Open abdomen (OA) has gained a wide acceptance in the management of abdominal surgical catastrophes. Definite reconstruction of OA is an operative challenge as various methods are used. Dynamic techniques are preferred for the closure of OA. If other methods fail to close the OA, then temporary split thickness skin graft can be applied and refer the definite closure for later. We used a modification of an existing technique, in a 47-year-old female patient with a big midline incisional hernia due to temporary closure of OA with partial-thickness skin graft, who was operated for permanent closure of the defect. In order to avoid complications from extensive dissection, we invaginated the grafted area and realigned the recti muscles with on lay mesh reinforcement with excellent outcome. This technique of inverting the previous grafted area when it can be applied is an easy and safe method with rewarding results.
Keywords: Definite closure, open abdomen, partial thickness skin graft, surgical technique
|How to cite this URL:|
Lorentziadis M, Nafady Hego MM, Al-Jurini H. A simple technique for definite closure of full thickness abdominal wall defect in open abdomen after temporary applied split thickness graft: A case report. Int J Abdom Wall Hernia Surg [Epub ahead of print] [cited 2023 Jan 28]. Available from: http://www.herniasurgeryjournal.org/preprintarticle.asp?id=336224
| Introduction|| |
A traditional way to protect the exposed viscera was the temporary closure of the fixed open abdomen (OA) when skin or muscle flaps are not available by using split-thickness skin graft as a lifesaving procedure, leaving the definite reconstruction of the defect for a later time. There are various methods of definite abdominal wall reconstruction as component separation technique, using synthetic meshes, autologous tissue, and more complex techniques with pedicle or free flaps.,,
We present a case of OA temporarily closed by split-thickness graft, successfully and definitely reconstructed by a modification of the technique proposed by Stark and Strigard of invaginating the grafted area.
| Case Presentation|| |
A 47-year-old female patient presented to our hospital complaining of a big incisional hernia [Figure 1]. Four years ago she underwent laparoscopy for infertility in another hospital and due to a large bowel injury with perforation and peritonitis, with late recognition, she was prolonged hospitalized in the intensive care unit (ICU) with OA. The abdominal defect could not be approximated, although the anterior component separation technique was done and it was temporarily closed by split-thickness graft. Preoperatively an abdomen CT confirmed a defect of 13 cm × 12 cm in the anterior abdominal wall displacing both recti muscles laterally, associated with herniation of the transverse colon, small bowel loops, and omentum with evident close attachment of the grafted area with the bowel [Figure 2]. The patient received preoperatively cefazoline 1 gr IV according to our preop antibiotic prophylactic protocol and a urinary bladder catheter was placed for monitoring the intraabdominal pressure (IAP). Under general anesthesia, the skin at the edge of the graft was incised circumferentially until reached to the fascia of rectus abdominis sheath without cutting the graft and without exposing the peritoneum or the covered by the graft viscera [Figure 3]. The skin and the subcutaneous fat flap was detached from the anterior surface of the rectus sheath and the dissection was continued until the flap was raised up to the midclavicular line bilateral [Figure 3]. The two edges of the grafted abdominal defect were approximated in the midline with Nylon loop No0 by stitching the fibrosed rims and avoiding entering in the peritoneal cavity. The grafted area was invaginated en block inside the peritoneal cavity repositioning the herniating intestines into the abdominal cavity [Figure 4] and [Figure 5]. An on-lay polypropylene mesh was applied in order to reinforce the repair [Figure 6]. The IAP was measured at the beginning of the procedure (preop IAP 8 mmHg) and after the invagination of the graft (postop IAP 11 mmHg) and it was within normal range. The subcutaneous space was drained and the skin flaps were stitched in the midline. The recovery was uneventful. One year after the repair, there is no recurrence [Figure 7]. The patient is fully satisfied with the result with a marked improvement in the quality of life.
