International Journal of Abdominal Wall and Hernia Surgery

ORIGINAL ARTICLES
Year
: 2021  |  Volume : 4  |  Issue : 4  |  Page : 195--201

Successful closure of the open abdomen utilizing novel technique of dynamic closure system with biologic xenograft


Yana Puckett, Beatrice Caballero, Shirley McReynolds, Robyn E Richmond, Catherine A Ronaghan 
 Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA

Correspondence Address:
Dr. Yana Puckett
Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
USA

Abstract

PURPOSE: The objective of this study was to demonstrate an alternative option for definitive fascial closure and accelerated wound healing of catastrophic open abdominal wounds utilizing a novel technique combining a mechanical closure system with biologic xenograft. MATERIALS AND METHODS: All patients who underwent abdominal closure with a dynamic wound closure system with biologic xenograft were analyzed between 2016 and 2017. ABRA® dynamic wound closure system was placed and adjusted daily until fascial closure was achieved. ACeLL® urinary porcine bladder matrix was placed in midline of wound once fascial closure was achieved. Information was abstracted on patient demographics and extent of open abdomen (OA) and postoperative outcomes. RESULTS: Fifty patients underwent novel closure of the OA with mean age of 48.3 years with males comprising 72%. The average body mass index was 35.0. Majority (62%) of OAs were secondary to abdominal sepsis. The average myofascial gap prior to closure of abdomen was 19.0 cm, incision length 28.9 cm, and visceral extrusion 7.7 cm. Prior to installation, the abdomen on average had 3.6 laparotomies and was open for 8.6 days. Primary myofascial closure was achieved in 49/50 (98%) patients; 3/50 (8.3%) developed a hernia. Surgical site infection (SSI) occurred in 4/50 (8%). CONCLUSION: We present a novel technique to achieve primary myofascial closure rate in critically ill patients with OA associated with low hernia rate and SSI.



How to cite this article:
Puckett Y, Caballero B, McReynolds S, Richmond RE, Ronaghan CA. Successful closure of the open abdomen utilizing novel technique of dynamic closure system with biologic xenograft.Int J Abdom Wall Hernia Surg 2021;4:195-201


How to cite this URL:
Puckett Y, Caballero B, McReynolds S, Richmond RE, Ronaghan CA. Successful closure of the open abdomen utilizing novel technique of dynamic closure system with biologic xenograft. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 May 18 ];4:195-201
Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/195/334562


Full Text



 Introduction



The term “open abdomen” (OA) refers to a defect in the abdominal wall with exposed abdominal viscera. Definitive closure for the OA remains a surgical challenge with reported hernia rates of up to 30%, if myofascial closure is achieved.[1],[2],[3] The most common etiologies for an OA are damage control surgery, abdominal compartment syndrome, and abdominal sepsis.[4],[5],[6]

Complications of the OA include fluid loss, protein loss, fistula formation, and loss of domain.[7],[8] Once a decision has been made to leave an abdomen open, it must be temporarily covered. Several techniques are available for temporary abdominal closure including a negative pressure wound system device which helps to counteract the retractile forces of the lateral oblique muscles thereby minimizing loss of domain and silo technique which involves suturing a large, sterilized translucent bag to the abdominal fascia or skin. Another option is to close the skin only with a towel clamp or a whip stitch.[9],[10],[11]

Adjunctive techniques exist which help pull the fascia to the midline, thereby minimizing lateralization of the oblique muscles. These techniques include placing vessel loops for traction of skin, use of fascial retention sutures, and even primary fascial release to relax the fascia of the oblique musculature.[12],[13],[14],[15],[16],[17]

The Abdominal Reapproximation Anchor system (ABRA®, Canica, Almonte, Ontario, Canada) has been available for approximately 15 years and is a technique used to close wounds based on dynamic elastic closure. It was originally designed specifically for OAs, however, its use has been broadly applied to other areas of the body such as extremities and fasciotomies.[12],[13],[14],[15],[16],[17] The utilization of a dynamic tissue closure device such as ABRA® has been reported in the literature before with previously reported rates of primary fascial closure of up to 88%.[13],[15] However, hernia rates still remain high with the technique (reported 4 hernias out of 16 that were able to close primarily or 25%).[14] Definitive abdominal closure is often still not possible, and patients are subject to skin grafting of the OA. These patients often develop large and debilitating hernias associated with poor quality of life.[18]

We present an alternative technique for OA closure that is associated with a 98% primary myofascial closure and accelerated wound healing. The technique utilizes the dynamic tissue closure device (ABRA®) in conjunction with biologic xenograft that is made with porcine urinary bladder matrix. The technique was begun by a single surgeon who noticed that outcomes with the novel technique were objectively remarkably better in terms of ability to close the abdomen without the need of skin grafting and has extremely low hernia rate as well as surgical site infection (SSI) rate. The surgeon also noted improved quality of life reported in many patients. This study reports a series of 50 such abdominal wall closures performed at a busy Level I trauma center.

