The mortality in SAP has decreased markedly in the last 20 years due to better understanding of the pathophysiology, early aggressive fluid resuscitation, timely surgical intervention, and aggressive monitoring and organ supporting intensive care . However, in some patients the massive fluid resuscitation leads to visceral edema and ACS, with an estimated prevalence of 10%, although the prevalence of the milder form, intra-abdominal hypertension, is much higher, up to 78% in a retrospective study (IAP > 15 mmHg) and 25% in a prospective study (IAP > 25 cmH2O) [3–6].
The standard treatment after exhausting conservative management options is decompressive midline laparostomy. Although percutaneous drainage of pancreatic ascites, when present, can sometimes be helpful at least as a temporizing method, it was not considered sufficient in this patient and was not performed preoperatively.
Midline decompressive laparostomy is effective in decreasing IAP, rapid and easy to perform, but it is associated with a high risk of intestinal fistulas (about 5% in trauma patients with open abdomen) , and in many cases failure to close the fascia requiring complex reconstructive surgery 9–12 months later . The subcutaneous approach eliminates the open abdomen, but might not be effective enough, as suggested by our own experience in 7 patients so far, where the decrease of IAP was sufficient in 4 patients. In addition, the subcutaneous fasciotomy always results in a ventral hernia requiring repair later on. Clinical experience also shows that early closure of the open abdomen is accompanied with improved clinical, nutritional and infection situation when the "catabolic drain" of the open wound is closed .
Transverse laparostomy is a promising alternative to the two techniques described above. A shown in the presented case, it was effective in treating the ACS, and gradual fascial closure could be performed with complete closure in 4 reoperations. Early follow up revealed no wound complications or hernia formation. It must be emphasized, however, that the overall incisional hernia rate in a large study of 2,983 laparotomy patients was 4.3% with 32% developing during the first 6 months . Whether the transverse incision has a lesser incidence of incisional hernia formation is not known, and the follow up period in the presented case is obviously still short.
Although the transverse laparostomy takes slightly longer to perform than midline laparostomy, same principles of open abdomen management can be applied without additional equipment. The major disadvantage could be the loss of abdominal and back extensor muscle functions, if fascial closure could not be achieved. This might require complex reconstruction procedures including innervated free flaps that not only restore continuity but also the functional integrity of the abdomen .
In SAP, infected pancreatic necrosis is an established indication for surgical necrosectomy, ideally postponed until four weeks after the onset of symptoms and performed most commonly through a transverse midline incision . Although the need for necrosectomy has decreased markedly in the last years, the transverse incision used for decompressive laparostomy could also be used for necrosectomy avoiding multiple incisions and associated surgical and cosmetic disadvantages. Whether standard midline laparostomy at least in patients with SAP should be replaced with transverse laparostomy requires further comparative studies.