A, Cross-sectional schematic diagram demonstrating the layers of the dynamic-retention surgical technique. Layer 1, nonocclusive dressing; layer 2, dressing and drainage catheter; layer 3, retention suture; layer 4, dressing; layer 5, bowel bag; and layer 6, omentum. B, Operative photograph demonstrating application of the dynamic-retention suture technique.
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Koniaris LG, Hendrickson RJ, Drugas G, Abt P, Schoeniger LO. Dynamic Retention: A Technique for Closure of the Complex Abdomen in Critically Ill Patients. Arch Surg. 2001;136(12):1359–1362. doi:10.1001/archsurg.136.12.1359
Management of the open abdomen in the setting of massive visceral swelling or extensive intra-abdominal abscess may pose an extremely difficult surgical scenario. We herein describe the technique and results of dynamic-retention sutures used in 13 patients with abdominal catastrophes after trauma, vascular reconstruction, tumor extirpation, and intra-abdominal infection. Three of these patients died during their acute care hospitalization. The remaining 10 patients were discharged to home with no resultant fistulas and 1 recurrent hernia (10%). Dynamic-retention sutures provide a useful technique for the closure of the complex surgical abdomen. We observed a low complication rate. In properly selected patients, this technique avoids the use of mesh or additional surgical procedures such as skin grafting or plastic surgical reconstruction of the abdominal wall.
After surgical exploration for abdominal catastrophe, operative misadventure, or development of an abdominal compartment syndrome, definitive closure of the abdominal fascia at the time of initial laparotomy may be technically impossible. Alternatively, access for early reoperation may be needed. Multiple techniques have been described in the trauma literature to address the management of these daunting scenarios. In patients whose injuries are associated with trauma, techniques that use mesh and that are based on delayed primary fascial closure have been reported with mixed results.1-7 To date, however, few reports address this problem in the context of patients undergoing abdominal operations for injuries not associated with trauma. We herein describe a modified delayed-closure technique that has been used in the management of a number of complex abdominal closures in children and adults. The technique maintains abdominal wall tension throughout and allows a graduated closure of the abdomen without use of mesh. It also allows intra-abdominal dressing changes in the intensive care unit (ICU), protects the abdominal viscera, preserves the integrity of the midline abdominal fascia while maintaining abdominal domain, and potentially decreases late complications such as evisceration, incisional hernia, and fistula formation. We have termed this technique dynamic-retention suture closure.
The technique has been applied in 15 patients from January 1, 1996, through January 31, 2001, at Strong Memorial Hospital, Rochester, NY. Two of these patients died within 24 hours of presentation due to injuries not associated with fascial closure and were therefore excluded from further analysis. Thirteen patients survived longer than 24 hours after undergoing the described technique. A retrospective review of the medical charts of these patients was undertaken to evaluate clinical course, outcome, fluid requirements, APACHE II (Acute Physiology and Chronic Health Evaluation II) findings, and Injury Severity Scores (ISSs).
Once the determination to delay fascial closure is made, a closed suction-type drain may be placed into the abdomen. A large bowel bag (Isodrape; Microtek, Staffordshire, England) is laid over the omentum and viscera. The corners of the bag are tucked into each abdominal quadrant, and the bag is laid flat. The bag is used as a sheet and not as an isolation bag. The omentum serves as an additional barrier to visceral injury and should be interposed beneath the isolation bag as anteriorly as possible. Four or more moistened burn dressings (Kendall, Mansfield, Mass) are flatly placed into each abdominal quadrant over the bowel bag and below the anterior parietal peritoneum. Next, 4 or 5 retention sutures are placed as shown in Figure 1. Horizontal retention sutures of No. 5 braided polyester (Polydek; Deknatel, Fall River, Mass) are placed through a large-diameter bolster, usually a 26F Silastic Foley catheter, and through the skin and fascia. Alternatively, flat Silastic sump drains, large red-rubber catheters, or chest tubes may be used. To avoid bowel contact with taut retention sutures, they are placed in an extraperitoneal and subfascial plane. Anteriorly, the retention suture penetration points are kept a minimum of 4 cm from each fascial edge (Figure 1, A). The height of each horizontal mattress stitch is generally 3 to 4 cm.
