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Weighted abdominal traction for assistance in abdominal closure
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Weighted abdominal traction for assistance in abdominal closure
T
∗
Wendy Jo Svetanoff , C. Jason Smithers, Russell Jennings Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Temporary abdominal closure Delayed closure Abdominal traction Weighted traction
Introduction: Loss of abdominal domain is an unsolved problem in many complex abdominal procedures. We report three patients who underwent weighted traction and use of retention sutures to prevent fascial retraction. Cases: Our first patient had esophageal metaplasia and a recalcitrant esophageal stricture after having esophageal atresia repair as an infant. Due to vascular congestion of his new conduit, his abdomen was left open. Respiratory compromise was noted on attempted closure, so the patient's abdominal fascia was placed on 20 pounds of traction to prevent fascial retraction. His abdomen was able to be closed after 7 days. Our second patient had a caustic ingestion and underwent a jejunal interposition. Due to the length of the procedure, the abdomen was left open. The fascia was sutured to a silastic silo and placed on 30 pounds of traction. After 8 days, the patient's abdomen was able to be closed primarily. Our third patient presented with persistent aspiration after esophageal atresia repair. Due to concern for her jejunal conduit, her abdomen was left open and placed on weighted traction. Once the abdomen was suitable for closure, an abdominal vac was placed, and continuous fascial tension was applied using #5 Ethibond sutures. Her abdomen was fully closed 10 days later. Discussion: One of the concerns with temporary abdominal closure is retraction of the fascia. We report three cases where the fascia and abdominal wall were placed on weighted traction, which allowed for retention of abdominal domain and delayed primary closure without grafts or mesh. This approach adds to the options available to aid in closure of the complex abdomen.
1. Introduction Temporary abdominal closure, once considered a failure in the surgical world, has now become the standard of care for multiple abdominal misfortunes, including trauma, peritonitis, vascular emergencies, and abdominal compartment syndrome [1–3]. This paradigm shift occurred after Rotondo et al. published a study showing that outcomes were better in trauma patients that underwent damage control laparotomy with resuscitation in the ICU compared to completing a full repair when the patient was coagulopathic, hypothermic, and acidotic [4]. Third-spacing from sepsis or shock, multiple blood products and fluids, and edema from injury or ischemia can all lead to significant thoraco-abdominal competition and ultimately abdominal compartment syndrome (with impaired cardiac function, blood flow, and pulmonary excursion) when trying to close the fascia. To prevent respiratory compromise, delayed fascial closure with management of the open abdomen is undertaken; the best technique, however, with which to achieve primary closure has yet to be determined.
Early techniques focused on packing of the injured areas for hemorrhagic control and prevention of desiccation of the bowel [2]. Since then, many different methods of closure have been entertained, with options ranging from loose packing, to mesh placement, and now negative pressure therapy (NPT) [2,3]. Eventual closure of the abdomen can then be facilitated by techniques such as mesh-mediated fascial traction (examples including a Wittmann patch) [3,5] and definitive closure aided with mesh, skin grafting, or component separation [1,6,7]. Current systems of fascial/muscle traction, however, are associated with increased abdominal compression, intra-abdominal pressure, and impaired ventilation. In this case report, we illustrate using weighted abdominal traction to facilitate continuous fascial tension and to prevent retraction without increasing abdominal pressure or compromising ventilation until the abdomen is suitable for closure. In three patients, we describe two similar, but distinctly different techniques, in how to approximate the abdominal wall without using mesh or artificial skin covering.
