Dr. Wittmann doing a STAR procedure in the late 80's.

Operative Technique

Introduction

STAR is one operation performed in multiple steps until it is concluded by final wound closure. Although a laparotomy or single abdominal entry is routine for any general surgeon, multiple sequential abdominal entries require more attention to details with respect to timing, infrastructure and operative manipulations such resections and excisions and suturing leaks and anastomoses. A meticulous technique and consideration of the details becomes essential for success of STAR because bowel walls are often extended and thin from ileus, and tissue may be extremely friable from inflammation and dysfunctional coagulation from sepsis or hemorrhage.

Please see 'Understanding STAR' for further information regarding the STAR procedure.


Informed Consent

Ideally, informed consent for STAR should include a reference to multiple planned abdominal re-entries. The patient and family need to understand that multiple surgeries should be expected and that withdrawing consent for a subsequent procedure may be detrimental to the overall success of the STAR procedure.

This understanding will help prepare the family to better anticipate the treatment course. Once the family understands the details of the procedure and learns that intra-operative problems can be addressed before becoming a complication, they may be more comfortable with their decision to consent. A good understanding by all family members involved has been found to decrease the chance of them being surprised by the need for multiple procedures and a lengthy hospital course. This in turn has led to fewer cases of family members wanting to withdraw consent for re-exploration.

For further discussion on this topic please see the discussion forum.

See Family and Loved Ones for a resource that can be used to help families and loved ones understand the implications and value of STAR.


Antibiotics

An additional dose of the antibiotic with full activity against target bacteria at peritoneal fluid levels should be administered within 1 hour prior to every abdominal reentry to assure sufficient antibacterial tissue levels during operative manipulations.

The antibiotic dosages must be sufficient to establish bactericidal concentrations within peritoneal fluid. STAR permits measuring antimicrobial fluid levels in peritoneal fluid. Good antibiotic choices have been 1g of imipenem/cilastatin TID or 2g of a third generation cephalosporin q8-12h combined with 500 mg metronidazole q12 hours, or a quinolone/metronidazole combination. For further reference see 'Antibiotic Therapy'.

Antibiotics

Peritoneal fluid: This fluid may be collected using the hypopack dressing system to measure antimicrobial levels, mediators such as TNF and proteins to allow for appropriate antibiotic dosing and meaningful protein replacement with FFP.



Preparation for Timely Hypobaric Wound Closure

Before starting the operating, have the suction device ready to be able to create negative pressure within the wound post op. This needs to be done instantly after applying the self-adhesive plastic drape to form the hypobaric wound space at the end of the first abdominal entry. If suction is not applied while the patient is still on the operating room table, fluid may force its way between plastic drape and skin and exogenous bacteria may gain access to the abdomen.


Number of STARs

Index STAR and Subsequent Staged
Abdominal Repairs

For logistic and practical purposes it is helpful to define each separate abdominal entry specifically. The first abdominal entry of a series is called index STAR, subsequent abdominal entries are numbered consecutively: STAR#2, STAR#3, etc. Most patients require less than four STAR entries, while some patients have required as many as 28.

The final fascial and skin closure should not be unduly delayed. Once source control is accomplished and inspection suggests that further leaks are unlikely, aggressive diuresis should be employed until final fascial closure is possible. Final fascial closure may be accomplished by applying more tension than one would exert on a fresh wound. The Klöppel suture technique is helpful in this situation. The longer the abdomen stays open, the more difficult will it be to eventually close.


Incision

Same patients at discharge from hospital

Incision

Example of a midline incision for STAR. The original appendectomy incision and added midline incision for STAR have been closed temporarily using Vicryl™ sheets.

Incision

The artificial bur for temporary abdominal closure can be utilized in longitudinal and transverse incisions. The incision of choice is a midline incision from the xyphoid process to symphysis pubis. The skin is incised with a scalpel, subcutaneous tissue including fascia are also separated using a scalpel or electrocautery. The peritoneum (mesothelial lining) is cautiously opened and transected using a pair of scissors as in any laparotomy. Care must be taken not to injure any of the distended and friable intestines or other visceral content and to handle tissue gently, avoid mass ligatures, and perform meticulous hemostasis. Subsequent steps are dictated by the underlying pathology and following general rules of abdominal surgery.


