Temporary abdominal closure
A prospective, open labelled, non-comparative study was carried out in two centres in South Africa between August 2010 and December 2011. Consecutive patients presenting with traumatic injury and 1) requiring damage control laparotomy with staged abdominal repair; or 2) developing abdominal compartment syndrome requiring laparotomy and temporary abdominal closure; or 3) with full thickness traumatic abdominal wall defects with exposed viscera requiring temporary abdominal closure were assessed for inclusion into the study. Patients with grade 1a,1b or 2a, 2b open abdomen, as classified by Bjorck et al.  (Table 1) were suitable for inclusion. The following exclusion criteria were also applied: <18 years, pregnant, malignancy in wound bed, unexplored fistulas, high risk for imminent death (as determined by the treating surgeon), pre-existing large ventral hernia, significant loss of abdominal wall fascia as a result of trauma or infection, patients with grade 4 open abdomen (Bjorck et al. classification, see Table 1), patients with a known history of poor compliance with medical treatment and any patients who had previously been withdrawn from the study. The trial was approved by local ethics boards at both institutions and was carried out in strict accordance with the Helsinki declaration. Informed consent was obtained where possible from the patient, but if the patient was incapable, the patient’s legal representative was asked to provide consent on the patient’s behalf. If this was not possible then independent physician consent was considered acceptable as approved by the local ethics committee. All patient information was anonymised at source.
Patients suitable for inclusion underwent initial damage control laparotomy, where initial control of haemorrhage and contamination was performed. This was followed by intra-peritoneal packing when required and TAC. Further resuscitation to near normal physiology in the intensive care unit (ICU) was continued. Re-laparotomy was performed at 48 hours or earlier if indicated. Negative pressure wound therapy (RENASYS-AB Abdominal Dressing and RENASYS EZ pump Smith & Nephew; St Petersburg, FL, USA) was applied to the wound in the following way. A fenestrated non adherent film was placed directly over the exposed viscera but under the rectus sheath. Polyurethane foam was then reduced along pre-cut perforations to the appropriate size and placed on top of the film within the open abdomen. A transparent film then covered the foam and the surrounding peri-wound skin before a suction port was connected to the NPWT pump. Negative pressure was delivered at a continuous -80 mmHg. The trial comprised a maximum of 20 days of treatment with the NPWT system with an additional 8 day post-treatment initiation follow up. Dressing changes usually took place at 48 hours during re-laparotomy for removal of packs and re-establishment of bowel continuity. Full medical and wound assessments were made. Wound closure was carried out when possible and at the discretion of the attending trauma surgeon.
The primary objective was to determine the number of days taken to achieve delayed primary fascial closure. Secondary objectives were mortality, change in OA classification, intra-abdominal pressure (IAP), length of stay (days) in ICU and hospital, incidence of complications (abdominal compartment syndrome (ACS), fistula formation, sepsis, multiple organ failure (MOF), acute respiratory distress syndrome (ARDS)). SOFA, APACHE, ISS, NISS scores were also recorded.