Laparostomy

Section: Abdominal wall and retroperitoneum Curriculum: Curriculum, page 4

Rational

• Damage control surgery
• Abdominal compartment syndrome
• Severe abdominal sepsis.
  • Allows enteric contents and pus to drain.
• Planned relook for evolving pathology
  • E.g. ischemic bowel
• Open and transfer/re-operation with a surgeon with a different skill set

Advantages

• In certain situations - this will reduce the rate of recurrent sepsis, minimise wound complications, and avoid IAH.
• Fast ventilator weaning.
• Facilitate early enteral nutrition.

Disadvantages

• Increased fluid and protein loss.
• Loss of domain (abdominal wall retracts laterally)
• Exposed bowel can fistulate.
• Considerable psychological distress.
• Challenging for nursing staff.
• Hernia formation is inevitable.

Options for laparostomy formation

Silo techniques

• A “Bogota Bag” - open up a sterile 3L IV bag and suture to the fascia
• It is difficult to control fluid losses.

Negative pressure systems

• This involves placing either a “towel” (i.e. Kerlex gauze) or “sponge” (i.e. black foam) over a semipermeable adhesive dressing with slits (i.e. Tegaderm or Ioban)
• Drains are placed in the towel or sponge.
• This is effective at removing and measuring fluid from the wound.
• It also helps prevent loss of domain.
• There is a concern that this method can cause fistulas

https://journals.lww.com/jtrauma/fulltext/2000/02000/vacuum_pack_technique_of_temporary_abdominal.1.aspx

AbThera

• Components
  • Fenestrated Visceral Protective layer
  • Perforated Foam
  • Suction pad
  • VAC drape
  • Pressure source unit
• Application
  • Place protective layer and trim to size
  • Place foam over the top
  • Place VAC drape over the top to ensure a seal
  • Cut a 2.5cm hole and the place suction pad
  • Turn on - 125mmhg

Stomas and laparostomies

• If you are ever creating a stoma - you should bring it through the oblique muscles (not rectus) to avoid problems with abdominal closure (i.e. its gets in your way)

Closing a laparostomy

Primary fascial closure

• This is the ideal option - but is often no possible.
• Rates of ventral hernia are very high
• If able to close, do so. Best to use figure of 8 interrupted 1-0 Nylon

Mediated closure

• Adjuvant fascial traction helps pull the fascia to the midline and improves primary fascial closure.
• Techniques include
  • Mesh mediated closure
  • Fascial tension sutures
  • Primary fascial release (making incision of the oblique musculature)
  • Graduated fascial closure technique
    • Abdominal re-approximation and Anchor System (ABRA)
    • Wittman patch
• There is evidence that adjuvant fascial traction increases rate of primary closure.

Mesh-mediated Closure technique

• Stitch polypropylene mesh to the edges of the fascia
• Each time you return to theatre - cut away central portion and pull edges together
• Place simple black sponge foam VAC over the top

Wittman Patch

• This is an example of graduated fascial closure technique
• A protective bowel barrier is placed into the abdomen.
• Hydrocolloid dressing is placed circumferentially around the defect to protect the skin.
• Bolsters are applied lateral to the rectus sheath
• The loop sheet  is placed into the abdomen - is trimmed to fit the defect.
• 1-Ticron suture is placed (bolster - abdominal wall - loop sheet - abdominal wall - bolster)
• The hook sheet is placed.
• The sheets are velcoed together re-approximating the fascia.
• Black foam is placed in the middle of the wound and VAC applied.
• The patient can then be brought back to theatre every 48 hours for wound inspection and tightening.
• Once the fascia has been re-approximated, it can be closed and the bolsters and sheets removed.
• https://www.starsurgical.com/wp.html

Unable to close

• After 7-10 days your aims transition from closure to coverage

Functional closure (planned hernia)

• Inlay mesh
  • This involves using an inlay biologic mesh or Vicryl mesh - drains can be placed on the mesh and skin closed over the top.
• Close skin
  • Close skin over bowel
• Skin graft
  • Leave open to granulate
  • Then skin graft over
  • This will take a long time to get enough granulation tissue to graft over and the wound management will be difficult without a VAC

Beware

• Main thing you want to avoid is a fistula!
• After 7-10 days, in danger territory of forming fistula if abdominal cavity remains open
• Main goal then becomes: AVOID A FISTULA
• If fistula avoided, no matter what the closure technique was, it will be a success
• Aim now becomes COVERAGE
• Fascia
  • Biologic mesh (but needs skin coverage or else it dessicates, can’t VAC)
  • Vicryl mesh, synthetic absorbable mesh (best option, can VAC over it, can promote granulation tissue, does not dessicate)
• Skin
  • Try to get skin coverage over the top if possible
  • If you cant apply VAC over the top – 75mmHg (concern of fistula, no evidence and what is the alternative?)
    • Wait for granulation tissue
    • Then apply skin graft