Author's: Neves, Miguel¹; Marques, Joana¹; Cardoso, Diogo¹; Alegre, Inês¹; Rebanda, Jorge¹; Nascimento, Carlos¹

Affiliations: 1 – General Surgery Department – Unidade Local de Saúde Lisboa Ocidental, Portugal (ULSLO);  

Corresponding author: Miguel Lopes das Neves; mlneves@ulslo.min-saude.pt;

ORCID: https://orcid.org/0009-0008-1692-9152

ABSTRACT 

Objectives

Laparostomy after damage control surgery is occasionally necessary in critical situations such as abdominal compartment syndrome, peritonitis or abdominal trauma. While life-saving, its use is associated with significant morbidity, thus prompt closure is prioritized. Delayed abdominal wall closure after a laparostomy poses a surgical challenge with vertical traction systems (VTS) potentially serving as adjunctive methods.

Case Report

We present the case of a 58-year-old woman with a previous abdominoplasty who, one week after undergoing liposuction, presented to the Emergency Department with generalized peritonitis due to iatrogenic jejunal perforation. She underwent urgent exploratory laparotomy, where the perforation site was identified, an enterorrhaphy was performed, and peritoneal toilet was conducted. On the 8th day, due to purulent peritonitis with multiple interloop abscesses, she underwent a new laparotomy, and peritoneal washing and the necessity for laparostomy, due to the impossibility to close the abdominal wall without tension. Upon review on the 10th day post the index surgery, primary closure of the abdominal wall was deemed impossible due to significant visceral edema and a history of previous aesthetic interventions. On the 12th day, the laparostomy was reassessed and the inability to close the abdominal wall persisted. Due to a distance of 10 cm between myofascial borders in the midline, the decision was made to utilize the Fasciotens® vertical traction system. Progressive fascial approximation was successfully achieved in two stages, with definitive closure completed on the 12th day post-laparostomy.

Conclusions

This case highlights the benefits of implementing an adjunctive system for abdominal wall closure like Fasciotens©, facilitating a quicker closure without the use of prosthetic material or abdominal wall reconstruction, proving to be safe and effective.

Keyword's: liposuction complications, fasciotens ®, open abdomen treatment, delayed primary fascial closure

INTRODUCTION

Open abdomen approach is often needed in critical situations like abdominal compartment syndrome, peritonitis, or trauma involving the abdomen in damage control surgery [1,2]. Albeit life-saving intent, its use has been associated with important morbidity and mortality. In fact, reported mortality rates in the literature range from 12 to 40% [1]. Additionally, the rate of major complications increases with delayed closure, with the risk of multi-organ failure in up to 30% of cases, intra-abdominal abscesses and surgical site infections in 20-30%, entero-atmospheric fistula formation in 10-20% and complex ventral abdominal hernia due to loss of domain in 20-30% of patients and it is associated with increased risk of bowel adhesions [3,4,5].

Therefore, early closure should be prioritized, as recommended in the 2018 guidelines published by the World Society for Emergency Surgery (WSES), once any requirements for ongoing resuscitation have ceased and the source control has been definitively reached [1,6]. Furthermore, delayed abdominal wall closure after laparostomy presents a major surgical challenge due to the retraction of myofascial abdominal wall and visceral edema [7]. Several techniques for temporary abdominal closure have been suggested to protect abdominal viscera and to help definitive fascial closure. WSES guidelines recommend a standard technique for temporary assisted closure with vacuum-therapy dressing (Negative Pressure Wound Therapy, NPWT) and horizontal mesh-mediated facial traction to facilitate the definitive fascial closure. These methods have heterogenous results in literature, with rates of primary fascial closure ranging from over 80%, depending on aetiology and clinical scenarios [1]. Nevertheless, isolated NPWT use is limited in medializing fascial margins and several studies show lower primary fascial closure rates in septic open abdomen compared with trauma patients, with rates as low as 22% [7,8,9]. Moreover, even with the use of adjunctive methods, there remains a high rate of complications, particularly incisional hernias which range from 20-40% [10,11]. Hence, recently there has been a need for new systems to prevent fascial retraction and adjuctives to early definitive fascial closure while reducing the complications including the incidence of incisional hernia.

Newly developed vertical traction systems, such as Fasciotens® Abdomen, can be adjunctive methods, decreasing fascial tension and facilitating abdominal wall closure [12,13,14].

Traditional horizontal traction systems, as recommended by the WSES guidelines, work by approximating fascial margins which limit and reduce the volume of the abdominal cavity, translating into increased intra-abdominal tension. In contrast, newly developed vertical traction theoretically functions in a more dynamic approach considering the vectorial forces applied by the abdominal wall, effectively preserving the volume of the abdominal cavity while extending the fascial margins, which is proposed to promote early fascial closure in patients with open abdomen [15].

CASE PRESENTATION

Hereby we present the case of a 58-year-old woman, who had previously undergone several plastic surgeries including an abdominoplasty.

One week after undergoing an abdominal wall liposuction, the patient presented to the emergency department with an acute abdomen. Blood work was significant for leucocytosis with neutrophilia and an increased C-reactive protein level of 31mg/dL. The CT scan showed findings compatible with peritonitis due to perforation of a hollow viscera, suggesting a segment of the jejunum at the epigastric level.