Source Control

Source control is essential to terminate further delivery of infectious material into the peritoneal cavity. Therefore all perforations and leaks must be closed. All contaminants e.g. feces, blood, and most of the necrotic tissue should be removed. Washing all abdominal pockets with about 10 liters of Ringer's Lactate solution usually does the job for cases of peritonitis from perforation or anastomotic leak. The lesser sack should be explored and the lesser omentum be opened, because pus may have accumulated there. At the end of the exploration all areas and pockets within the peritoneum should must have been inspected and cleansed by irrigation. For further reference, see History of Source Control or Source Control of Colonic Origin by Dr. Dietmar Wittmann.

Source Control

Suctioning feculent pus and removing necrotic tissue

Irrigation

A dysfunctional colon transversum, that had been left



Irrigation

Irrigation during STAR

Irrigation

Numerous publications address advantages and disadvantages of peritoneal lavage. Much of this discussion has become obsolete with the introduction of advanced operations for peritonitis such as STAR because irrigation is routinely used to wash out pus, infected or contaminated fluids, blood and necrotic tissue, and other adjuvants before closing the abdomen temporarily with the artificial bur. Copious irrigation the abdomen allows for easier subsequent repair of intra-abdominal pathology. The more physiological Ringer's solution may be preferred over normal saline. After washing out the abdominal cavity, bacterial counts are reduced only temporarily. Without antibiotic therapy bacterial counts return to their original count after 24 hours. This fact supports the concept of daily exploration and irrigation. For further reference, see History of Bur.



Leaks and Perforation

Leaks and perforations should be resected and closed with as little tissue loss as possible. Because fresh wound edges encourage healing, leaks and perforations should not simply be overseen. If the patient is too unstable to tolerate the more complex excision and closure, damaged areas may be resected by stapler and final management deferred to a later STAR. Staples have been found to be a better alternative than hand sewn resections/anastomoses because staples are applied with the same pressure regardless of the level of bowel wall edema. While this may seem counterintuitive, unlike carefully tied hand sutures, staples will not loosen as bowel edema subsides. (Closing the stapler jaws very gently allows for squeezing edema out of the tissue and thereby avoiding tissue disruption).

Historically sewing of anastomoses in the face of infection or contamination has been discouraged because of concerns of anastomotic failure. STAR permits suturing anastomoses and closing leaks in the presence of inflammation and infection because the healing anastomosis can be observed by daily inspection and, if necessary revised. Thus STAR becomes a surgical procedure (know what you do) where nothing is left to chance.

Leaks and Perforation

Inspection of sutured duodenal leak

Leaks and Perforation

Preparing rectal stump for anastomosis

Leaks and Perforation

EEA 32 within rectal stump to prepare for anastomosis



Colostomies

When performing STAR, "protective" colostomies are no longer needed because anastomoses can be observed to assure proper healing. Experience has shown that with a functional rectum present, previous colostomies can be safely taken down and the bowel anastomosed early during STAR. This avoids contamination of the abdominal wound with feces. Colostomy take down and observing the anastomosis heal during subsequent abdominal entries is one of the major advantages of STAR. Additionally, this results in higher patient satisfaction and quality of life.

Colostomy

Colostomy before take down procedure

Colostomy

Colostomy after take down procedure

Colostomy

Checking sutures of the taken down colostomy between STAR entries.



Suturing Artificial Bur to the Fascia

Accommodating the abdominal wound with the artificial bur is relatively simple

Suturing Artificial Bur to the Fascia

At the completion of the index STAR urgent intra-abdominal pathology such as perforations and leaks should be operatively controlled by either primary repair or by leaving blind hollow viscus loops stapled, i.e. without anastomosis.

To prepare for temporary closure, the omentum, if possible, is directed to the lower abdomen to cover the bowel. Then a lap sponge, an 18" × 18" cm laparotomy gauze cloth (LAP)1 is used to cover the content of the abdominal cavity at the bottom of the incision.. On top of the sponge, a plastic protector (FISH)2 may be used to temporarily protect the swollen intra-abdominal structures while suturing the fascia.

At this point, the wound edges are usually separated about 10 to 30cm with abdominal content protruding through the incision.

The artificial bur is removed from the sterile packaging and both, the hook and the loop sheet are identified. The loop sheet consists of soft material representing loops. The backside is reinforced with soft material. The hook sheet is the more rigid sheet.



Suturing the Loop Sheet to the Fascia

The loop sheet is sutured to the fascial edge on one side (right fascia) of the incision with the loops facing outwards; the reinforced back is soft and tissue friendly and covers the omentum and viscera.

