1 Resuscitation

Patients who require open abdomens usually fall into one of two categories: those who still have an acute process ongoing (Fig. 16-2) and those who are in the stable phase and are in the process of having their abdomens closed (Fig. 16-3).

Figure 16-2

Figure 16-3

Those in the acute phase need to have physiologic abnormalities—acidosis, hypothermia, and coagulopathy—corrected. Providing crystalloid and blood products will accomplish this, although volume resuscitation can itself have adverse effects, specifically on intraabdominal pressure and the development of abdominal compartment syndrome (ACS). Even if the abdomen has a temporary covering in place, intraabdominal pressures need to be monitored. This is typically done with monitoring of bladder pressure. If bladder pressure is elevated or if the patient is clinically developing ACS, then the closure that was placed on the abdomen needs to be loosened to allow the viscera to expand and take pressure off of the vena cava, kidneys, and lungs.

2 Pharmacologic Management

Whether or not a patient who has an open abdomen needs to remain paralyzed and intubated has been questioned. Obviously, if the patient is critically ill or if there are other reasons why intubation and paralysis are necessary, these will take precedence over the open abdomen. If, however, the patient does not have acute physiologic derangements, then weaning of paralysis and just maintaining the patient on sedation is reasonable. Whereas some would extubate these patients, in this author’s experience, extubation is not warranted for patients who are going back to surgery frequently and who also usually have other medical issues that are being addressed.

The other pharmacologic question is that of antibiotic use. There have been no randomized controlled trials and very few case-control series using antibiotics with an open abdomen if there is no gross contamination or infection. Thus, antibiotics in clean and clean-contaminated cases cannot be justified beyond 24 hours. If the wound is contaminated or infected, then prophylactic/therapeutic antibiotics should be administered. The length of time depends on the severity of contamination or infection and the patient’s other comorbidities. One final issue is the abdomen that has laparotomy pads in place to control bleeding. These patients should be placed on prophylactic antibiotics because of an increased incidence of intraabdominal abscess.

Nutrition also can be considered a pharmacologic intervention. There is no contraindication to enteral nutrition just because the abdomen is open. Although there may be other reasons not to institute enteral feedings, the presence of an open abdomen is not one of them.

3 Planned Open Abdomen

There is a subset of incisional hernia patients for whom it is known before surgery that the patient will need to have an open abdomen after the initial operation. Candidates include hernias with loss of domain, significant abdominal wall infection, and multiple abdominal wall fistulae. With infection and fistulae, definitive hernia repair often has to wait until there is decontamination of the abdominal wall. With loss of domain, the abdominal domain often has to be “reclaimed” by stretching the rectus and lateral abdominal complexes, and this requires the patient to have an open abdomen.

1 Decision to Leave the Abdomen Open

The decision to leave an abdomen open depends on the clinical scenario, as previously stated. It does not matter if the patient’s condition is acute or chronic; anatomy and physiology are what drive the decision. Once the decision is made, the steps are similar no matter the reason.

2 Technique

The focus of the technique is to maintain the anterior abdominal domain, and, if a fistula is present, to control effluent while still providing for visceral protection.

All visceral surgery should be completed, if possible. Once this is done, a temporary coverage for the intestine is fashioned. This can be a plastic drape, iodine-impregnated drape (Figs. 16-4 to 16-9), or a commercially available visceral drape (Figs. 16-10 to 16-13). The key point is to get the drape under the abdominal wall and passed all the way laterally to the paracolic gutters. The author believes that some sort of support of the visceral drape is needed to accomplish this. The Barker technique, in which an operative towel is sandwiched between two iodine-impregnated drapes, is favored. This provides enough support such that the covering will not shift once placed.

Figure 16-4

Figure 16-5

Figure 16-6

Figure 16-7

Figure 16-8

Figure 16-9

Figure 16-10

Figure 16-11

Figure 16-12

Figure 16-13

After the visceral coverage is in place, drains are placed over the cover in the abdominal wound. For a midline laparotomy, these drains are not placed in the gutters of the wound but instead looped in the superior and inferior recess of the wound. This is where most leakage occurs and thus is where the drains need to be.

A blue operative towel is placed over the drains and is then covered by another sheet of iodine-impregnated plastic. Before placing this final sheet of plastic, the drains are connected to wall suction and maintained on wall suction until just before transfer out of the operating room.

3 Fascial Closure

While none of these patients are candidates for complete fascial closure, most patients can have part of their abdominal wall reapproximated at each operation (Figs. 16-14 to 16-16). Every time a patient goes to the operating room, an attempt should be made to bring at least some of the fascia back together. This may be just one or two stitches, but in the end, it is progress, and progress is what is needed in these difficult patients.

Figure 16-14

Figure 16-15

Figure 16-16

1 General Care Issues

General postoperative care is used in all patients. Ensuring adequate resuscitation, appropriate antibiotic therapy, and nutritional support are critical. These patients have very large wounds, and they need all of the aforementioned in place to allow for healing.

Most patients are admitted to an intensive care unit. As previously stated, management of paralysis and intubation are made on a case-by-case basis, depending on what other issues are present.

Another aspect of postoperative care is maintaining the dressing. The drains should be kept to low continuous wall suction. This keeps fluid from building up under the dressing and dissecting the dressing away from the abdominal wall, leading to leakage from the dressing. This leakage is bad in that it does not allow for quantification of fluid from the abdomen, in addition to leading to maceration of the skin.

2 Reoperation

Patients should be taken to surgery whenever it is felt that more progress can be made with regards to their closure. Usually this means every day or every other day. At the time of these procedures, every attempt should be made to reapproximate some fascia.

3 Complications

The main complication unique to this patient population is enteroatmospheric fistula. While surgeons are used to managing enterocutaneous fistulae, this fistula is present in the middle of a large visceral block of tissue. Early identification and management of the fistula effluent is critical. If there is any question that a fistula has developed, the patient should be taken to the operating room and evaluated. Presence of a fistula usually means the abdomen cannot be entirely closed. However, one can proceed with as much fascial closure as possible, possibly sparing the patient from a very large ventral hernia defect.