Supplement 28: Should We Attempt to Achieve Same Hospital Stay Closure of the Open Abdomen?
As the inability to achieve primary fascial closure after damage control laparotomy has been associated with increased morbidity and reduced quality of life among critically ill adults, efforts to close the abdominal fascia before discharge could potentially lead to improved outcomes.
Evidence Summary:
We identified no valid RCTs or observational studies that evaluated whether efforts to achieve closure of open abdominal wounds before hospital discharge were associated with patient-important outcomes. The only relevant RCT compared the outcomes of trauma patients who underwent temporary abdominal closure using negative pressure wound therapy (NPWT) (predominantly Barker’s vacuum pack technique) versus polyglactin mesh [163]. However, this trial was likely underpowered, used a combination of commercial and non-commercial NPWT techniques [some patients received the Kinetic Concepts Incorporated (KCI) vacuum-assisted closure device], and used gastrostomies and jejunostomies (potentially increasing risk of abdominal fistulae) [[1]]. Four systematic reviews also examined the outcomes of critically ill adults with open abdominal wounds who were treated with several different types of abdominal closure techniques and reported conflicting results (see below under negative pressure wound therapy).
Recommendation:
The WSACS RECOMMENDS that among ICU patients with open abdominal wounds, conscious and/or protocolized efforts be made to obtain an early or at least same hospital stay closure (GRADE 1D; Management Statement).
Rationale:
From a patient and societal perspective, same hospital stay abdominal fascial closure appears desireable. While protocolized care in general improves patient outcomes across a wide variety of settings [[2]], which techniques or strategies should be utilized in order to achieve earlier abdominal fascial closure among those with open abdominal wounds remains controversial.
References
1. Bee TK, Croce MA, Magnotti LJ, Zarzaur BL, Maish GO, 3rd, Minard G, Schroeppel TJ, Fabian TC, (2008) Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. The Journal of trauma 65: 337-342; discussion 342-334
2. Roberts DJ, Zygun DA, Grendar J, Ball CG, Robertson HL, Ouellet JF, Cheatham ML, Kirkpatrick AW, (2012) Negative-pressure wound therapy for critically ill adults with open abdominal wounds: A systematic review. The journal of trauma and acute care surgery 73: 629-639