The sheet is sutured to the fascia using a running ##1 or 0 nylon suture. Subcutaneous fat and skin are not included.. Stitches should be 2 cm apart and reach 1.5cm lateral to the fascial edge. Inclusion of muscle should be avoided. With the running suture tension is evenly distributed minimizing potential damage and infection to the fascia. After attaching one side of the sheet to the fascia, its free part is gently slipped underneath the opposite fascia.


Suturing the Hook Sheet to the Opposite Fascia

Following attachment of the loop sheet to the fascia on one side of the wound, the hook side is then sutured to the opposing fascia on the other side (left sided fascia) of the incision with the same technique. The hooks should face inward, and the backside reinforcement of the hook sheet facing outward. The last stitch is performed in the lower suprapubic corner of the fascia close to the last stitch of the opposing loop sheet.


Plastic Drape

Protecting the Abdomen with a Plastic Drape

The back surface of the loop sheet is very smooth and tissue friendly and thus inserting a plastic sheet underneath the loop sheet for visceral protection is not necessary. Dr. Kwang Suh from St. Louis recently suggested plastic bag, such as a bowel bag, insertion between parietal and visceral peritoneum when STAR entries are done in the ICU bed. This may allow better fascial movement to the center for final fascial closure. This should, however, only be used in straightforward STAR entries that are performed in the ICU. STAR entries during which management of intra-abdominal leaks, suture insufficiencies or bleeding is expected should be performed in the operating room with its available infra structure to manage all potential complications and unforeseen circumstances. Once there is no more risk for complications or new pathology, and the only remaining reason for subsequent STAR entries is daily re-approximations of the fascia to prepare final fascial closure, the STAR entry may be done safely in the ICU.



Closing BUR

After attaching both sheets to opposing fascial edges the hook sheet is gently pressed onto the loop sheet that is covering the abdominal content. Using scissors excessive material is now trimmed off the hook sheet only to fit the sheet size to the wound size. Now the hook sheet and loop sheet are separated again. The hook sheet is pulled laterally and the loop sheet is also removed from the left side of the abdominal cavity and pulled laterally to the right side. The laps (and, if used, the fish) are removed and the loop sheet reinserted between the left anterior abdominal wall fascia and the abdominal viscera. The loop sheet can be trimmed, but this is usually not necessary.

Once the loop sheet is inserted underneath the opposing fascia, the closure is completed by gently pressing the hook side into the loop side of the loop sheet while exerting a slight tension on the fascia and pressing hooks into the loops of the loop sheet. This establishes temporary abdominal closure.

The wound is left open with fascia apart enough to avoid excessive tension or intra-abdominal pressure.

The intra-abdominal pressure should not exceed 10 to 15 mm Hg after closure and there is sufficient tension on the fasciae to prevent their retraction. For further reference on measuring intra-abdominal pressure, see 'Measuring Intra-Abdominal Pressure'.

Loop Sheet
Loop Sheet


Hypopack

The Hypopack Wound Sealing has been part of STAR since 1991.

Hypopack

Suction Dressing

Prior to applying the hypopack vacuum dressing the presence of a portable pump or adequate wall suction should be assured. Suction must be applied as soon as the steridrape has been placed to provide an airtight seal.

Kerlix and Suction Drain Placement

Gauze such as Kerlix is used to cover the hook sheet and the subcutaneous tissue up to the level of the skin. A suction drain is imbedded into the Kerlix gauze.


Steridrape

Once the Kerlix and drain are in place, a self-adhesive plastic drape is applied to the skin to cover the entire abdominal wall and the wound, leaving a tunnel with a mesentery for the drain. This seals the abdominal cavity and avoids exogenous contamination. The area of the skin covered by the plastic drape should cover a distance of 20cm from any edge of the abdominal wound. Once this plastic drape seals off the abdominal cavity a suction of 10cm water is applied to the suction drain to collect abdominal fluid for measurement of protein losses and other factors for possible replacement.

Steri Drape
Steri Drape
Steri Drape


Intensive Care Unit

Between operations the patient remains in the intensive care unit. Routine vital signs including intra-abdominal pressure are monitored. Fluid losses and nutritional needs are managed. The patient is usually remains mechanically ventilated, sedated, and if necessary paralyzed to maximize tissue oxygen delivery and wound healing. See below for ICU STAR.


