Elsevier Global Medical News

Novel Approach Avoids Skin Grafts in Open Abdomens

BY PATRICE WENDLING
Elsevier Global Medical News
Breaking News

LAKE BUENA VISTA, FLA. (EGMN) – The use of transabdominal wall traction to close domain-loss abdomens has avoided the need for skin grafting or a planned ventral hernia, and is now part of the open abdomen protocol at Chicago’s Cook County Hospital.

Transabdominal wall traction (TAWT) uses myofascial cutaneous release via isometric traction to close abdomens in the subset of patients who, after resuscitation and diuresis, cannot be closed, Dr. Andrew Dennis explained at the annual meeting of the Eastern Association for the Surgery of Trauma. This subset of patients is increasing, largely because of the resounding success of damage control laparotomy and decompressive laparotomy.

“TAWT has revolutionized the way we manage domain-loss, open-abdomen patients, and has virtually eliminated the acceptance of planned ventral hernia,” Dr. Dennis said.

Cook County Hospital is one of the nation’s busiest trauma units, with more than 5,000 trauma patients annually. Over a 24-month period, TAWT was used in 28 damage control laparotomy patients and 1 decompressive laparotomy patient who had achieved physiologic steady state and near dry weight, but demonstrated domain loss precluding fascial closure. Their Injury Severity Scores were greater than 30 and their wounds massive at an average width of 18.3 cm (range, 9.5-30 cm) by 30.7 cm in length (range, 12-40 cm).

The technique utilizes an artificial bur (Wittmann Patch) that consists of two biocompatible polymeric sheets linked together via a meshwork of small hooks and loops. To avoid necrosis of the fascial edge, which can occur when the sheets are sewn directly to the fascia, the patch is placed into the abdomen as an underlay, noted Dr. Dennis, a surgeon at the hospital and chair of surgery at Midwestern University in Downers Grove, Ill.

The patch is secured with large braided sutures sewn through all layers of the abdominal wall at the lateral edge of the rectus muscle. Predrilled, 1-inch-wide padded aluminum bolsters are then placed cephalad to caudad over the skin of the anterior abdominal wall, which has been covered with a layer of hydrocolloid dressing for protection.

Adding the aluminum bolsters prevents skin breakdown, erosion of the sutures through the skin, and most importantly, preserves the fascial blood supply and leading fascial edge by sandwiching the abdominal wall between the patch and the bolsters. This disperses medial traction forces throughout all layers of the abdominal wall rather than focusing them on the leading edge of the fascia, as is the case during primary closure.

Domain recovery is achieved by tightening the device approximately 2-4 cm every 48 to 72 hours. When the TAWT and mid-wound distance is less than 2 cm, the system is removed and the abdomen closed primarily with interrupted absorbable suture and an inlay or underlay of bioprosthetic mesh (Gore Bio A).

“TAWT has defeated the surgical myth that domain loss is a nonrecoverable entity,” Dr. Dennis said in an interview. “By treating the muscles of the abdomen as if they are in a state of contracture and shortening, the TAWT device applies concepts learned from the physical medicine literature regarding contractures. That is, by applying constant countertraction to the muscles, in line with the fibers, we are able to lengthen the muscles and thus restore original length.” In the case of the abdomen, this restores the fascial edge to midline and allows for primary closure.

At the time of placement, TAWT decreased the initial defect in the 29 patients by 54% or an average of 9.9 cm. Primary facial closure was achieved in all patients without use of components separation or bridging biologic meshes. The patients returned to the operating room for tightening and wash out of the wound an average of 2.2 times, excluding TAWT insertion and final closure operations, the investigators said.

The average time from initial operation to TAWT placement was 9.5 days, and average time from TAWT placement to primary closure was 9.2 days.

The hospital has been using TAWT for 2 years in its acute trauma population with a near 100% success rate and has begun using it in their chronic giant ventral hernia population, Dr. Dennis said.

“We have brought those patients back, taken down their adhesions and skin grafts, applied the TAWT device in conjunction with our protocol, and subsequently closed all of them,” he said.

Dr. Dennis and his coauthors offered several pearls, including the recommendation that the minimum time for TAWT is 7-10 days, and that extubation should be attempted between tightening operations when possible. The device should be tightened to physiologic tolerance, although intraoperation total paralysis is recommended for maximal tightening.

It is critical to maintain a fenestrated plastic bowel protection barrier extending to all areas of the abdomen in all directions to prevent fusion of the abdominal wall to the viscera. “As long as the two remain independent, then successful domain recapture remains an option,” he said.

TAWT should be continued regardless of the presence of ostomy or enteral leak, which can be controlled with drains. The approach should be aborted, however, if there is no domain recovery and the mid-wound gap remains constant despite multiple attempts at tightening. The maximum number of tightenings in the study was six.

The cohort ranged in age from 16 to 59 years, and 90% were male. In all, there were 20 penetrating traumas, 8 blunt traumas, and 1 emergency surgery for perforated viscus, the authors reported. Fistula was present in four (13%) and an ileostomy or colostomy in seven (24%).

Dr. Dennis and his coauthors reported no financial conflicts of interest.

Subject Codes:
surgery;

http://www.imng.com

January 26, 2012 11:14 AM EST