Options for Closure of the Infected Abdomen

Abstract

Background: The infected abdomen poses substantial challenges to surgeons, and often, both temporary and definitive closure techniques are required. We reviewed the options available to close the abdominal wall defect encountered frequently during and after the management of complicated intra-abdominal infections. Methods: A comprehensive review was performed of the techniques and literature on abdominal closure in the setting of intra-abdominal infection. Results: Temporary abdominal closure options include the Wittmann Patch, Bogota bag, vacuum-assisted closure (VAC), the AbTheraÔ device, and synthetic or biologic mesh. Definitive reconstruction has been described with mesh, components separation, and autologous tissue transfer. Conclusion: Reconstructing the infected abdomen, both temporarily and definitively, can be accomplished with various techniques, each of which is associated with unique advantages and disadvantages. Appropriate judgment is required to optimize surgical outcomes in these complex cases.

Open Abdomen in Trauma and Critical Care

“…NPWT systems are effective in removing and quantifying abdominal fl uids, some of which may be infectious, and in preventing lateral retraction, potentially an aid in eventual closure of the fascia. 3,4,23 These systems, including the VAC abdominal dressing (KCI; Figure 3) and the ABThera system (KCI; Figure 4), are most these systems may increase the rate of healing by stimulating the formation of granulation tissue and also may prevent the loss of domain that occurs when the fascia retracts unopposed, preventing delayed primary closure and yielding a giant hernia. 4,7,24 The continuous medial traction provided by the negative pressure thwarts this loss of domain.…”

“…This multiple refastening optimizes the wound condition, thus enhancing defi nitive delayed closure of the fascia. 18,23 The benefi cial outcomes associated with the open abdomen may be related, in part, to the removal of the is applied to the drains to achieve negative pressure and closure of the abdominal wall. 20,23 Many NPWT products are now available with a polyurethane sponge in place of the moist towel layer.…”

“…18,23 The benefi cial outcomes associated with the open abdomen may be related, in part, to the removal of the is applied to the drains to achieve negative pressure and closure of the abdominal wall. 20,23 Many NPWT products are now available with a polyurethane sponge in place of the moist towel layer. 4 Commercially available products are prevalent in the management of the open abdomen and provide easy access for reoperation, placement without sutures, and isolation and protection of the abdominal viscera from contamination.…”

“…The patient should be afebrile and infection free. 23 Once these goals are achieved, definitive closure can be planned as either a delayed primary closure (the wound can be sutured closed days after the initial surgery when the adverse conditions have resolved) or closure with biological or synthetic mesh grafting material that can then be covered with a skin graft if the wound edges cannot be approximated. 44 Early fascial closure has been associated with improved outcomes for patients with the open abdomen.…”

“…6 The increased IAP thus prevents complete thoracic expansion. 6,23 No irrefutable evidence or expert consensus exists about the time frame within which the open abdomen should undergo closure. Fascial closure may be impossible because of ongoing intra-abdominal infection, visceral edema, or fistula formation.…”