Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems

Abstract

Background Management of the post‐traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure. Methods Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero‐atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration. Results We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero‐atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = − 0.294, p = 0.036). Conclusion For the post‐traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.

Dynamic closure techniques for treatment of an open abdomen: an update

“…In total, 13 studies fulfilled the criteria [12][13][14][15][16][17][18][19][20][21][22][23][24]. All included studies are observational cohort studies, and no studies reported on the use of either the Wittmann patch or the ABRA system.…”

“…Two studies reported on the ABRA system in combination with NPWT [12,13], while 9 reported on meshmediated fascial traction (MMFT) combined with NPWT [14][15][16][17][18][19][20][21][22]. Other types of fascial traction, either by dynamic suture lines [23] or by a self-made silastic tube system, and NPWT [24] were reported in 2 studies.…”

Factor V Leiden and superior mesenteric artery occlusion: A case study

“…The principal indicator for an open abdomen is a second look laparotomy; other indicators include vascular injuries, swelling and the risk of abdominal compartment syndrome 23 . Optimisation of the patient's haemodynamic condition between operations can lead to potentially salvaging bowel that once potentially appeared ischaemic 23,24 . The current gold standard for management of an open abdomen is NPWT at a minimum negative pressure; however, there is discussion around this causing bowel damage and further anastomotic complications 24,25 .…”

“…Optimisation of the patient's haemodynamic condition between operations can lead to potentially salvaging bowel that once potentially appeared ischaemic 23,24 . The current gold standard for management of an open abdomen is NPWT at a minimum negative pressure; however, there is discussion around this causing bowel damage and further anastomotic complications 24,25 . Conversely, a retrospective study concluded that non-open abdomen patients after SMA occlusion more frequently required a further bowel resection at the second look, subsequent short bowel syndrome and a higher incidence of sepsis 24 .…”

Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry

“…The combination of different OAT elements such as vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM), negative-pressure wound therapy (NPWT) and dynamic fascial sutures (DFS) is associated with the highest frequency of DFC [11,[16][17][18][19]. The purpose is to create synergistic effects of edema reduction and gradual fascial approximation [18,[20][21][22].…”