Late fascial closure in lieu of ventral hernia: the next step in open abdomen management.
BACKGROUND
The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients.


METHODS
The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure > or = 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC.


RESULTS
From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99).


CONCLUSIONS
VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided.
Miller
Preston R
PR
Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27514, USA. pmiller@wfubmc.edu
Thompson
James T
JT
Faler
Byron J
BJ
Meredith
J Wayne
JW
Chang
Michael C
MC
D000007:Abdominal Injuries / Q000601:surgery*; D000009:Abdominal Muscles / Q000601:surgery; D000328:Adult; D016009:Chi-Square Distribution; D003161:Compartment Syndromes / Q000601:surgery; D000071938:Fasciotomy; D005260:Female; D006555:Hernia, Ventral; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000379:methods*; D008297:Male; D016879:Salvage Therapy / Q000379:methods; D013526:Surgical Mesh; D013536:Suture Techniques; D016896:Treatment Outcome; D014618:Vacuum