 Materials and Methods



All patients who underwent abdominal closure with a dynamic wound closure system with biologic xenograft were analyzed between May 2016 and November 2017. ABRA® dynamic wound closure system was placed and adjusted daily until fascial closure was achieved. ACeLL® urinary porcine bladder matrix was placed in midline wound once fascial closure was achieved. Information was abstracted on the age of patient, body mass index (BMI), incision length, myofascial gap size before and after ABRA® placement, visceral extrusion size, number of ABRA® adjustments, and total time to fascial closure. Bjorck classification of OA was used to depict its severity.[19],[20] In all patients, one surgeon applied the system and supervised the patients. A clinic visit 1 year postoperatively was scheduled with the cohort to evaluate for incisional hernias, quality of life, and return to work rate. If patients did not follow-up in clinic, they were contacted via phone and screened for incisional hernias, and available computed tomography (CT) imaging was also reviewed to identify any abdominal defects.

ABRA® dynamic tissue system (DTS)

The abdominal re-approximation anchor (ABRA®) (Canica Design Inc., Almonte, Ontario, Canada) system developed by Southmedic company uses this technique. It utilizes a progressive tension band system which allows the fascial edges to be approximated over time to allow primary wound closure.[15],[17],[21] Gently, the dynamic appositional forces counter the retracting forces that keep open abdominal wounds open. The pathophysiology thought to affect progressive apposition is that cyclic stretching promotes collagen and fiber rotation and stretching, which leads to tissue adaptation.

Porcine urinary bladder matrix

ACeLL® manufactures urinary porcine matrix management products which are used in this novel technique. The Cytal wound matrix comprised urinary bladder epithelial basement membrane and assists in wound healing by facilitating remodeling of tissues. The Cytal wound matrix comes in 1, 2, 3, and 6 layers. This technique calls for a two-layer Cytal wound matrix, which is intended to treat partial and full-thickness burns, pressure ulcers, venous ulcers, and surgical wounds.

MicroMatrix

MicroMatrix is used to facilitate remodeling as well and is composed of powder epithelial basement membrane porcine urinary bladder. The powder is used in this technique as the first step in closure of the midline wound after primary myofascial closure is achieved.

Installation

The patient is positioned supine on the operative table. After adequate general endotracheal anesthesia is achieved, bilateral sequential compression devices, Foley catheter, and warming blanket are applied. The abdomen is widely prepped and draped after removing the outer wound vacuum sponge. The wound vacuum plastic visceral protector is removed, and a large volume paracentesis is performed.

After careful re-exploration of the abdomen, the surgeon assesses if the patient is deemed ready for the installation of the ABRA® DTS system to begin definitive closure of the OA. The surrounding abdominal skin is then lightly sprayed with an adhesive spray. The visceral mass is covered with a laparotomy sponge. An antimicrobial incise drape is carefully applied, completely covering the abdominal skin. Laparotomy sponge and antimicrobial incise drape overlying the abdominal visceral are carefully removed. The right medial fascial edge is identified and, and an ellipse is created 5 cm lateral to the medial fascial edge on the right as well as the left side. This marks the elastomer insertion sites. Then, utilizing two ABRA® buttons, 3 cm markings are symmetrically created to cover the full length of the myofascial defect. The length of the incision, visceral extrusion, and myofascial gap are measured and recorded. Peak inspiratory pressure is measured and recorded as well at the beginning of the case prior to the installation of the ABRA® DTS.

Dermotomies are then created at the 3 cm hash-marks where they intersect with the 5 cm ellipse beginning on the left [Figure 1]. Utilizing the cannulator, the elastomers are positioned traversing the entire abdominal wall at a right angle. This is repeated on the right such that all elastomers now traverse the myofascial gap. The buttons are placed securing the elastomers, but under no dynamic tension at this point. The silicone visceral protector is then placed to cover and protect the visceral mass. The silicone elastomer retainer is then trimmed and positioned on top of the silicone visceral protector in the midline. The elastomers are then placed in the silicone visceral protector to maintain symmetrical dynamic tension. Adhesive spray is applied to the antimicrobial incise drape lateral to the buttons to ensure adherence of the button tails.{Figure 1}

The button tails are then secured to the elastomers taking care not to place the junction under high tension. Throughout the case, periodic two-region osteopathic maneuvers are performed [Figure 1]. Our recommendation is for at least six osteopathic maneuvers to be performed during the entire case. The elastomer adjustments then ensue until the hash-mark stretch across the myofascial gap is approximately two times normal. A black sponge negative pressure wound therapy device is applied to the midline and placed to continuous 25 mmHg negative pressure. An absorptive, antishear wound dressing is placed underneath each elastomer button.