After completion of the horizontal mattress sutures, the burn dressings may require slight repositioning to keep them interposed between the bowel bag and the intra-abdominal portion of the retention sutures. The burn dressings protect the viscera from possible cutting or visceral erosion by the retention sutures, especially if delayed bedside closure will be performed. Depending on the degree of abdominal swelling, the retention sutures may be tightened at initial laparotomy to allow for partial abdominal closure. Bladder and peak pulmonary pressures should be monitored if partial closure is attempted. Our practice has been not to tighten beyond the point where peak airway pressures increase. A single throw is made in the retention suture, and a Crile or Kelly clamp is applied to prevent slippage. The retention sutures are not knotted. A second layer of burn dressings and a large occlusive dressing (Ioban; 3M, Saint Paul, Minn) is placed over the midline wound to complete the initial procedure. A drain (Jackson-Pratt; Baxter, McGaw Park, Ill) can be placed under the occlusive dressing and applied to continuous suction to control fluid effluent. This facilitates fluid management and nursing care.
In the ICU, the retention sutures may be tightened as tolerated by simply readjusting the horizontal mattress suture and reapplying the Crile clamp. Peak airway and bladder pressures are monitored to prevent excessive closing tension. Based on the patient's subsequent clinical course, the open abdomen may be closed in the operating room when the patient is stable, usually within 72 to 96 hours, or alternatively in the ICU by means of sequential tightening of the retention sutures until the fascial edges are opposed. Sequential tightening has been used in the presence of intra-abdominal infection or continued hemodynamic lability at 96 hours after the initial surgery. Under these conditions, using sterile techniques, dressing changes may be performed in the ICU. Depending on the surgeon's preference, when the intra-abdominal septic process is controlled, the patient is returned to the operating room for primary fascial and cutaneous closure.
When delayed closure in the operating room is undertaken, the burn dressings and visceral bag are removed, the abdomen is copiously irrigated, and the midline wound is closed in a running or interrupted fashion at the discretion of the surgeon. It has also been our practice to perform a delayed primary skin closure at this time. The previously placed retention sutures are tied at this point and become standard-retention sutures (with the bolsters running parallel to the incision, not over it). In our experience, the visceral bag prevents the formation of adhesions from the abdominal viscera to the anterior abdominal wall and therefore removes easily, even 7 to 14 days after placement.
The patient cohort is summarized in Table 1and Table 2. Average age was 50 years (range, 10-75 years). The group consisted of 8 male and 5 female patients. Mean APACHE II score was 17 (range, 10-29). The ISSs were calculated for the 4 patients whose injuries were associated with trauma; mean ISS was 43 (range, 25-54). Average crystalloid administration in the initial perioperative period was 14 L (range, 2-33 L). Average blood and blood product administration in the initial perioperative period was 19 U (range, 0-100 U). Two of the 13 patients died within 30 days of the injury and 1 patient at 40 days. All other patients were discharged to home with follow-up as described. Mean follow-up was 21 months (range, 3-52 months). Of the 13 patients, 7 were returned to the operating room and subsequently underwent midline fascial closure within 96 hours. No instances of fistulas were observed in these 7 patients. One hernia was seen in patient 9, who had a history of evisceration and was steroid dependent.
In 6 patients, the midline fascia was not closed within the first 96 hours, and instead the retention sutures were sequentially tightened until the fascia was reapproximated as described. Dressing changes were performed in the ICU in 4 patients with intra-abdominal infection. Two of these 6 patients did not undergo delayed fascial wound closure; instead, their wounds were allowed to undergo secondary closure. No deaths occurred among these 6 patients. In most cases, retention sutures were removed by 8 weeks after abdominal closure.