Interval Between Two STAR's

The interval between two abdominal entries during STAR should not exceed 36 hours. It is very important that the surgeon can commit to the 24-36 hour interval. Longer intervals make it more difficult to separate the bowl loops and check healing of anastomoses or other repairs. After 24 hours, neo-vascularization has begun and manipulation may induce more bleeding than when done within 24th hour after the previous STAR entry. STAR entires beyond 48 hours traumatise tissue.

It is important to close the abdomen definitively as early as possible after most of the peritoneal edema has subsided. Because the surgical pathology will have been controlled, edema resolution can aided by aggressive diuresis. With every abdominal re-entry the fascial edges should be pulled together to decrease the gap between the fascias. Using scissors, the bur itself may be trimmed to fit the diminishing size of the abdominal wound.


Best Place for STAR: OR vs ICU

Because there is a high risk of intra-abdominal complications in the inflamed friable abdomen with coagulopathies from sepsis and other causes, as a general rule STAR should be performed in the OR where appropriate help to respond to major intraoperative complications is readily available. However, when no further inspection or need for separation of bowel loops is expected and only further fascial approximation is necessary, the procedure can be done in the ICU.


Re-Opening of the Artificial BUR
Wittmann Patch

Re-Opening of the Artificial BUR

Generally: At each STAR entry, the hook sheet is peeled off the loop sheet after the usual preparation of the wound and adjacent skin. Both sheets are folded back over the wound edges and the abdomen explored. The artificial bur should not interfere with surgical manipulations. Upon completion of the abdominal entry, the two bur sheets are re-fastened.

More specifically: The steridrape is peeled off the abdominal wound and the abdominal wall. The gauze and drain are removed and the patient's skin and the wound is prepped with Betadine, hexachlorophene or other approved disinfectants/antiseptics. Prepping includes the skin around the abdominal wall opening and the outer surface of the artificial bur. This is done before all operations. Sterile drapes are now placed around the operating field and the instruments positioned as done with other laparotomies.

To open the abdomen, the hook sheet is peeled off the loop sheet by pulling it perpendicular off the loop sheet and toward the left side (see video at top of page). Then a lap is placed into the wound and the hook sheet pressed into the lap. Both the lap with the hook sheet are pulled away from the wound toward the left side and bent over the wound edges. Then the loop sheet is removed from underneath the left sided fascia of the abdominal wall, similarly pulled over to the right side and bent over on top of the abdominal wall wound.

Now the abdominal wound is open and ready for inspection, debridement, irrigation, and necessary repair. At the end of the procedure the abdomen is closed the same way as it was closed at the index STAR: The loop sheet is inserted underneath the left side of the fascia of the abdominal wall to cover all abdominal structures of the wound. Then the LAP sheet is removed from the hook sheet and the hooks are inserted onto the loops of the loop sheet by exerting some tension on the fascia. Intra-abdominal pressure should be between 5-10mm Hg. This can be measured transvesically. Following closure of the artificial bur, gauze is placed on top on the wound to cover the hook sheet and subcutaneous tissue up to the level of the skin. A suction drain is imbedded into gauze. Following this a Steridrape is applied to the skin to cover the entire abdominal wall and the wound, leaving a tunnel with a mesentery for the drain. This seals the abdominal cavity and keeps it sterile. The area of the skin covered by the plastic drape should cover a distance of 20cm from any edge of the abdominal wound. Once this plastic drape seals off the abdominal cavity a section of 10cm water is applied to the suction drain to collect abdominal fluid for measurement of protein losses and other factors for possible replacement. Subsequent re-entries are numbered by counting the index STAR as STAR #1, the second STAR as STAR #2 etc.



Re-approximation of Fascial Edges and Final Closure

The abdominal aperture may be decreased in size by pulling the fascial edges together via the bur sheets. When this is done the hook portion is trimmed with scissors. At the final operation, the bur sheets are removed from the fascia and the abdomen is closed primarily by suturing the two fascial borders together.

Once the pathology within the abdominal cavity is treated, intra-abdominal pressure is less than 15-20mm Hg and when the fascial edges are approximated with healing most likely to continue without further complication, the abdominal cavity can be closed.

This is done by removing the running sutures that had attached both artificial burr sheets to the abdominal wall fascia.