Visceral extrusion, myofascial gap, and incision length should be remeasured and recorded. Peak inspiratory pressure should be noted and recorded [Figure 1].

Adjustment

The patient is taken to the operating room in 1–2 days and remains supine on the surgical intensive care unit (ICU) bed during the entire procedure. The wound black sponge is removed. The abdomen is prepped and draped. Of note, the original antimicrobial incise drape is not to be removed. Large volume paracentesis is completed. New myofascial gap, visceral extrusion measurements are recorded. A new negative pressure wound therapy black sponge is reapplied, and a good seal is obtained [Figure 1].

Closure

The patient is taken to the operating room and moved to the operating table. Thigh-high bilateral sequential compression devices are in place, as well as a Foley catheter. A warming blanket is applied to the lower extremities. General endotracheal anesthesia is achieved. The negative pressure wound therapy sponge is removed, and the abdomen is prepped and draped.

Large volume paracentesis is completed. The patient’s myofascial gap (the gap between two sides of abdominal wall fascia present after open abdominal surgery) and myofascial apposition if any are recorded. Peak inspiratory pressures are recorded at the beginning and end of the procedure. If the patient is deemed ready for deinstallation of the ABRA® DTS and primary myofascial closure, intraoperative abdominal X-rays are ordered to confirm no retained surgical foreign bodies.

Subcutaneous flaps are raised circumferentially to carefully delineate the entire myofascial unit. The silicone elastomer retainer is removed. In a bidirectional fashion, #2 Vicryl Smead-Jones interrupted closure is completed in a bidirectional fashion. The sutures are secured in place, and the elastomers are sequentially cut as primary myofascial closure proceeds. Once the primary myofascial closure is complete, the peak inspiratory pressures are noted.

One gram of MicroMatrix is sprinkled directly on the primary myofascial closure and subcutaneous tissue, taking care to cover the entire incision length and surface area of the wound. Gentrix three-layer wound matrix is then implanted in a taco configuration to ensure contact not only with the myofascia but also with the subcutaneous tissues [Figure 1]. Aquacel Ag Hydrofiber Extra (absorbent cloth) is applied to all of the elastomer exit sites and secured in place with 2-inch strips of vacuum drape tape. ABDs are secured in place with medium dressing. At the termination of these procedures, all sponge and needle counts are counted. The patient is transported to the surgical ICU, intubated.

The patient remains in the ICU under general anesthesia. If peak inspiratory pressures are high, the patient may be paralyzed and tube feeding limited and parenteral nutrition started. The bedside care of the patient must be done daily which includes keeping skin and buttons dry and performing osteopathic maneuvers, otherwise known as “the move.” Ostomy care is meticulously performed to keep the elastomer buttons and midline wound clean and dry if ostomies are present.

Osteopathic maneuver for myofascial release: “the move”

Both palms are placed parallel to the abdomen on each side of the patient over patient’s oblique (two people required). Tension-reducing force is applied in circular, massaging motion with emphasis on medializing the wound and relaxing the oblique muscle and fascia. Each move should last approximately 30 s and released slowly. The move is repeated three times.

Postoperative midline wound xenograft management

The wound is observed and if xenograft gets wet, the vacuum drape tape is taken down vertically so as not to disturb and remove the xenograft. The excess moisture is removed with ABD dressings and a dry, clean ABD pad is placed in the midline wound. The skin edges are once again re-approximated with vacuum drape tape. The dressing changes typically occur every other day initially and after that as needed. At our institution, a single wound care specialist was in charge of this wound care regiment while the patient was in-hospital and followed them home as well. It is important to note on top of the dressing that the dressing need not be removed as that can result in loss of the xenograft. Typical time of the midline wound healing is approximately 8 weeks.

Patient follow-up

The patients were screened for an incisional hernia at least 12 months after the procedure by telephone or by a CT scan that they had obtained for other reasons.

 Results



A total of 50 patients were reviewed. The mean age of the patient was 48.32 ± 14.75 years with males comprising 72% of the population. Caucasians comprised 66% of the population followed by Hispanics (28%) and African-Americans (6%). Type 2 diabetes mellitus was present in 12% of the patients; cancer was present in 12% of the patients; and hypertension was present in 36% of the patients [Table 1].{Table 1}

The main reasons for the OA were bowel surgery, perforation, and abdominal sepsis (62%), followed by abdominal compartment syndrome (16%), followed by incisional hernia with loss of domain (10%), enteric fistula (6%), and non-bowel surgery (4%) [Table 1]. Majority or 48% of the OAs were Bjork classification type 2B and 16% were Bjork classification type 2A [Table 1].

