Understanding STAR

Staged abdominal repair (STAR) was conceived and is used to provide a definitive surgical strategy, including serial explorations and debridements for acute catastrophic abdominal conditions.

The term STAR was first coined in 19916 and includes five management principles:

  1. Control of the source of infection
  2. Elimination of toxic material from the abdominal cavity
  3. Decompress abdominal hypertension
  4. Frequent inspection and early repair of intra-abdominal complications
  5. Definitive abdominal wall (fascia and skin) closure
Star Mortality

STAR Series I1-9

Star Mortality

STAR Series II11,12


Definition

STAR is one operation consisting of multiple serial abdominal entries planned either before or during the first index STAR. STAR abdominal entries are performed every 24 ±12 hours until final fascial closure is accomplished.

STAR includes:

Purpose

The purpose of STAR is to treat abdominal compartment syndrome and/or to perform multiple planned abdominal operations with the goal to:

Quality of Surgery Control

STAR permits better quality control of surgical procedures by allowing daily inspection of the healing process, by encouraging early intervention and correction of new or missed problems in order to avoid difficult to manage complications.

Requirements

Although a laparotomy or single abdominal entry is routine for any general surgeon, multiple sequential abdominal entries require even more attention to detail. With STAR, timing, infrastructure and operative manipulations such as resections, excisions, suturing leaks and anastomoses become critically important. Both meticulous surgical technique and attention to detail are essential for success of STAR. Bowel walls are often thinned from ileus, tissue can be very friable secondary to inflammation and coagulation may be impaired from sepsis, hemorrhage and hypothermia.

STAR implies daily abdominal re-entries in the operation room, sometimes for more than 2 weeks. Thus, STAR requires a significant time commitment by the surgeon and care team, including total attention, dedication, sacrifice and self-discipline. Repeated trips to the operating room can tax any ICU and OR. To assure the best outcome daily surgical explorations are necessary. The team will need to recognize that while ICU explorations may seem quicker and safer they can lead to life threatening surgical situations being encountered outside the operating room.

Single Surgeon Task

Best results are achieved when the same surgeon performs or assists during all STAR entries. The complex nature of the intra-abdominal pathology is not easily communicated to another surgeon and management errors are more likely with multiple surgeons assuming primary responsibility for one patient. Optimal performance of the STAR procedure is achieved when the same surgeon is present for the entire length of therapy.

Helping Families Understand STAR

Educating loved ones of a STAR patient is a major challenge requiring careful explanation and daily conferences to update the family about progress and setbacks. This needed level of communication, compassion and commitment must be appreciated before engaging in STAR. Information that may provide a basis for discussion with the family of STAR patient can be found here.

Most STAR patients present with an extremely poor prognosis and mortality predictions often exceed the 20-30% range. STAR improves outcome significantly.

Benefits of Artificial Bur Closure

Advantages of STAR

References

1 Wittmann DH, Bergstein JM, Aprahamian C.: Film: Velcro for temporary abdominal closure. 9th International Congress of Emergency Surgery, Strassbourg , 364. 1989.

2 Wittmann DH, Bergstein JM, Aprahamian C. Etappenlavage for diffuse peritonitis. Beitr Anäst Intensivemed 1989;30:199-221.

3 Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. VelcroTM, temporary abdominal closure for planned relaparotomy in trauma. Eastern Assoc.for the Surgery of Trauma, Naples 38. 1990.

4 Wittmann DH, Aprahamian C, Bergstein JM. Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure. World J Surg 1990;14(2):218-26.

5 Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma. Journal of Trauma 1990;30(6):719-23.

6 Wittmann DH, Aprahamian C, Bergstein JM, Bansal N. Staged abdominal repair (STAR) compares favorably to conventional operative therapy for intra-abdominal infection when stratifies by APACHE-II. 22nd Annual Meeting of the Western Trauma Association Feb./March 19

7 Wittmann DH, Aprahamian C, Bergstein JM, Edmiston CE, Frantzides CT, Quebbeman EJ, et al. A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies. Eur J Surg 1993;159(2):75-9.

8 Wittmann DH, Bansal N, Bergstein JM, Wallace JR, Wittmann MM, Aprahamian C. Staged abdominal repair compares favorably with conventional operative therapy for intra-andominal infections when adjusting for prognostic factors with a conventional operative therapy for intra-abdominal infections when adjusting for prognostic factors with a logistic model. Theoretical Surgery 1994;25:273-284.

9 Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Annals of Surgery 1996;224(1):10-8.

10 Wittmann DH. Operative and nonoperative therapy of intraabdominal infections. Infection 1998;26(5):335-41

11 Wittmann DH, Bergstein JM, Wallace JR, Aprahamian CA: STAR and STIR Effectively Treat Abdominal Compartment Syndrome and Reduce Mortality of Traumatic and Infectious Abdominal Catastrophes 59th (Boston) and 60th (San Antonio) Annual Meeting of the AAST; 2000; Booklet of Abstracts, Session IV Poster 68

12 Wittmann DH. Staged Abdominal Repair: Development and Current Practice of an Advanced Operative Technique for Diffuse Suppurative Peritonitis. Acta Chir Austriaca (European Surgeon); 2000;32(4):171-178

13 Taviloglu K. Staged abdominal re-operation for abdominal trauma. Ulus Travma Acil Cerrahi Derg 2003;9(3):149-53.

14 Ozguc H, Yilmazlar T, Gurluler E, Ozen Y, Korun N, Zorluoglu A. Staged abdominal repair in the treatment of intra-abdominal infection: analysis of 102 patients. J Gastrointest Surg 2003;7(5):646-51Cipolla J et al. A proposed algorithm for managing the open abdomen. Am Surg 71(2005)202

15 Fantus RJ et al. Use of controlled fascial tension and an adhesion preventing barrier to achieve delayed primary fascial closure in patients managed with an open abdomen. Am J Surg 192(2006)243

16 Hadeed JG et al. Delayed primary closure in damage control laparotomy: the value of the Wittmann patch. Am Surg 73(2007)10

17 Tieu BH et al. The use of the Wittmann Patch facilitates a high rate of fascial closure in severely injured trauma patients and critically ill emergency surgery patients. J Trauma 65(2008) 865

18 Weinberg JA et al. Closing the open abdomen: improved success with Wittmann Patch staged abdominal closure. J Trauma 65(2008)345

19 Keramati M et al. The Wittmann Patch as a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn. Burns 34(2008)493

20 Wittmann, DH. Staged abdominal repair (STAR) For Penetrating Abdominal Trauma. In Lenworth Jacobs (ed.) TECHNICAL OPERATIVE PROCEDURES: HOW I DO IT. Tips from Master Surgeons - ATOM-II, Chapter 1, p. 29-32, 2010