∗
Corresponding author. E-mail addresses: WendyJo.Svetanoff@childrens.harvard.edu (W.J. Svetanoff), [email protected] (C.J. Smithers), [email protected] (R. Jennings). https://doi.org/10.1016/j.epsc.2017.11.004 Received 13 September 2017; Received in revised form 9 November 2017; Accepted 9 November 2017 Available online 11 November 2017 2213-5766/ © 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
2. Case #1 Our first patient is a fourteen-year-old male with long-gap esophageal atresia who initially underwent a Foker procedure as an infant to re-establish esophageal continuity. He was found to have metaplasia of his distal esophagus during workup for a recalcitrant esophageal stricture. A jejunal interposition was proposed as the best means to remove the esophageal metaplasia as well as the esophageal stricture. Unfortunately, due to venous congestion of the jejunal interposition, multiple surgeries were required, and the patient's abdomen was left open with a VAC sponge. Upon attempted closure of the abdomen, it was noted that patient's tidal volumes and ventilator pressures changed drastically, despite having close to 10 cm between fascial edges. In order to prevent further fascial retraction until the abdomen could be closed, the edges of the fascia were sutured to a reinforced silastic silo with #1 Prolene sutures and large felt pledgets, creating a watertight closure. Further 0 Prolene sutures were then attached to the silo and to the skin of the abdomen; this was placed on 20 pounds of traction, using a pulley system similar to orthopedic traction. Using this system, we were able to prevent further competition with the thoracic cavity by containing the abdominal viscera in a silo, yet still allowing tension on the fascia to prevent retraction. The patient's abdomen was able to be closed primarily after 7 days in traction and aggressive diuresis. 3. Case #2 This technique was later duplicated in a nineteen-year-old female, who suffered a caustic ingestion at three years of age, requiring esophageal dilations and a gastric pull-up. Due to persistent aspiration and reflux, she presented to Boston Children's for a jejunal interposition in hopes of regaining adequate oral nutrition. The procedure included resection of the gastric conduit and a jejunal interposition with roux-en-y reconstruction. Due to the length of the procedure and fluid resuscitation, the abdominal contents were too edematous for adequate closure. Upon return to the operating room, fascial closure was unable to be obtained due to respiratory compromise. Similar to the previous patient, the edges of the fascia were sutured to a reinforced silastic silo with 0 Prolene sutures and large felt pledgets, and another layer of 0 Prolene sutures were attached to the silo and to the skin of the abdomen (Fig. 1). The patient was placed on 30 pounds of traction and brought back to the ICU. After 8 days of continuous traction, the patient's abdomen was able to be closed primarily with #1 interrupted PDS sutures without any difficulty or respiratory embarrassment. 4. Case #3 Our third patient is a twenty-five year old female with a history of esophageal atresia. Her surgical history included a jejunal interposition and subsequently a colonic interposition to restore adequate gastrointestinal continuity. Despite these interventions, she was unable to tolerate oral intake; she was also found to have severe gasto-colonicesophageal reflux despite multiple Nissen fundoplications, which lead to continued aspiration and chronic lung disease, requiring BiPAP. She was taken to the operating room, where a laparotomy and sternotomy were performed, the colonic interposition was taken down, and a new jejunal conduit was put in place. Due to the extensive nature of the surgery and concern for health of the new conduit, both her sternum and abdomen were left open; she was taken to the ICU with negative pressure therapy in place over her sternum and a silo dressing that was placed on 30 pounds of traction covering her abdominal cavity (Fig. 2). Unfortunately, after closing her sternum 3 days later, her esophagojejunal anastomosis leaked due to ischemia of the conduit, which required resection and a cervical esophagostomy. She required multiple
Fig. 1. A silastic silo was used for bowel protection, while the fascia and skin were suspended under 30 pounds of weighted traction.
