title: Not so fast to skin graft: transabdominal wall traction closes most "domain loss" abdomens in the acute setting.
abstract: BACKGROUND
  Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation.
  
  
  METHODS
  From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable "domain loss abdomens" after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked.
  
  
  RESULTS
  During this 36-month period, OAP/TAWT was applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWT was 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations.
  
  
  CONCLUSIONS
  OAP/TAWT has revolutionized the way we manage "domain loss" open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting.
  
  
  METHODS
  Therapeutic study, level III.
authors.affiliation: Cook County Trauma Unit, JSH Cook County Hospital, Chicago, Illinois 60612, USA. adennis@cookcountytrauma.org
authors.forename: Andrew
authors.initials: A
authors.lastname: Dennis
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Vizinas
authors.forename: Kimberly
authors.initials: K
authors.lastname: Joseph
authors.forename: Samuel
authors.initials: S
authors.lastname: Kingsley
authors.forename: Faran
authors.initials: F
authors.lastname: Bokhari
authors.forename: Frederic
authors.initials: F
authors.lastname: Starr
authors.forename: Stathis
authors.initials: S
authors.lastname: Poulakidas
authors.forename: Dorion
authors.initials: D
authors.lastname: Wiley
authors.forename: Thomas
authors.initials: T
authors.lastname: Messer
authors.forename: Kimberly
authors.initials: K
authors.lastname: Nagy
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery*; D034861:Abdominal Wall / Q000601:surgery*; D058107:Abdominal Wound Closure Techniques; D000293:Adolescent; D000328:Adult; D002985:Clinical Protocols; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods; D008875:Middle Aged; D016038:Skin Transplantation / Q000379:methods*; D013536:Suture Techniques; D014143:Traction / Q000379:methods*; D055815:Young Adult