CV
after operation for intra-abdominal catastrophe, most of
which were rAAA. Eighteen of 23 survived.
Abdominal wound closure for rAAA patients, all of whom
were repaired by open techniques, was achieved at a mean
of 4 days. Graft infection was not observed in this series of
patients with a mean follow up of 53 months.
A more recent study by Acosta et al. [20] evaluating the
fascial closure rate of patients treated with an open abdomen utilizing vacuum and mesh-mediated traction techniques did identify a single patient with an aortic stent graft
infection.
In their study, 111 patients were treated with the combined
vacuum and mesh-mediated traction technique (VAWCM),
and of these 45 patients were treated secondary to vascular
disease. The authors reported a mortality of 29.7%, median
time to closure of 14 days, a 76.6% primary fascial closure
rate overall in their intention-to-treat analysis, as well as an
89% fascial closure rate in per-protocol analysis.
Factors associated with failure of closure included development of intestinal fistula and >14 days of open abdomen
treatment.
A single patient of 30 (3%) reported with repair of a rAAA
developed an aortic graft infection. However, no other
information specifically pertaining to this single patient was
presented in their analysis.
Risk factors for development of ACS in association with REVAR reported by Mehta et al. [1] include aortic balloon occlusion, massive transfusion, coagulopathy, and conversion
to an aorto-unilateral device. In 6 of 30 patients, in this
group’s initial experience, treated by REVAR, the diagnosis
was made in 4 at the time of the index procedure.
Decompressive laparotomy was immediately performed
and 2 of the 4 survived. Death was observed in 2 patients in
whom the diagnosis and decompressive laparotomy were
delayed.
Based on this experience, on-table decompressive laparotomy was recommended for patients with abdominal distention, signs of organ failure, and risk factors for ACS regardless of intraoperative bladder pressure measurements.
No clear recommendations have otherwise been established
to guide the timing of decompressive laparotomy in the
setting of REVAR.
One note of caution, however, relates to the phenomenon of
decompression bleeding with decompressive laparotomy in
this setting. Marin et al. [31] reported one death due to this
phenomenon and now take measures to close the site of
rupture at the time of decompressive laparotomy. Coagulopathy may contribute to this phenomenon.
8. Management of the Abdominal Wound
Many different techniques have been described for maintaining abdominal domain and eventually achieving
closure, either by permanent mesh, absorbable mesh, tissue
transfer, or closing fascia primarily [14].
14
Table 4: Proposed classification of the open abdomen.
Adapted from Bjorck et al. [35].
Grade
Description
1A
Clean OA without adherence between bowel
and abdominal wall or fixity (lateralization of
the abdominal wall)
1B
Contaminated OA without adherence/fixity
2A
Clean OA developing adherence/fixity
2B
Contaminated OA developing adherence/
fixity
3
OA complicated by fistula formation
4
Frozen OA with adherent/fixed bowel; unable
to close surgically; with or without fistula.
Bozeman, Ross
Our preference is to use a negative pressure, vacuum-pack
system either with or without a mesh fascial bridge [17].
Advantages of using mesh sutured to the fascia, with
bowel protected by underlying plastic sheeting and towels,
include maintenance of abdominal domain, avoidance of
dehiscence, and a theoretical avoidance of possible fistula
formation when applying vacuum suction.
Patients with a negative pressure dressing incorporating
a mesh bridge can even be extubated and managed off the
ventilator prior to definitive closure. At the time of definitive closure, the mesh is removed and fascia sewn together.
Opponents of this technique argue that suturing mesh to
fascia is unnecessary and may cause weakening or even necrosis of the fascia, subsequently decreasing fascial integrity
at the time of definitive closure.
When mesh is not used, we create a negative pressure
dressing by placing a soft, fenestr FVB