wash-outs and remained with an open abdomen until the infection resolved. Upon trying to close the abdomen, it was noted that she had significant thoraco-abdominal competition, with tidal volumes of only 2 cc/kg. Her initial gap between fascial edges was 18 cm. To allow for the best chance at a primary fascial closure, relaxation of the abdominal wall was achieved with a Botox injection (110 units on each side) into the bilateral abdominal musculature; a NPT system with continuous fascial tension was constructed using #2 Ethibond sutures with felt
60
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
placement of a skin graft and then eventual ventral hernia repair [2], mesh patches to bridge the gap between fascial edges [3], or NPT with or without continuous tension [1,7]. Willms et al. describes attaching vicryl mesh to the fascial edges and intermittently reducing the fascial distance by resecting the mesh from the middle of wound; this prevented fascial deterioration from repeated suturing of the closure device to the fascia. Their results, looking at 53 patients, showed an 89% intention-to-treat closure rate without any enteroatmospheric fistula or dehiscence [5]. A retrospective study from Austria looked at 160 patients who had horizontal vessel loops placed intermittently on the fascia to prevent retraction [8]. This allowed for gradual closure of the abdomen; however, 16 patients required patch placement due to persistent inability to close the abdomen. We were able to demonstrate full closure initially by using weighted traction, which will not only prevent fascial retraction but can induce growth, allowing for an easier abdominal closure in the future. While we do not have a standard system for determining the amount of weight needed in each patient, the goal was to provide enough tension that the torso was barely touching the bed - similar to adjusting weight needed for somebody on traction for an unstable cervical spine injury or orthopedic injury. The weight was adjusting accordingly during the initial traction set-up. In our third case that required longer management of the open abdomen, we were able to obtain continuous fascial traction using Ethibond sutures instead of mesh or vessel loops. The advantage of Ethibond sutures is that they can be sequentially closed at the bedside without need for multiple trips to the operating room. Neither mesh nor graft placement was required to obtain complete closure in any of our cases. One area of interest that has little published literature is the management of the open abdomen in the pediatric population. Most data has focused on the use of temporary abdominal closure after liver transplantation. Multiple studies have shown that the use of silastic or PTFE patches as temporary closure has allowed for appropriate flow to the transplant without any difficulty in closing the abdomen, most of which were closed within 1–2 weeks post-transplant [9–11], A study from South Africa looked specifically at the use of NPT in neonates, including patients not only with congenital defects (gastroschisis, CDH) but also those that required second-look procedures for NEC or perforations [12]. The average length of the NPT was 4 days, and there was only one enterocutaneous fistula (6.7%). However, this study did not look at use of continuous fascial closure techniques as most of these defects were not large; therefore, most of these patients were able to get their abdomen closed within only a few days of the sentinel operation. We have also started applying this technique to infants with giant omphaloceles or gastroschisis; however, due to the severe abdominal defect and need for extensive growth induction of the fascia in these patients, traction times are longer than those who initially have an intact abdominal wall and experience abdominal compartment syndrome or massive fluid shifts after surgical procedures. No articles to date have been found looking at negative pressure therapy with continuous fascial tension in the pediatric population.
Fig. 2. Construction of the suspension initially took place in the operating room and was finalized once the patient had been moved to her ICU bed.
Fig. 3. A wound vac was placed to protect the bowel. Ethibond sutures were placed into the fascia and secured with Roeder's knots that were intermittently tightened in the intensive care unit. A negative pressure dressing was placed on the surface.
Gore-Tex pledgets placed in a horizontal mattress pattern along the abdominal fascia. Seven sutures were used in total. Roeder's knots were used to tie the horizontal mattress sutures, which allowed for progressive tightening of the abdominal wall, bringing each side of the fascia and abdominal wall closer together (Fig. 3). The sutures were tightening three times over a span of ten days, allowing for sequential closure of the abdomen, prior to the final removal of the wound vac sponge and the final closure of the fascia and abdomen. None of the sutures pulled through during the tightening process, and the fascia was closed without any need for skin grafting or mesh placement (Fig. 4). 5. Discussion
6. Conclusion
One of the concerns of leaving the abdomen open after a trauma laparotomy or an extensive abdominal operation is the feasibility of closing the abdomen at a later date, as fascial retraction starts as early as 3 days after surgery [5]. Therapy of the open abdomen has included allowing granulation tissue to form over the open abdomen with
We describe three cases of placing weighted traction on the fascial edges in situations where there is not only a significant loss of domain but that the abdominal viscera is so edematous that closing the abdomen would cause respiratory embarrassment. Placing a silo on weighted traction in these situations can avert potential compartment syndrome while preventing fascial retraction. Once the edema of the abdominal contents decreases, the fascia can either be closed primarily or an intra-abdominal wound vac with continuous fascial tension can be applied. We believe this procedure can be used for a variety of cases that require an open abdomen, including intra-abdominal sepsis, progressive bowel edema, concern for intra-abdominal hypertension due to length and fluid resuscitation during surgery, in trauma patients, and in the pediatric population as well.
Fig. 4. Complete primary closure of the fascia 10 days later.
