Component separation technique for closure of burst abdomen

Component separation technique for closure of burst abdomen

AshrafGoda, MD; MohamedNasr,  MD; Osama H Gharib, MD;

MostafaBMohamed, MD

General Surgery Department, Faculty of Medicine, Zagazig University.

Background: Burst abdomenis a continuing problem for thegeneral surgeon as theincidence of such complication may reach 3% with a mortality rate exceeding 25%.

Methods: Component  separation  of all layers of anterior  abdominal  wall would give  an extra length on each side towards medial advancement. 20 patients, 12 men and 8 women aged

35-65 {mean, 48.6) years, with burst abdomen after major gastrointestinal and hepatobiliary surgery whose abdomen could not be   closed primarily  were managed  using this technique. Long term follow up of patients was done for development of complications.

Results:   One  patient  died  on  the  fourth postoperative  day  from pulmonary  embolism

{mortality  5%),  and  2  patients  developed  subincisional  abscesses  (10.5%).  Skin necrosis occurred in 1 patient  (5%). No single case of reburst occurred  Only one patient showed  few symptoms of abdominal compartment  syndrome. The mean hospital stay was 18.5 days. Long term follow up showed only one case ofincisional hernia (5.5%) in a patient with biliary fistula.

Conclusion: The component separation technique is a suitable, straightforward and tension free method   with a comparable  mortality  and morbidity  to other conventional  methods  for closure of burst abdomen.

Key words: Component separation, burst abdomen, abdominal closure.

Introduction:

Burst  abdomen  is  a continuing  problem for the general surgeon, as the incidence may reach 3% of major laparotomy woundsl  with mortality rate ranging from 24%2 to more than

44%.3 There was no difference  in mortality between patients with evisceration  and those with dehiscence only.4 The closure under tension is doomed to failure so that if we are unable to reapproximate the fascia without tension,  then  we will usually have to place a fascial substitute.  Many different methods have  been  used  to  close  the   dehiscence, ranging from simply closing the skin over the defect and leaving the fascia and peritoneum wide  open  to  doing  relaxing  incisions  of both  fascia  and  skin  well  away  from  the wound, closing the primary wound  and skin grafting the resulting defect.  More recently, the vacuum pack technique,5  with mesh of some type, has been used, including Proline,

Marlex, PTFE and Vicryl, or more complex

closures using pedicled or rotation flaps are being used.6,7 None ofthese methods proved to be  ideal or  without  a significant  hazard, and certain disadvantages inherent in each technique require departure from the ideal: primary tension-free  parietal closure without use of prosthetic material.8

Patients and methods:

After    obtaining    Institutional     Review Board approval, we studied all patients undergoing component separation technique for  closure  of burst  abdomen from  January

2009to  February 2011 atthe  Emergency Unit

of Zagazig  University  Hospital. All patients included developed  burst abdomen  between the 7th and 15th day after major gastrointestinal operations        done   through             a   longitudinal abdominal incision. All were taken to surgery once their bursts  were  discovered. Analysis for patient demographics  including sex, age,

original surgery and hospital stay was done

Am-Shams] Surg 2014; 7(14):1-10

Table (1). One patient had liver cirrhosis and developed postoperative ascites after the first operation before burst. The midline defects after maximal gentle approximation ranged from  4  to  10  em.  Patients  were  followed up for mortality and for early postoperative complications (reburst, sepsis, fistula, abdominal compartment syndrome, skin necrosis). Long-term follow-up was done for development  of incisional hernia.

Technique:      All      patients      underwent

general anesthesia and received preoperative parenteral antibiotic prophylaxis (cefuroxime

1,500  mg/Clindamycin  600  mg,  30  min.

before surgery). The laparotomy was started at   the          midline             above   the       laparostomy. A          complete     adhesiolysis    was        generally performed to get a clear view on the anatomy and to free the bowel from the abdominal wall. Full exploration of the abdominal cavity was performed.  The subsequent  abdominal  wall closure was performed using the components separation technique as described by Ramirez et al.9  The skin and subcutis were separated from the underlying  abdominal  musculature in lateral direction up to the anterior axillary line.  Next, the  aponeurosis  of  the  external oblique   muscle   was   incised   pararectally. Subsequently,  the  external  oblique  muscle was  separated  from  the  underlying  internal oblique   muscle   by   blunt   dissection   in  a relatively avascular plane. This was followed by the separation of the rectus muscle from the  posterior  rectus  sheath.  The  separation of the muscle components  of the abdominal wall   allowed   mobilization   of   each   unit over  a  greater  distance  with  less  tension. Subsequently, the abdominal wall was closed using PDS  1  Figures (1-4) with two suction drains routinely used between the mobilized skin   and   abdominal   wall   musculature   to drain  the  dead space.  The  skin  was  closed because  leaving  the  skin  open  would  not guarantee adequate drainage (via the suction drains)   of  the  large  subcutaneous   wound surfaces.  Therefore,  skin  closure  combined with  closed  wound  drainage  was preferred. Postoperatively, no         abdominal                binders were applied routinely.  In case  of a wound infection,  the  running  sutures  were (partly)

removed for adequate drainage.

