Fig. 1
A male patient of 44 years injured from a traffic accident was transferred into our hospital 2 days after undergoing exploratory laparotomy, partial resection of right liver, diaphragmatic repair, and duodenal repair, with an intra-bladder pressure of 24 mmHg. a Abdominal swelling; b the patient underwent IAVA assisted by VSD through downward extension of the original incision
3 Key Techniques of OA
3.1 Temporary Abdominal Closure (TAC)
Skin closure techniques is to use skins or other materials to keep the integrity of the abdominal wall, mainly including continuous skin suture, towel clips, silo technique, three-litre bag and silicone diaphragm placement. This technique is prompt, economic and easy to implement. However, its disadvantages are also remarkable. It may increase skin necrosis , abdominal contamination, ascites leak, evisceration and cannot reverse the process of abdominal wall retraction. The incidence of ACS is 13–36 %, primary fascial closure is no more than 30 %, and the incidence of intestinal fistula varies considerably, ranging from 0 to 14.4 % [12]. Therefore, the techniques mentioned above are mainly used in the early stage of TAC development while rarely employed nowadays. Based on 549 cases of 10 articles, the mortality is 17–58.4 %. The mean incidence of intestinal fistula from 3 articles is 7.41 %.
Fascial closure techniques (FCTs) is to insert grafting materials and suture them to the fascia [13, 14]. Materials once used clinically include three-litre bag for parenteral nutrition or peritoneal dialysis, various kinds of surgical dressings, nonabsorbable meshes including polypropylene mesh (Marlex mesh), Wittmann mesh, expanded polytetrafluoroethylene (ePTFE) mesh, polypropylene and ePTFE composite mesh, and absorbable meshes including hydroxy acetic acid polyester mesh (Vicry1), polyglycolic acid mesh (Dexon). In order to prevent intra-abdominal hypertension, redundant materials are often used to keep the abdominal wall relax, and gradually tightened in postoperative stage [15–17]. The greatest advantage is the achievement of reversible and tension-free TAC, facilitating reoperations, especially for cases with limited opportunity of definitive closure for open abdomen within 1 week [18]. However, this kind of technique is not able to evacuate peritoneal fluid and lack the ability of wound drainage, which may lead to recurrent IAH or wound impregnation. Nonabsorbable mesh may accompany with a relevant high incidence of intestinal fistula (6–18 %) [19], even up to 75 % [20]. Other disadvantages of nonabsorbable mesh include incapability to prevent adhesion between viscera and anterior abdominal wall, low primary closure rate, increasingly expensive materials and are hardly available in domestic. Nowadays, Velcro-like Wittmann mesh is usually applied in clinical practice. Five articles with 365 cases reported the mortality, incidence of fistula and primary fascia closure rate are 7.7–67 %, 1.3 % and 78–100 %, respectively [21].
Vacuum-assisted closure is a technique in which the intestine is covered by omentum majus underlying the wound. Polyvinyl alcohol and gelatin sponge composite material is tailored to proper size and sutured with abdominal wall with/without sheet in order to fully accommodate the viscera, provide physical environment and avoid desiccation of the viscera. Besides, it is the way of abdominal wall reconstruction, may help to prevent mechanical damage of the viscera, avoid abdominal cavity contamination, evacuate peritoneal fluid, as well as reduce and maintain IAP. Biological membrane is set to seal the foam and wounds (3–4 cm over the edge of incision), then the silicone tube is connected with negative pressure equipment (45–60 mmHg). The vacuum-assisted closure system is sealed by biological membrane and the abdominal cavity is separated with the outside environment. This may help to expand the abdominal volume considerably, reduce IAP and prevent bacterial invasion. Besides, it may reduce postoperative workload due to unnecessity of regular dressing change. The continuous vacuum drainage is benefit for alleviation of inflammation and edema, as well as wound healing. This is the most commonly used technique with multiple choices [15, 16, 22]. The author applied vacuum-assisted closure system to manage 20 open abdomen cases since 2008 and all patients had satisfactory outcome. Among the 20 patients, 12 cases received primary abdominal wall reconstruction within 5–9 days, 8 were conducted skin grafting to cover the wound after 2 weeks (Fig. 2a–c) to develop planned ventral hernia (Fig. 2d). A review of vacuum-assisted closure in the treatment of open abdomen in 1744 cases from 20 articles showed a mortality of 17–60 % and the mean incidence of fistula of 7.26 % [3].
Fig. 2
A male patient of 28 years old with abdominal stab wound was transferred to our hospital 3 days after primary laparotomy with transverse colon repair and ileostomy. The temperature was 39.2 °C and the IVP was 18 mmHg. Intra-abdominal volume increment was applied after admission. a abdominal viscera bulging after sutures removal, b temporary abdominal closure with VSD, c granulation under the foam 10 days after open abdomen, d planned ventral hernia after skin grafting
3.2 Locations and Incisions of Open Abdomen
Patients who need to be performed open abdomen are often with unstable vital signs. They even cannot be transferred to the operation room and the operations may be conducted at the ICU bedside [23] (Fig. 3). However, if the operation room is able to supply relevant equipments, vacuum device, staff and sterile condition, it is the best choice.