61
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
References
[7] Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg 2015;39:912–25. [8] Kafka-Ritsch R, Zitt M, et al. Open abdomen treatment with dynamic sutures and topical negative pressure resulting in a high primary fascia closure rate. World J Surg 2012;36:1765–71. [9] de Goyet De Ville, Struye De Swielande, et al. Delayed primary closure of the abdominal wall after cadaveric and living donor graft transplantation in children: a safe and useful technique. Transpl Int Off. J Eur Soc Organ Transplant 1998;11(2):117–22. [10] Seaman DS, Newell K, et al. Use of polytetrafluoroethylene patch for temporary wound closure after pediatric liver transplantation. Transplantation 1996 Oct 15;62(7):1034–6. [11] Ong TH, Strong R. The management of difficult abdominal closure after pediatric liver transplantation. J Pediatr Surg 1996 Feb;31(2):295–6. [12] Hattori K, Numanoglu A, Cox S. Temporary vaccuum-assisted closure of the open abdomen in neonates. Eur J Pediatr Surg 2017 Jan 18https://www-thieme-connectcom.cuhsl.creighton.edu/DOI/DOI?10.1055/s-0036-1598010.
[1] Cristaudo A, Jennings S, Gunnarsson R, DeCosta A. Complications and mortality associated with temporary abdominal closure techniques: a systematic review and meta-analysis. Am Surg 2017 Feb.;18:191–216. [2] Huang Q, Li J, Lau W. Techniques for abdominal wall closure after damage control laparotomy: from temporary abdominal closure to early/delayed fascial closure – a review. Gastroenterol Res Pract 2016:1–15. [3] Regner JL, Kobayashi L, Coimbra R. Surgical Strategies for management of the open abdomen. World J Surg 2012;36:497–510. [4] Rotondo MF, Schwab CW, et al. ’Damage control’ an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993 Sep;35(3):375–82. [5] Willms A, Gϋsgen C, Schaaf S, Biler D, Von Websky M, Schwab R. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbeck's Arch Surg 2015;400(1):91–9. [6] Sharrock AE, Barker T, Yuen HM, Rickard R, Tai N. Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis. Int J Care Inj.
62
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Weighted abdominal traction for assistance in abdominal closure
T
∗
Wendy Jo Svetanoff , C. Jason Smithers, Russell Jennings Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Temporary abdominal closure Delayed closure Abdominal traction Weighted traction
Introduction: Loss of abdominal domain is an unsolved problem in many complex abdominal procedures. We report three patients who underwent weighted traction and use of retention sutures to prevent fascial retraction. Cases: Our first patient had esophageal metaplasia and a recalcitrant esophageal stricture after having esophageal atresia repair as an infant. Due to vascular congestion of his new conduit, his abdomen was left open. Respiratory compromise was noted on attempted closure, so the patient's abdominal fascia was placed on 20 pounds of traction to prevent fascial retraction. His abdomen was able to be closed after 7 days. Our second patient had a caustic ingestion and underwent a jejunal interposition. Due to the length of the procedure, the abdomen was left open. The fascia was sutured to a silastic silo and placed on 30 pounds of traction. After 8 days, the patient's abdomen was able to be closed primarily. Our third patient presented with persistent aspiration after esophageal atresia repair. Due to concern for her jejunal conduit, her abdomen was left open and placed on weighted traction. Once the abdomen was suitable for closure, an abdominal vac was placed, and continuous fascial tension was applied using #5 Ethibond sutures. Her abdomen was fully closed 10 days later. Discussion: One of the concerns with temporary abdominal closure is retraction of the fascia. We report three cases where the fascia and abdominal wall were placed on weighted traction, which allowed for retention of abdominal domain and delayed primary closure without grafts or mesh. This approach adds to the options available to aid in closure of the complex abdomen.
1. Introduction Temporary abdominal closure, once considered a failure in the surgical world, has now become the standard of care for multiple abdominal misfortunes, including trauma, peritonitis, vascular emergencies, and abdominal compartment syndrome [1–3]. This paradigm shift occurred after Rotondo et al. published a study showing that outcomes were better in trauma patients that underwent damage control laparotomy with resuscitation in the ICU compared to completing a full repair when the patient was coagulopathic, hypothermic, and acidotic [4]. Third-spacing from sepsis or shock, multiple blood products and fluids, and edema from injury or ischemia can all lead to significant thoraco-abdominal competition and ultimately abdominal compartment syndrome (with impaired cardiac function, blood flow, and pulmonary excursion) when trying to close the fascia. To prevent respiratory compromise, delayed fascial closure with management of the open abdomen is undertaken; the best technique, however, with which to achieve primary closure has yet to be determined.