The patient was proposed for urgent laparotomy, which confirmed generalized peritonitis caused by an iatrogenic jejunal perforation. An enterorrhaphy and peritoneal toilet were performed, and the abdominal wall was closed.

On the 8th postoperative day, due to recurrent purulent peritonitis with multiple interloop abscesses and sepsis, a second laparotomy and abdominal lavage were carried out. It was decided to temporarily leave the abdominal wall open, with a vacuum-assisted closure (NPWT) AbThera® dressing (KCI, San Antonio, Texas, US), to allow to revisit the abdomen and complete source control.

Upon the first review, on the 10th postoperative day of the index surgery, primary closure was deemed impossible due to significant visceral edema, abdominal wall retraction, and the past medical history of previous aesthetic interventions which compromised the abdominal wall compliance.

On the 12th postoperative day of the index surgery, the laparostomy was re-looked, and the inability to close the abdominal wall persisted.

Intraoperatively and after being fully relaxed with the muscle relaxant agent and due to a maintained fascia-to-fascia distance of 10cm (figure 1), the decision was made on the 14th postoperative day to use the Fasciotens® Abdomen vertical traction system (figure 2, 3, 4). Prior to applying it, abdominal lavage and surgical debridement of the fascial margins were performed, and the vacuum-assisted closure (NPWT) AbThera® dressing applied. A doubled strip of vicryl® woven mesh was sewed on both aponevrotic margins (figure 1) and the system was used as per the instruction manufacturer’s specifications, by using sutured commercial threads (polyfil, USP-2, Novosyn® BBraun, Melsungen, Germany; Vicryl® Ethicon, Johnson&Johnson) on each side (figure 2 and 3) which were directly vertically or cross-fastened on the device, to traction forces between 60-80 N (6-8 according to the scale of the device) (figure 4) applied during therapy in the ICU.

Progressive fascial approximation was successfully achieved in two stages (figure 5), with definitive closure completed on the 12th day of open abdomen (figure 6 and 7), and 20th day after the first surgical intervention.

The rest of the postoperative period was uneventful and one year postoperatively the patient had no complications with great aesthetic results and no incisional hernia (figure 8).

DISCUSSION/CONCLUSION

Early primary fascial closure is paramount to mitigate well-known complications of open abdomen. Following the need to find the best primary fascial closure systems, combinations of temporary abdominal wall closure systems with dynamic closure procedures (ABRA®, Access Pro Medical Inc., Augusta, GA, USA) have been used to achieve better outcomes and enhance faster fascial closure [1].

The novel vertical traction device Fasciotens® Abdomen (Essen, Germany) was derived from studies conducted by Eickhoff et al. It was first proposed in a porcine model to reduce the necessary traction for fascial closure and later shown in a case report which managed to successfully enhance early primary fascial closure without prosthetic material or complex abdominal wall reconstruction, in a single patient and without significant complications [12,13]. Recently Fung et al. showed similar success in a series of cases (n=20), reporting a significant decrease in fascia-to-fascia distance of 5cm only 48h following device application and with median time to primary fascial closure of seven days [14].

A major advantage of vertical traction systems is not only the ability to prevent fascial retraction but also to facilitate myofascial advancement and extension of the abdominal wall in cases with increased intra-abdominal pressure due to visceral edema [14], as it preserves the volume of the abdominal cavity while simultaneously extending fascial margins [15].

In earlier studies, the success rate of primary fascial closure has been reported to depend on the aetiology of open abdomen. In the systematic review by Brunhin et al., patients with septic open abdomen displayed lower fascial closure rates at the end of the therapy. Interestingly, when combined with a dynamic closure device, NPWT showed increased primary fascial closure rates [2].

Reimer et al. reported a primary fascial closure rate of 61% for their mixed patient cohort of septic and non-septic open abdomen and Verdam et al. reported a primary fascial closure rate of 88% in patients with septic open abdomen, using as adjunctives the application of the horizontal traction system after a mean open abdomen duration of 25 days (range 7–48 days) [16,17]. These studies emphasized that timing to approximation could be a major factor for closure success. Fung et al. recently reported that using the dynamic vertical traction system the primary fascial closure rate was 100% after a mean duration of open abdomen of 11.5 days (range 5-28 days) and with a median time to primary fascial closure of seven days [14]. Additionally, last year in a consecutive case series (n=9), Dohmen et al. showed combining the vertical traction system and NPTW, reported a primary fascial closure rate of 100% and achieved a mean time to fascial closure of 9± 3 days [15].

These results are in line with our case report, in which primary abdominal wall closure was successful after 12 days of open abdomen and with a time to fascial closure of 6 days after implementing a combination of NPTW temporary abdominal closure system (AbThera® KCI, San Antonio, Texas, US) and of the vertical traction device. This case highlights and confirms the benefits of implementing vertical traction systems in the approach to primary fascial closure with similar success in our institution to previous reports when combined with negative pressure wound therapy (NPWT) in large fascial defects, facilitating a quicker closure without the use of prosthetic material or abdominal wall reconstruction, proving to be safe and effective.

The use of vertical traction systems in open abdomen still lacks robust evidence, and further studies with prospective controlled trials, with a higher number of patients, are needed to assess efficacy, long-term complications such as incisional hernia, and further data to develop algorithms or guidelines to find which patients might benefit the most from early vertical traction systems.

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