Vacuum and mesh-mediated fascial traction for primary closure of open abdomen in critically ill surgical patients (Br J Surg 2012; 99: 1725–1732)

Open abdomen treatment is the standard of care in multiple challenging clinical situations, that can be summarized in the following four clinical scenarios. The septic contaminated abdomen that cannot be closed or when second-look laparotomy is mandatory. The patient with a tense abdomen after massive resuscitation or a prolonged surgical procedure is at risk of developing abdominal compartment syndrome and may be a candidate for prevention. When abdominal compartment syndrome or intra-abdominal hypertension has already developed. Finally, the damage-control situation in trauma and emergency surgery may include an open abdomen approach when the patient remains inadequately resuscitated or in need of intensive care before definitive surgical repair¹.

Abdominal compartment syndrome can be prevented by proactive management, including colloids and diuretics to mobilize fluid overload, neuromuscular blockade in patients on mechanical ventilation, and postoperative pain control, in particular epidural anaesthesia.

Open abdomen treatment is not without morbidity. The most feared complications are enteroatmospheric fistula and giant ventral hernia, both of which are associated with prolonged treatment and failure to close the open abdomen. A dual strategy is required to achieve early closure: first, to prevent adhesions between the intestines and bowel wall, and second, to prevent fixity and lateralization of the bowel wall. These two strategies permit a progressive approximation of the bowel wall towards the midline and closure¹.

Rasilainen and colleagues report excellent results for one method that adopts this dual strategy. Combining the abdominal vacuum-assisted closure system, including a plastic semipermeable layer preventing adhesions between the intestines and bowel wall and negative topical pressure, with a polypropylene mesh sutured to the fascial edges permitting traction of the abdominal wall towards the midline, was first described in 2007². In a multicentre prospective cohort study, a primary delayed fascial closure rate of 89 per cent among survivors and low complication rates were reported³. The present study validates the findings in a different country and patient population. In the absence of randomized controlled trials, which are difficult to perform without true equipoise, multiple observational studies reaching similar conclusions may represent the best level of evidence that we can achieve for this important clinical issue.

Disclosure

The author declares no conflict of interest.