Early techniques focused on packing of the injured areas for hemorrhagic control and prevention of desiccation of the bowel [2]. Since then, many different methods of closure have been entertained, with options ranging from loose packing, to mesh placement, and now negative pressure therapy (NPT) [2,3]. Eventual closure of the abdomen can then be facilitated by techniques such as mesh-mediated fascial traction (examples including a Wittmann patch) [3,5] and definitive closure aided with mesh, skin grafting, or component separation [1,6,7]. Current systems of fascial/muscle traction, however, are associated with increased abdominal compression, intra-abdominal pressure, and impaired ventilation. In this case report, we illustrate using weighted abdominal traction to facilitate continuous fascial tension and to prevent retraction without increasing abdominal pressure or compromising ventilation until the abdomen is suitable for closure. In three patients, we describe two similar, but distinctly different techniques, in how to approximate the abdominal wall without using mesh or artificial skin covering.
∗
Corresponding author. E-mail addresses: WendyJo.Svetanoff@childrens.harvard.edu (W.J. Svetanoff), [email protected] (C.J. Smithers), [email protected] (R. Jennings). https://doi.org/10.1016/j.epsc.2017.11.004 Received 13 September 2017; Received in revised form 9 November 2017; Accepted 9 November 2017 Available online 11 November 2017 2213-5766/ © 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
2. Case #1 Our first patient is a fourteen-year-old male with long-gap esophageal atresia who initially underwent a Foker procedure as an infant to re-establish esophageal continuity. He was found to have metaplasia of his distal esophagus during workup for a recalcitrant esophageal stricture. A jejunal interposition was proposed as the best means to remove the esophageal metaplasia as well as the esophageal stricture. Unfortunately, due to venous congestion of the jejunal interposition, multiple surgeries were required, and the patient's abdomen was left open with a VAC sponge. Upon attempted closure of the abdomen, it was noted that patient's tidal volumes and ventilator pressures changed drastically, despite having close to 10 cm between fascial edges. In order to prevent further fascial retraction until the abdomen could be closed, the edges of the fascia were sutured to a reinforced silastic silo with #1 Prolene sutures and large felt pledgets, creating a watertight closure. Further 0 Prolene sutures were then attached to the silo and to the skin of the abdomen; this was placed on 20 pounds of traction, using a pulley system similar to orthopedic traction. Using this system, we were able to prevent further competition with the thoracic cavity by containing the abdominal viscera in a silo, yet still allowing tension on the fascia to prevent retraction. The patient's abdomen was able to be closed primarily after 7 days in traction and aggressive diuresis. 3. Case #2 This technique was later duplicated in a nineteen-year-old female, who suffered a caustic ingestion at three years of age, requiring esophageal dilations and a gastric pull-up. Due to persistent aspiration and reflux, she presented to Boston Children's for a jejunal interposition in hopes of regaining adequate oral nutrition. The procedure included resection of the gastric conduit and a jejunal interposition with roux-en-y reconstruction. Due to the length of the procedure and fluid resuscitation, the abdominal contents were too edematous for adequate closure. Upon return to the operating room, fascial closure was unable to be obtained due to respiratory compromise. Similar to the previous patient, the edges of the fascia were sutured to a reinforced silastic silo with 0 Prolene sutures and large felt pledgets, and another layer of 0 Prolene sutures were attached to the silo and to the skin of the abdomen (Fig. 1). The patient was placed on 30 pounds of traction and brought back to the ICU. After 8 days of continuous traction, the patient's abdomen was able to be closed primarily with #1 interrupted PDS sutures without any difficulty or respiratory embarrassment. 4. Case #3 Our third patient is a twenty-five year old female with a history of esophageal atresia. Her surgical history included a jejunal interposition and subsequently a colonic interposition to restore adequate gastrointestinal continuity. Despite these interventions, she was unable to tolerate oral intake; she was also found to have severe gasto-colonicesophageal reflux despite multiple Nissen fundoplications, which lead to continued aspiration and chronic lung disease, requiring BiPAP. She was taken to the operating room, where a laparotomy and sternotomy were performed, the colonic interposition was taken down, and a new jejunal conduit was put in place. Due to the extensive nature of the surgery and concern for health of the new conduit, both her sternum and abdomen were left open; she was taken to the ICU with negative pressure therapy in place over her sternum and a silo dressing that was placed on 30 pounds of traction covering her abdominal cavity (Fig. 2). Unfortunately, after closing her sternum 3 days later, her esophagojejunal anastomosis leaked due to ischemia of the conduit, which required resection and a cervical esophagostomy. She required multiple
Fig. 1. A silastic silo was used for bowel protection, while the fascia and skin were suspended under 30 pounds of weighted traction.