The average number of laparotomies a patient underwent prior to installation of DTS was 3.66 ± 2.07 with a range of 1–9. Length of stay on average was approximately 39.84 ± 21.55 days with the range being 7–116 days. The average total days of having an OA before DTS installation was 8.57 ± 7.31 (range 0–35) [Table 1].

The average myofascial gap prior to installation of DTS was 19.02 ± 6.11 cm (range 10–35). Visceral extrusion prior to installation of DTS was on average 7.66 ± 3.27 cm and went immediately to 0.11 ± 0.52 cm on all patients after DTS installation. The patient needed paralysis after installation of DTS for an average of 2.92 ± 5.54 days [Table 1].

There were four cases (8%) of SSIs, and 2% or one patient developed pneumonia. The 30-day mortality was 8% (4/50 patients). A total of three people required de-installation and reinstallation due to an intra-abdominal problem that developed due to their underlying pathologies such as a bile leak or anastomotic leak. Here, 2/50 patients died while ABRA DTS in place, whereas 2/50 patients died after removal of ABRA DTS. All patients died due to non-ABRA-related causes. Primary myofascial closure was achieved in 98% of the patients. The single patient not able to be closed primarily had a bladder repair by urologists who incorporated myofascia inferiorly as such making it impossible to install the device inferiorly. Her abdomen was partially closed utilizing the described technique.

Postoperatively, on 1-year hospital follow-up, only 36 patients were followed up and only 8.33% or 3 patients developed a hernia. No patients required complex abdominal wall reconstruction [Table 2].{Table 2}

 Discussion



At our institution, previous OA patients who were not able to be closed underwent skin grafting of the viscera after daily wound care management either with wound vac or wet to dry dressing changes with an attempt at abdominal wall closure at a later date with component separation techniques. Currently, due to our success rate, since the inception of the novel technique, no patient has undergone a skin grafting of their OAs since 2014.

Previous studies with ABRA® DTS technique depict a primary myofascial closure between 33% and 88% with majority of the population matching ours (majority with septic abdomens).[10],[11],[13],[14] One study by Verdam et al. depicts a closure rate of 88%.[22] This is the most successful closure rate published in the literature. However, in their series of 16 patients, only 14 were able to achieve primary myofascial closure (88%). The two patients who were not able to be closed underwent a component separation technique to close the midline fascia. The hernia rate for the patients who achieved primary myofascial closure was 28.6%. We present our results with a novel technique that achieved primary myofascial closure in 98% of the patients with a hernia rate of 8%. No patients required a complex abdominal wall reconstruction. To date, we report the lowest hernia rate after primary abdominal closure in a catastrophic OA series. We also report the highest achievement of primary myofascial closure and a very low SSI rate.

The study also reported pressure sores from elastomer buttons that occurred in 12 out of 18 cases or 67%.[22] We did not experience this complication with our patient population. This positive outcome in our technique is likely attributed to the placement of antimicrobial incise drape over the skin prior to installation of the device and keeping it there until de-installation of the device.

In addition, meticulous technique of keeping the skin dry during care in the ICU postinstallation also likely contributed to no pressure sores from elastomer buttons as well as placement of the absorptive dressing under the buttons. This likely works by absorbing fluid and as underlying padding for the buttons.

We speculate that the addition of biologic xenograft made of porcine urinary bladder matrix to the midline wound after myofascial closure may be the key component of our success rate. Porcine urinary bladder matrix is associated with antibacterial properties which likely contributes to our low SSI rate and hence non-existent wound dehiscence rate and subsequent 8% hernia rate.[23],[24] The one patient who developed a hernia had a massive loss of domain before their primary myofascial gap closure. Future research efforts will be dedicated to identifying whether certain patients are at an increased risk of hernia.

It is possible that the excellent results presented here are due to meticulous techniques performed by a single surgeon, which may be hard to reproduce. In order to mitigate that, a video of the procedure as well as a manuscript of the installation is available at www.Jove.com.[24]

 Conclusion



In conclusion, we describe a useful novel technique that utilizes a DTS along with porcine urinary bladder matrix. It is associated with complete primary closure in almost all patients with low hernia and SSI rate. Since the implementation of this technique, no patient has received skin grafting of abdominal wall defect. Furthermore, there has been no need for complex abdominal wall hernia repair. Future research efforts will be directed on the cost analysis and analysis of quality of life after our novel technique.

Acknowledgments

We would like to acknowledge the Clinical Research Institute at Texas Tech University Health Sciences Center in Lubbock, TX for help with Institutional Review Board assistance. We would also like to thank Michelle Estrada and Virginia Tran with their help with data collection.

Ethical statement

Texas Tech University Health Sciences Center Institutional Review Board (IRB) approval was obtained before the start of the study. The IRB determined that our study was exempt from needing to obtain informed consent from patients.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr Catherine Ronaghan is an AceLL speaker and proctor.

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