International consensus conference on open abdomen in trauma
Osvaldo Chiara1, Stefania Cimbanassi, Walter Biffl
1From the Trauma Center (O.C., S.C., S.S., A.M., F.S., M.L., L.T.), Trauma Surgery and Intensive Care, and Wound Healing Service (J.N.), Niguarda Hospital; and General and Emergency Surgery (P.D.R.), Policlinico Hospital, Milano; Emergency Surgery and Intensive Care (F.C., A.V.), Parma Hospital, Parma; General Surgery (L.A., S.M., F.C., R.M.), Papa Giovanni XXIII Hospital; and General Surgery (M.Z.), Policlinico S Pietro Hospital, Ponte San Pietro, Bergamo; Neurosurgical-Orthopedic Anesthesia and Intensive Care (A.C.), Careggi Hospital, Firenze; General and Emergency Surgery and Intensive Care (M.B., E.D.B.), Rummo Hospital, Benvento; Intensive Care (G.G.), Bufalini Hospital, Cesena; Trauma Surgery and Intensive Care (G.T., S.D.S., G.G., F.M., C.C.), Maggiore Hospital, Bologna; Shock e Trauma Service (G.N., E.C.), San Camillo Hospital; and General Surgery (S.R., F.G.), Umberto 1 Hospital, Roma; General Surgery (P.P., L.F.), San Gerardo Hospital, Monza; General Surgery (P.D.), San Matteo Hospital, Pavia; Trauma Surgery (G.N.), and General Surgery (M.C.), Cardarelli Hospital, Napoli; Department of Surgery (S.R.), Insubria University, Varese; and Emergency Surgery (S.R.), Umberto Parini Hospital, Aosta, Italy; Trauma and Acute Care Surgery (W.B.), Denver Health Medical Center, Denver, Colorado; R Adams Cowley Shock Trauma Center (T.M.S., S.H.), Baltimore, Maryland; and Emergency Surgery (A.L.), Department of Surgery, Meilahti Hospital, Helsinki, Finland.
Background:
A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.
Methods:
The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.
Results:
OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).
Conclusion:
OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.
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