title: Management of complex abdominal wall defects associated with penetrating abdominal trauma.
abstract: BACKGROUND
  The paradigm of Damage Control Surgery (DCS) has radically improved the management of abdominal trauma, but less well described are the options for managing the abdominal wall itself in an austere environment. This article describes a series of patients with complex abdominal wall problems managed at the UK-led Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan.
  
  
  METHODS
  Contemporaneous review of a series of patients with complex abdominal wall injuries who presented to the Role 3 MTF between July and November 2012.
  
  
  RESULTS
  Five patients with penetrating abdominal trauma associated with significant damage to the abdominal wall were included. All patients were managed using DCS principles, leaving the abdominal wall open at the end of the first procedure. Subsequent management of the abdominal wall was determined by a multidisciplinary team of general and plastic surgeons, intensivists and specialist nurses. The principles of management identified included minimising tissue loss on initial laparotomy by joining adjacent wounds and marginal debridement of dead tissue; contraction of the abdominal wall was minimised by using topical negative pressure dressing and dermal-holding sutures. Definitive closure was timed to allow oedema to settle and sepsis to be controlled. Closure techniques include delayed primary closure with traction sutures, components separation, and mesh closure with skin grafting.
  
  
  CONCLUSIONS
  A daily multidisciplinary team discussion was invaluable for optimal decision making regarding the most appropriate means of abdominal closure. Dermal-holding sutures were particularly useful in preventing myostatic contraction of the abdominal wall. A simple flow chart was developed to aid decision making in these patients. This flow chart may prove especially useful in a resource-limited environment in which returning months or years later for closure of a large ventral hernia may not be possible.
authors.affiliation: 212 Field Hospital, Sheffield, UK.
authors.forename: G Suren
authors.initials: GS
authors.lastname: Arul
authors.affiliation: Department of Surgery, William Beaumont Army Medical Centre, El Paso, Texas, USA.
authors.forename: B J
authors.initials: BJ
authors.lastname: Sonka
authors.affiliation: San Antonio Military Medical Centre, Joint Base Sane Antonio, San Antonio, Texas, USA.
authors.forename: J B
authors.initials: JB
authors.lastname: Lundy
authors.affiliation: Department of Surgery, Royal Centre for Defence Medicine, Birmingham, UK Derriford Hospital, Plymouth, UK.
authors.forename: R F
authors.initials: RF
authors.lastname: Rickard
authors.affiliation: Department of Surgery, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: S L A
authors.initials: SL
authors.lastname: Jeffery
mesh_terms: D000007:Abdominal Injuries / Q000209:etiology / Q000601:surgery*; D034861:Abdominal Wall / Q000601:surgery*; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000150:complications / Q000601:surgery*; D003646:Debridement; D006801:Humans; D008297:Male; D008889:Military Personnel; D054843:Negative-Pressure Wound Therapy; D060051:Occupational Injuries / Q000209:etiology / Q000601:surgery*; D016038:Skin Transplantation; D013526:Surgical Mesh; D013536:Suture Techniques; D006113:United Kingdom; D014948:Wounds, Gunshot / Q000150:complications / Q000601:surgery*
keywords: Plastic & Reconstructive Surgery; Trauma Management