The abdomen is closed similarly to closing after a standard laparotomy, either by running suture technique using a looped #1 Maxon or PDS suture material or by the preferred technique of the surgeon. If after 7 days there is still some swelling and there is no medical reason to keep the abdomen open, the patient will tolerate fascial closing under some tension. This can be done easily by using the Klöppel technique. In normal, non-immune compromised patients, after five STAR procedures (approx. five days after the index STAR) the skin can be closed similarly because there is sufficient granulation tissue to prevent wound infection. Before STAR Entry # 5 one may leave the subcutaneous tissue and the skin open and wait until good granulation tissue has formed before suturing skin to skin.

A single additional dose of prophylactic antibiotic, usually the antibiotic being used to treat the underlying infection is given within 1 hour prior to abdominal entry.

Closing Definitively

Final Closure
Final Closure


Lessons Learned

Technical

Infectious

Abdominal Hypertension & Mediators


Reference for Materials Used

  1. LAP = A sponge gauze measuring 18" x 18". Official name is laparotomy sponge. The manufacturer is Medical Action, 150 Motor Park Way, #204; Hauppaugae, New York 11788-5108; Tel: 1-800-645-7042; Fax: 1-516-231-4600.
  2. FISH = A sterile-radiopaque plastic product that is called the Glassman Viscera Retainer. The large size is used. Produced by Adept-Med International; 5040 Robert J. Mathews Pkwy; El Dorado Hills, CA 95762
  3. O-Loop Nylon = Nylon suture, Tradename Ethilon, black monofilament 150cm or 60in. suture of size 0 (3.5 metric) and looped on a ½ circle taper CT needle. Produced by Ethicon Inc. Special order # D-4734.
  4. Steri drape = Ioban-2; 90cm x 80cm. The manufacturer is 3M; Catalog #6651. Order from: Baxter Allegiance Valuelink; 3651 Birchwood Drive; Waukegan, IL 60085; Tel: 1-800-477-0811; Fax 708-578-2163; Sales Rep: Dale Micelspurger
  5. O loop maxon = Synthetic suture of monofilament polyglyconate, Tradename O Maxon 75cm of 30in suture of size 0 (1.5 metric) and looped on a ½ circle taper T60 needle. Produced by Davis & Geck Product #3641-63.
  6. Kerlix = 6 ply-4.5in x 4.1 yd (11.4cm x 370cm) stretched. 1 roll supplied by Kendall, Order #6730. Kendall Health Care Products Company, Division of Kendall Company, Mansfield, MA 02048. Product information 1-800-962-9888.

References Bibliography

  1. Wittmann DH, Bergstein JM, Aprahamian C. Etappenlavage for diffuse peritonitis. Beitr Anast Intensivemed 1989;30:199-221.
  2. Wittmann DH, Bergstein JM, Aprahamian C. Film: Velcro for temporary abdominal closure. 9th International Congress of Emergency Surgery, Strassbourg , 364. 1989.
  3. Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. Velcr(TM), 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):218-226
  5. Wittmann DH, Aprahamian C, Bergstein JM. New technique to facilitate etappenlavage (planned relaparotomies) for abdominal trauma and peritonitis. 11th World Congress, Collegium Internationale Chirurgiae Digestivae, New Dehli . 1990.
  6. Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma. J Trauma 1990;30(6):719-723.
  7. 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 1992. [Abstract]
  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 logistic model. Theor Surg 1994;25:273-284.[Original paper]
  9. Wittmann DH, Aprahamian C, Bergstein JM, et al. A BUR-like device to facilitate temporary abdominal closure in planned multiple laparotomies. Eur J Surg 1993; 159:75-79
  10. Schein M, Wittmann DH, Aprahamian C, Condon RE. The abdominal compartment syndrome. The physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:745-753.
  11. Wittmann DH. Newer methods of operative therapy for peritonitis. In Nyhus LM, Baker RJ, Fischer JE., eds. Mastery of Surgery. Boston: Little, Brown and Company, 1996
  12. Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. [Review]. Annals of Surgery 1996;224(1):10-18
  13. Wittmann DH. Operative and non-operative therapy of intraabdominal infections. Infection 1998;26(5):335-341.
  14. Wittmann, DH, Staged Abdominal Repair (STAR) with Wittmann Patch Closure For Penetrating Abdominal Trauma. In LM Jacobs and SS Luk (ed) ATOM Advances Trauma Operative Management, American College of Surgeons, Committee on Trauma, Cine-Med Publishing, Inc, Woodbury, CT, 2010