed in stages, beginning with the elastomer retainer. Standard exploration and large-volume paracentesis is completed.

X-rays are obtained to exclude retained foreign objects. The primary myofascial closure is completed in a bidirectional fashion with Number Two Vicryl on a TP-1 needle using a far-near, near-far Smead-Jones technique. The sutures are tied in place, again, in bidirectional fashion.

Then elastomers are cut as demonstrated. This allows for continued dynamic tension during the closure. Eventually, once the elastomers and the mid-portion of the incision are cut, the silicone visceral protector is carefully removed from the abdominal cavity and remaining sutures are tied in place, completing the primary myofascial closure.

Note that the drapes have now been cut to expose the entire Dynamic Tissue System. The iodine-impregnated adhesive barrier, buttons, button tails, and cut elastomers are carefully removed from the skin to avoid epidermal shear injury. The circulating nurse examines and counts all elements of the Dynamic Tissue System.

Typical xenograft requirements include a one-gram of ground-up porcine urinary bladder matrix and a 10-by-15 centimeter two-layer wound sheet. Hydrate the wound sheet in its original packaging with sterile irrigation fluid as demonstrated for at least three to five minutes. Prior to implantation of the porcine urinary bladder matrix, the elastomer exit sites are covered with a Hydrofiber wound dressing.

After the surrounding skin is generously spritzed with medical adhesive spray. These are secured in place with strips of vacuum drape tape. The ground-up porcine urinary bladder matrix is sprinkled on the myofascial closure.

The delaminated two-layer wound sheet is positioned in the wound such that the myofascia and subcutaneous tissue are exposed to the xenograft. The skin edges are opposed with strips of vacuum drape tape after liberal spritzing of skin with medical adhesive spray. This is an example of the sutureless skin closure where the skin edges are opposed with strips of vacuum drape tape.

This example combines a vertical panniculectomy with the deinstallation primary myofascial closure and PUBM implantation. This is a layered suture closure after the vertical panniculectomy and subcutaneous flap elevation. Note the PUBM is implanted as each layer is closed.

This is the appearance of an abdominal closure approximately three weeks postop. Following the procedure guidelines as outlined, the ABRA Dynamic Tissue System installation can easily be completed within two to three hours of operative time. Once the ABRA Dynamic Tissue System is installed, it's important to perform the two-region osteopathic maneuvers, not only in the operating room, but at least three times a day at bedside.

We recommend the maneuver be performed for at least 60 seconds at a time. Once the device is deinstalled and primary myofascial closure is achieved, the two-region osteopathic maneuvers are continued postoperatively three times a day for at least five days. There are a number of ongoing research projects.

Our team continues to explore quality of life outcomes, enterocutaneous and enteroatmospheric fistula rates prior to and since the introduction of this technology at our institution. In addition, we will continue to surveil our patients closely for the development of incisional hernias, bowel obstructions, and other sequelae associated with major abdominal surgery. So after watching this video, you'll have a good understanding and all the tools necessary to close the most complex open abdomens utilizing the ABRA Dynamic Tissue System.