Jernigan T Wright, Fabian Timothy C, Croce Martin A, Moore Natalie, Pritchard F Elizabeth, Minard Gayle, Bee Tiffany K
Department of Surgery, University of Tennessee Health Science Center, 956 Court Avenue, Suite G228, Memphis, TN 38163, USA.
Ann Surg. 2003 Sep;238(3):349-55; discussion 355-7. doi: 10.1097/01.sla.0000086544.42647.84.
Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects.
Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates.
Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%).
The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.
休克复苏常导致内脏水肿，常使腹壁无法关闭。我们已制定了一种分阶段方法，涵盖从急性处理到确定性腹壁重建。本报告的目的是分析我们应用该技术治疗开放性腹部和巨大腹壁缺损患者的经验。
我们对巨大腹壁缺损的处理方案包括三个阶段：第一阶段，插入可吸收网片进行临时关闭（如果水肿在3 - 5天内迅速消退，可逐渐折叠网片，允许延迟筋膜关闭）；第二阶段，对于水肿未消退的患者（插入后2 - 3周，以使内脏形成肉芽并固定），移除可吸收网片，并使用中厚皮片或全厚皮片覆盖内脏形成预期的腹疝；第三阶段，在6 - 12个月后（待炎症和致密粘连消退），使用改良的成分分离技术进行确定性重建。对1993年至2001年在单一机构的连续患者进行了评估。按处理阶段分析结果，重点关注伤口相关的发病率和死亡率、瘘管和复发性疝的发生率。
共处理了274例患者（35例患有脓毒症，239例患有失血性休克）。男性212例（77%），平均年龄37岁（范围12 - 88岁）。缺损平均大小为20×30厘米。在第一阶段组中，108例（占所有死亡病例的92%）因休克死亡。其余166例采用聚乙醇酸910编织可吸收网片进行临时关闭。随着内脏水肿消退，37例患者（22%）通过在床边折叠可吸收网片实现了延迟筋膜关闭。在第二阶段组中，9例（占所有死亡病例的8%）死于与其基础疾病相关的多器官功能衰竭，其余120例中的96%在内脏上放置了中厚皮片。未发生与伤口相关的死亡。共有14例瘘管（占总数的5%，幸存者的8%）。在第三阶段组中，迄今为止，120例中的73例已使用改良的成分分离技术进行了确定性腹壁重建。无死亡病例。平均随访24个月（范围2 - 60个月）。这些患者中有4例（5%）出现复发性疝。
对巨大腹壁缺损患者进行分阶段处理，不使用永久性网片，为初始处理和确定性处理提供了一种安全且一致的方法，发病率低且无技术相关的死亡率。可吸收网片能有效临时覆盖腹壁缺损，瘘管发生率低。由于复发性疝发生率低且避免使用永久性网片，成分分离技术是确定性腹壁重建的首选方法。
