Management of the Open Abdomen

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Preoperative Considerations

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  Management of the open abdomen begins with the decision to open the abdomen. Practice patterns have evolved from an era where management of an open abdomen was extremely rare to a culture of damage control surgery with a very low threshold to leave the abdomen open. In those scenarios, patients were returned to the operating room for re-exploration and possible closure after being fully resuscitated with physiologic abnormalities such as acidosis and coagulopathy resolved. Damage control resuscitation, now employing a more balanced strategy of crystalloid and blood products, results in much less tissue edema and resultant increased ability to achieve primary fascial closure. More recent data indicate that earlier return to surgery is beneficial and that the abdomen can be closed despite acidosis, coagulopathy, hypothermia, and even incomplete resuscitation.

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  A pathologic condition such as abdominal compartment syndrome (defined as intra-abdominal pressures >20 mm Hg with evidence of end-organ hypoperfusion) typically mandates that the abdomen not be closed after decompressive laparotomy. Opening the abdominal fascia releases the excessive pressure by allowing the viscera to expand outside the domain of the peritoneal cavity. Maneuvers such as abdominal wall component separation or placement of bridging mesh are inappropriate at this point, and one can move quickly to a temporary abdominal closure device, provided that no additional pathology is discovered on exploration.

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  Massive volume resuscitation during laparotomy may result in bowel edema that prohibits fascial closure because of inadequate intraperitoneal volume ( Fig. 18.1 ). Although damage control resuscitation strategies have decreased this indication for the open abdomen, this situation will remain a challenge to the surgeon. Although this situation often can be anticipated, sometimes unexpected bowel edema prevents primary fascial closure.

  

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  Planned second-look laparotomy, when the surgeon predetermines the indication for a second exploration during the index operation, is often used in cases of bowel ischemia regardless of resection or anastomosis. It is often thought to mandate leaving the abdomen open in between procedures. This is not mandatory, and the best physiologic state for the patient is with a closed abdomen. If there is no physical limitation to closing the fascia, it can be closed. Second-look procedures can begin with reopening the suture line. This technique does not increase the rate of ventral hernia or dehiscence at final closure. The physiologic ramifications of the open abdomen are significantly worse than the assault on the fascial edges from incision, closure, reopening, and reclosure. No extraordinary techniques are required at either closure.

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