wash-outs and remained with an open abdomen until the infection resolved. Upon trying to close the abdomen, it was noted that she had significant thoraco-abdominal competition, with tidal volumes of only 2 cc/kg. Her initial gap between fascial edges was 18 cm. To allow for the best chance at a primary fascial closure, relaxation of the abdominal wall was achieved with a Botox injection (110 units on each side) into the bilateral abdominal musculature; a NPT system with continuous fascial tension was constructed using #2 Ethibond sutures with felt
60
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
placement of a skin graft and then eventual ventral hernia repair [2], mesh patches to bridge the gap between fascial edges [3], or NPT with or without continuous tension [1,7]. Willms et al. describes attaching vicryl mesh to the fascial edges and intermittently reducing the fascial distance by resecting the mesh from the middle of wound; this prevented fascial deterioration from repeated suturing of the closure device to the fascia. Their results, looking at 53 patients, showed an 89% intention-to-treat closure rate without any enteroatmospheric fistula or dehiscence [5]. A retrospective study from Austria looked at 160 patients who had horizontal vessel loops placed intermittently on the fascia to prevent retraction [8]. This allowed for gradual closure of the abdomen; however, 16 patients required patch placement due to persistent inability to close the abdomen. We were able to demonstrate full closure initially by using weighted traction, which will not only prevent fascial retraction but can induce growth, allowing for an easier abdominal closure in the future. While we do not have a standard system for determining the amount of weight needed in each patient, the goal was to provide enough tension that the torso was barely touching the bed - similar to adjusting weight needed for somebody on traction for an unstable cervical spine injury or orthopedic injury. The weight was adjusting accordingly during the initial traction set-up. In our third case that required longer management of the open abdomen, we were able to obtain continuous fascial traction using Ethibond sutures instead of mesh or vessel loops. The advantage of Ethibond sutures is that they can be sequentially closed at the bedside without need for multiple trips to the operating room. Neither mesh nor graft placement was required to obtain complete closure in any of our cases. One area of interest that has little published literature is the management of the open abdomen in the pediatric population. Most data has focused on the use of temporary abdominal closure after liver transplantation. Multiple studies have shown that the use of silastic or PTFE patches as temporary closure has allowed for appropriate flow to the transplant without any difficulty in closing the abdomen, most of which were closed within 1–2 weeks post-transplant [9–11], A study from South Africa looked specifically at the use of NPT in neonates, including patients not only with congenital defects (gastroschisis, CDH) but also those that required second-look procedures for NEC or perforations [12]. The average length of the NPT was 4 days, and there was only one enterocutaneous fistula (6.7%). However, this study did not look at use of continuous fascial closure techniques as most of these defects were not large; therefore, most of these patients were able to get their abdomen closed within only a few days of the sentinel operation. We have also started applying this technique to infants with giant omphaloceles or gastroschisis; however, due to the severe abdominal defect and need for extensive growth induction of the fascia in these patients, traction times are longer than those who initially have an intact abdominal wall and experience abdominal compartment syndrome or massive fluid shifts after surgical procedures. No articles to date have been found looking at negative pressure therapy with continuous fascial tension in the pediatric population.
Fig. 2. Construction of the suspension initially took place in the operating room and was finalized once the patient had been moved to her ICU bed.
