Staged abdominal closure

Closing a Laparostomy

Primary fascial closure

• This is the ideal option - but is often not 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