Trauma

Trauma with Hemorrhage

Blunt Trauma with Intra-abdominal Hemorrhage
Patients with trauma induced hemorrhage are often hemodynamically unstable, hypothermic and become coagulopathic from either one or both of these problems.  Often they develop massive peritoneal edema and abdominal organs mushrooms out upon incision.  These patients do not tolerate lengthy operations and can be stabilized better in the ICU environment.  The damage control procedures concept allows deferral of the more definitive repair until the patient’s hemodynamics have stabilized and coagulation has normalized.  At the end of the first abdominal exploration  the damage control concept should be combined with a dynamic closing procedures such as STAR which combines deferred repair with temporary dynamic fascia closure and allows control of intra-abdominal pressure secondary to massive edema.  Detrimental abdominal hypertension is thus prevented and delayed primary fascial closure made more likely.
Abdominal Wall Hernia Following Open Abdomen Technique and Covering Defect
Using the vacuum-only system or other Bogota bag techniques does not provide tension on the fascia.  Allowing the fascia to retract may lead to increased length of hospitalization (either during the current or during a later admission)to  stretch the fascia for final closure.  Static meshes and retention sutures do not provide the means to re-oproximate the fascia in preparation for delayed primary closure.  After static coeliotomies some patients end up with large, open or  epithelized ventral hernias.

The artificial bur permits a faster and definitive fascial closure, earlier patient discharge and reduces overall costs.

Trauma with Intestinal Perforation

Pus from 5 Day Old Small Bowel Perforation
Both blunt trauma and penetrating trauma may require laparotomy for intestinal perforations to control or prevent subsequent intra-abdominal infection.  Perforations often remain hidden after multiple blunt injuries and are diagnosed late if the patient is not operated emergently for abdominal hemorrhage.  Peritoneal edema may prevent fascial closure.  STAR lends itself to this scenario.  The fascial defect can be bridged with the artificial bur and STAR performed until fascial closure is possible.

STAR also permits early discovery of unexpected complications such as massive blood clot formation.  In the case, Blunt abdominal and closed cranial trauma with subdural hematoma, had STAR not been employed the blood clots would have remained in the infected abdominal cavity and progressed to intra-abdominal abscesses.

Staged abdominal repair combines the initial damage control with the path to definitive closure of the abdominal fascia.  The fascia does not retract sideways and is always subject to moderate tension while the tension is adjusted to hemodynamic conditions.  As soon as conditions improve, fascial edges are re-approximated and final fascia-to-fascia closure accomplished.

Outcome of Trauma using Advanced Procedures

Previously the trauma scenarios described above have been treated with a multitude of different methods.  While there is information available related to abdominal decompression methods, it is mostly anecdotal and thus difficult to analyze.  In only a few studies have risk factors assessed reproducibly to allow for comparison.  Prospective randomized trials are difficult to perform because of the small number of patients who may benefit from the new advanced procedures.  To compare the benefits of these procedures a different approach may provide some insights.

Open Abdomen Procedures Classification
The various open abdomen approaches can be classified into three categories of advanced procedures based on their potential for closing the fascia:

Static Procedures

Open coeliostomy is defined as laparotomy without the re-approximation and suture closure of the abdominal fascia.  The abdomen is simply left open.  The mesh coeliostomy is a laparotomy without re-approximation and suture closure of the abdominal fascia, where the facial gap is bridged with a mesh of Marlex, Vicryl, or other material. 

Static Procedures - Complication Rates
Most methods used in the past fall into the category of static advanced operations and are associated with high complication rates - see table.  Static methods leave re-approximation and abdominal closure to either natural healing or the fascial defect is later closed using a permanent mesh. 

An abdomen left open may close over time by wound constriction resulting in a more or less qualitatively inferior scar “fascia”, a fibrous tissue layer covering the defect.  The natural healing process starts with the formation of granulation tissue which epithelializes from the wound edges.  Eventually the entire open abdomen is covered with epithelium.  This process is often accelerated by covering the granulation tissue with a split thickness skin graft.

Open abdomina lack an intact envelope of the abdominal space.  The normal counter pressure exerted by an intact abdominal fascia is absent.  This increases the risk of hollow viscus perforation, frequently leading to fistula formation.  This is especially associated with illeus and bowel distention - a common feature of an abdomina left open.

Mortality Reported for Various Forms of Coeliostomy
In an earlier study we identified 37 publications reporting results of 869 open and mesh coeliostomas.  In 3 studies there were 195 patients entered into control groups for comparison.  Mortality was high.  A wound infection was present in all published cases.  The average reported fistula rates in open coeliostomas and mesh coeliostomas were 16% and 22 % in 344 and 156 patients respectively.

69% of the surviving patients developed huge abdominal wall hernia.  No difference between open coeliostomy and standard single stage operation was demonstrated when comparing patients groups with same risk factors.

Dynamic procedures

Mortality Rate Comparison
Mortality Rate Comparison
Closing the first trauma laparotomy with the artificial bur provides a sure and quick  avenue to primary delayed fascial closure.  Using a running suture with widely spaced stitches when placing the artificial bur distributes suture tension evenly over the full length of the fascia-bur interface. This decreases the risk of fascial necrosis.

 Inspection can be performed every 24 to 36 hours and packs removed when there is no further bleeding.

The overall result with STAR in trauma patients have been excellent and are shown in tables.

A recent publication1 reviewed data of 3169 cases from 57 studies and identified mortality, closure and complications rates with the various closing methods. Of all methods the artificial bur had the lowest mortality, lowest complication and highest closure rates - see Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen.

References

1 van Hensbroek PB,Wind J,Dijkgraaf MGW,Busch ORC,Goslings JC. Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen. World J Surg; 2009;33(2):199-207