Fig. 3. A wound vac was placed to protect the bowel. Ethibond sutures were placed into the fascia and secured with Roeder's knots that were intermittently tightened in the intensive care unit. A negative pressure dressing was placed on the surface.
Gore-Tex pledgets placed in a horizontal mattress pattern along the abdominal fascia. Seven sutures were used in total. Roeder's knots were used to tie the horizontal mattress sutures, which allowed for progressive tightening of the abdominal wall, bringing each side of the fascia and abdominal wall closer together (Fig. 3). The sutures were tightening three times over a span of ten days, allowing for sequential closure of the abdomen, prior to the final removal of the wound vac sponge and the final closure of the fascia and abdomen. None of the sutures pulled through during the tightening process, and the fascia was closed without any need for skin grafting or mesh placement (Fig. 4). 5. Discussion
6. Conclusion
One of the concerns of leaving the abdomen open after a trauma laparotomy or an extensive abdominal operation is the feasibility of closing the abdomen at a later date, as fascial retraction starts as early as 3 days after surgery [5]. Therapy of the open abdomen has included allowing granulation tissue to form over the open abdomen with
We describe three cases of placing weighted traction on the fascial edges in situations where there is not only a significant loss of domain but that the abdominal viscera is so edematous that closing the abdomen would cause respiratory embarrassment. Placing a silo on weighted traction in these situations can avert potential compartment syndrome while preventing fascial retraction. Once the edema of the abdominal contents decreases, the fascia can either be closed primarily or an intra-abdominal wound vac with continuous fascial tension can be applied. We believe this procedure can be used for a variety of cases that require an open abdomen, including intra-abdominal sepsis, progressive bowel edema, concern for intra-abdominal hypertension due to length and fluid resuscitation during surgery, in trauma patients, and in the pediatric population as well.
Fig. 4. Complete primary closure of the fascia 10 days later.
61
Journal of Pediatric Surgery Case Reports 29 (2018) 59–62
W.J. Svetanoff et al.
References
[7] Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg 2015;39:912–25. [8] Kafka-Ritsch R, Zitt M, et al. Open abdomen treatment with dynamic sutures and topical negative pressure resulting in a high primary fascia closure rate. World J Surg 2012;36:1765–71. [9] de Goyet De Ville, Struye De Swielande, et al. Delayed primary closure of the abdominal wall after cadaveric and living donor graft transplantation in children: a safe and useful technique. Transpl Int Off. J Eur Soc Organ Transplant 1998;11(2):117–22. [10] Seaman DS, Newell K, et al. Use of polytetrafluoroethylene patch for temporary wound closure after pediatric liver transplantation. Transplantation 1996 Oct 15;62(7):1034–6. [11] Ong TH, Strong R. The management of difficult abdominal closure after pediatric liver transplantation. J Pediatr Surg 1996 Feb;31(2):295–6. [12] Hattori K, Numanoglu A, Cox S. Temporary vaccuum-assisted closure of the open abdomen in neonates. Eur J Pediatr Surg 2017 Jan 18https://www-thieme-connectcom.cuhsl.creighton.edu/DOI/DOI?10.1055/s-0036-1598010.
[1] Cristaudo A, Jennings S, Gunnarsson R, DeCosta A. Complications and mortality associated with temporary abdominal closure techniques: a systematic review and meta-analysis. Am Surg 2017 Feb.;18:191–216. [2] Huang Q, Li J, Lau W. Techniques for abdominal wall closure after damage control laparotomy: from temporary abdominal closure to early/delayed fascial closure – a review. Gastroenterol Res Pract 2016:1–15. [3] Regner JL, Kobayashi L, Coimbra R. Surgical Strategies for management of the open abdomen. World J Surg 2012;36:497–510. [4] Rotondo MF, Schwab CW, et al. ’Damage control’ an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993 Sep;35(3):375–82. [5] Willms A, Gϋsgen C, Schaaf S, Biler D, Von Websky M, Schwab R. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbeck's Arch Surg 2015;400(1):91–9. [6] Sharrock AE, Barker T, Yuen HM, Rickard R, Tai N. Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis. Int J Care Inj.
62