title: Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis.
abstract: BACKGROUND
  Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies.
  
  
  METHODS
  Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.
  
  
  RESULTS
  26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay.
  
  
  CONCLUSIONS
  Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK. Electronic address: sharrock@doctors.org.uk.
authors.forename: A E
authors.initials: AE
authors.lastname: Sharrock
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: T
authors.initials: T
authors.lastname: Barker
authors.affiliation: Department of Primary Care and Population Sciences, South Academic Block, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD.
authors.forename: H M
authors.initials: HM
authors.lastname: Yuen
authors.affiliation: Department of Primary Care and Population Sciences, South Academic Block, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD.
authors.forename: R
authors.initials: R
authors.lastname: Rickard
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: N
authors.initials: N
authors.lastname: Tai
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery*; D058107:Abdominal Wound Closure Techniques; D005205:Fascia; D000071938:Fasciotomy; D006555:Hernia, Ventral / Q000209:etiology / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000379:methods; D054843:Negative-Pressure Wound Therapy / Q000379:methods*; D017410:Practice Guidelines as Topic; D013997:Time Factors; D016896:Treatment Outcome
keywords: Acute component separation; Acute mesh repair; Damage control laparotomy; Delayed primary closure; Trauma