One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol.

BACKGROUND

Multiple techniques have been introduced to obtain fascial closure for the open abdomen. Vacuum-assisted closure has reduced but not eliminated the use of either split-thickness skin grafts to cover the exposed bowel or mesh (prosthetic or biological) approximation of the fascia. We hypothesized that a sequential closure technique performed by a systematic protocol would achieve a higher rate of primary fascial closure than other described techniques.

METHODS

Our technique of sequential fascial closure was initiated in 2005. Patients with a postinjury open abdomen undergoing the technique were compared with those patients who did not follow the protocol. In brief, vacuum-assisted closure white sponges cover the bowel; the fascia is placed under moderate tension over the white sponges with no. 1-polydioxanone sutures; the black sponge is placed on top of this with the standard occlusive dressing; patients undergo partial fascial closure and replacement of the sponge sandwich every 2 days until completely closed. Protocol violations were defined as not returning to the operating room every other day and absence of fascial retention sutures. Patients who died before return to the operating room in the first 48 hours were excluded.

RESULTS

One hundred consecutive patients underwent damage control surgery during the five-year study period and survived to second laparotomy; 49 patients attained fascial closure at the second laparotomy. Fifty-one patients required an open abdomen after the second laparotomy and comprise the study population. The majority were men (80%) with a mean age of 34.7 years ± 2.0 years, mean injury severity score of 37.1 ± 2.4, and mean abdominal trauma index of 26.4 ± 2.1. Average initial base deficit was 15.7 ± 0.6 and 24-hour red cell transfusions were 20.4 ± 2.4 units. Of the 51 patients, 29 followed the protocol and 100% had fascial closure. Of the 22 patients who did not follow the protocol, 12 (55%) attained fascial closure. There were no significant differences in injury severity score, abdominal trauma index, base deficit, or red cell transfusions between the two groups.

CONCLUSIONS

A methodical approach with sequential fascial closure achieves 100% fascial approximation in our experience. This technique reduces the morbidity of the open abdomen and the cost of either complex abdominal reconstruction or biological mesh insertion.