|Figure 1: Preoperative picture of the created ventral hernia after the temporary closure of OA with partial-thickness skin graft|
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|Figure 2: Preoperative abdomen CT scan showing the defect and the herniating viscera as well as the attachment of the covering graft (red arrows). In the transverse section, the previous anterior component separation is obvious|
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|Figure 3: Skin incision at the edge of the grafted area and dissection of the flap up to the midaxillary line|
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|Figure 5: Two edges of the grafted abdominal defect fully approximated in the midline (yellow arrows). The yellow lines delineate the midclavicular lines|
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|Figure 6: Reconstruction of the abdominal wall was re-enforced by on lay polypropylene mesh|
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|Figure 7: Six months postoperatively without evidence of hernia recurrence|
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| Discussion|| |
As Sir William Ogilvie in 1940 introduced the OA, this approach has gained a wide acceptance in the management of abdominal surgical catastrophes. The term of OA is a clinical condition according to the European Hernia Society (EHS), in which a laparotomy incision is left without closure and it is an intended surgical treatment option when required to support the patient generally, control abdominal sepsis, minimize damage to the abdominal contents while the abdomen is open and minimize adherence of the abdominal contents to the anterior abdominal wall.,
After the first phase of metabolic derangement due to systemic inflammation/sepsis, hemorrhage, and cardiovascular instability in which repeated intraabdominal procedures are needed, definite closure of the OA should be attempted. The OA should be closed within 8–12 days in order to avoid laterization of the fascial edges with a frozen visceral sac which will increase the size of the defect making the primary closure difficult. Closure of the OA is challenging and dynamic closure techniques should be preferred, according to the guidelines of the EHS, for the closure of the abdomen than static closure techniques (Bogota bag, Negative Pressure Wound Therapy (NPWT)). Dynamic closure techniques include ABRA system, Wittmann Patch, ABRA system combined with NPWT, and fascial traction (mesh or other) with NPWT. If it is not possible, the abdomen should remain open. By the end of the second phase where no other intraabdominal procedures are required and the tissue edema has subsided, the fascial approximation is facilitated. If a new attempt for closure using other than skin grafting techniques fail to achieve definite abdominal closure, during the initial hospitalization period, then direct application of split thickness skin graft over the exposed viscera can be used (planned ventral hernia)., This is a temporary solution to close the defect in order to save peritoneal fluid, avoid protein loss, reduce the risk of infection, and avoid fistula formation. The definite reconstruction should be delayed for at least 10–12 months, which is the third phase of OA until by the pinch test, the skin graft can be separated from the underneath bowel. The removal of the grafted skin layer from the intestinal surface at the definite reconstruction of the gap is sometimes difficult; it increases the operative time and exposes the patient to bowel injury with possible enteroatmospheric fistula and development of adhesions., In our case, the abdomen computed tomography (CT) scan showed close attachment of the grafted skin with the bowel increasing the possibility of traumatic complications during repair of the hernia. As the split-thickness graft lacks skin appendages, it can safely be invaginated without complications. It is microscopically proved that the inverted partial-thickness graft, after few years, loses the skin adnexa and the skin cells are transformed to a stable connecting tissue layer. This technique was first introduced by Stark B and Stringard K in four patients with full-thickness abdominal defects, treated initially with split-thickness skin grafting of the exposed viscera., Measurement of the IAP, preoperatively and postoperatively, is necessary because if the IAP is increased to the range of hypertension or abdominal compartment syndrome, another method for reconstruction of the abdominal wall should be attempted after the release of the invaginated graft.
| Conclusion|| |
The described technique of intraabdominal invagination of the split-thickness graft without opening the peritoneal cavity and approximating in the midline the recti abdominis muscles with mesh reinforcement is a simple and effective method of definite reconstruction of abdominal defects, which were temporarily closed by split-thickness skin graft.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Department of General Surgery, Imam Abdulrahman Bin Faisal Hospital, P.O. Box 4616 Dammam 31412
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]