The closure of the complex abdomen after massive intra-abdominal swelling or in the setting of potentially nonviable bowel is a challenging surgical problem with serious complications. The use of synthetic mesh, including Marlex (Boston Scientific, Oakland, NJ), Gore-Tex (W.L. Gore & Associates, Flagstaff, Ariz), or other synthetic materials to aid in the closure of such wounds has been reported by a number of authors.1,4-6,8 Unfortunately, these series have noted a fistula rate in the range of 12% to 50% and the frequent requirement of skin grafting or tissue expanders to close midline granulating wounds.8 Moreover, recurrent hernia rates as high as 40% have also been reported when using these techniques. Nevertheless, in the setting of major abdominal wall loss or preexisting deficient abdominal domain, techniques using mesh or organic fascial agents may be unavoidable. We limit the use of mesh agents to situations in which a major loss of abdominal wall has occurred, such as necrotizing fasciitis or abdominal wall tumor.9
In the setting of an abdomen that may not or should not be closed primarily, we have favored a delayed primary-closure approach without the use of mesh. A lower rate of fistula and hernia formation (0%-10%) has been reported1-3,7 with delayed primary closure. Successful approaches have included towel clipping of the skin or temporary retention-suture placement. Generally, all these techniques take advantage of the fact that visceral swelling generally resolves within 72 to 96 hours after initial laparotomy, allowing most patients to undergo an abdominal closure at that time.
The technique described herein is a modification of that reported by Bender and colleagues3 and provides the surgeon with a number of advantages compared with previously described delayed primary-closure techniques. These advantages include all of those reported with previous delayed primary-closure techniques as well as the ability to reapproximate the abdominal fascia at the bedside without a formal operative procedure should concomitant illness make such a procedure undesirable. This technique, unlike towel clipping of the skin, prevents retraction of the rectus abdominis and loss of domain. Unlike temporary mesh or membrane closure, it does not disrupt the edges of the fascia. These advantages facilitate subsequent final closure. Moreover, our technique, unlike that of Bender et al,3 uses materials that are routinely present in most operating rooms. We have also used this technique in the management of a wide variety of intra-abdominal catastrophes, not only trauma. The use of dynamic-retention sutures has resulted in fascial healing without resultant hernia in 9 of the 10 patients who survived (Table 1and Table 2).
Patients who require complex abdominal closure are preferably returned to the operating room at 72 to 96 hours, and the midline fascia is definitively approximated.10 The alternative technique of ICU retention-suture tightening and delayed fascial closure was considered if a patient remained critically ill and was at prohibitive operative risk, or if an intra-abdominal suppurative process remained poorly controlled. In the case of ongoing intra-abdominal infection, the bowel bag and burn dressing were removed as the fascia was tightened, and the abdomen was kept open to allow deep dressing changes and irrigation. The ability to close the abdomen at the resolution of the septic phase was retained. Although delay in fascial closure is clearly not as desirable as delayed secondary closure at 96 hours, tightened retentions are far more desirable than a nonreinforced, granulating midline wound with exposed viscera or exposed mesh as has been used by other authors. Both of these latter techniques generally require additional procedures such as skin grafting, and may result in massive bowel adherence to the broad midline granulation reaction, posing a risk of fistula and making subsequent laparotomies difficult.
The surgeon must be familiar with techniques to manage difficult abdominal closure. We find that the dynamic-retention suture technique is an expedient and simple one to use at the time of the first procedure. The technique affords the surgeon great latitude in the management of the difficult abdomen. It permits definitive delayed closure or repetitive access to the abdomen for dressing changes and control of ongoing sepsis in the ICU. Abdominal domain and fascial integrity are maintained. The viscera are protected, and resultant hernia and fistula rates appear low. We believe that this technique should be used more widely so that outcomes can be compared with historical methods.
Corresponding author and reprints: Luke O. Schoeniger, MD, PhD, Box Surg, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14562 (e-mail: Luke_Schoeniger@URMC.rochester.edu).
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