Results:

Component  separation  technique  for closure  of  burst  abdomen  was  done  on  20 cases. There were 12 men and 8 women with a  mean  age  of  48.6  years  (range,  35-65y) Table (1).   One  patient  died  in  the  fourth postoperative day from pulmonary embolism (mortality 5%) that was not related to the technique   and  this   patient   was   excluded from the mean hospital stay and long term follow up. None of the patients needed a ventilator postoperatively. 2 patients of 19 developed wound complication in the form of subincisional  abscesses (10.5%), which were successfully drained. Only 1 patient (5%) showed skin ischemia with subsequent limited necrosis that was treated by debridement and secondary suture. No single case of reburst occurred. Only the patient with liver cirrhosis and moderate ascites showed few symptoms of     abdominal     compartment      syndrome (tense abdomen and dyspnea) in the early postoperative period, but the patient survived. One patient had a biliary fistula after bile-duct reconstruction for iatrogenic bile duct injury. This  was also  not related  to the  technique, and inspite of the wound being continuously soaked with bile from the fistula, causing an overlying skin necrosis, reburst did not occur and the wound healed well, but incisional hernia occurred and was treated later on by surgical repair with synthetic mesh Table (2). The mean  hospital  stay was 18.5 days,  and only the cirrhotic ascitic patient stayed longer (28 days). Two patients were not included in the  long-term  follow-up  analysis  (1  patient died and 1 patient was lost to follow-up evaluation). The mean follow-up period for patients (n =18) was 12 months (range, 1-24).

Discussion:

There are a number of circumstances on both the trauma and general surgery services when apposition of the fascial edges of the incision is either not feasible or is potentially detrimental. With tissue loss following injury or debridement and abdominal wall retraction, reapproximation   of  the  fascial   edges  may

Figure {1):Cross-sectional view. Skin and subcutaneous tissue are separated  from the underlying abdominal muscle in lateral direction up to the anterior axillary line. Next the aponeurosis of the external oblique muscle is incised pararectally, and the external oblique muscle is separated from the underlying internal oblique muscle by blunt dissection {A and B). Additionally, {C) the rectus muscle is separated  from the posterior rectus sheath.

Figure {2): The aponeurosis  of the external oblique muscle was incised pararectally.

Figure {4): Closure of the defect by mobilized abdominal muscles

be impossible. Similarly, an increase in the volume of intra-abdominal contents due to the insertion of packs or edema of the midgut secondary  to  resuscitation  may   preclude

Figure  {3):   The  separation   of  the  rectus muscle  from the posterior rectus sheath.

Figure {5): Patient a fewmonths after closure with no hernia.

fascial closure. So any surgeon may, and indeed will be, presented with the inability to close the abdomen. Closing the abdomen under tension may lead to fascial dehiscence,

Table  1. Original surgery, age, gender, duration  of hospital  stay and mortality  of the study group.

CBD:common  bile duct.

a)       This patient died on the 4th postoperative day and was excluded from mean hospital stay and long term follow up.

b)       This is the cirrhotic ascitic patient.

Table 2. Incidence, type of complications  and mortality.

a)       Mild symptoms and signs in the patient with cirrhosis.

b)       The patient died from pulmonary embolism unrelated to the technique on the 4th

postoperative day.

fascial necrosis, skin necrosis, infection of the incision, incisional hernia, and the sequel of the abdominal compartment syndrome.3,11,12

To date, no one technique has proven to be appropriate for all circumstances.  Because of the high mortality and morbidity rate of burst abdomen, an attempt to prevent it by the use of  mass  closure  had reduced  the  incidence from 3%to 1%.1

Many  reconstruction  methods  for abdominal  dehiscence  have been  described,

such   as   direct   tissue   closure,   prosthetic mesh   repair,   rectus   abdominis   advanced flap reconstruction,9,16 tensor fascia lata flap reconstruction,17,18 and vacuum-assisted closure.19,20

Using a synthetic mesh to bridge the fascial defect usually requires one or more delayed procedure(s) to close the wound or cover the visceral  mass with skin  graft and results  in

large abdominal wall hernias. 11,21 The overall

complication   rate  of   polypropylene   mesh

closure approaches 80%, to the extent that some authors recommend covering the mesh with full-thickness skin or muscle flaps in the early postoperative  period or even removing the  mesh  at  the  earliest  time  conductive to  fascial   closure  (within  2  weeks)  in  an attempt  to  reduce  the  complication   rate. 22

The use of absorbable mesh shows advantage

compared  with nonabsorbable  mesh,23 but incisional hernia is inevitable, and it does not completely prevent development of fistulas.8

Myocutaneous  flaps or  even  split-thickness

skin coverage of the defect is being attempted by some authors to avoid the late complications of mesh usage.22 Bilateral incisions to relax the  skin  and  rectus  fascia  were  proposed. This technique permits medial myocutaneous advancement,  up to  10 em from  each side, and primary tension-free skin closure of midline laparotomy  incisions, but it was not clear how this "10 em" was measured. All patients develop midline wound hernias, with

25% mortality and 13% incidence of reburst

with very long convalescence (20-180; mean

88  days). The  lateral  wounds  heal  with  an ugly scar.8 The use  of a specially  designed external tissue expanders to allow delayed primary healing with full thickness skin and subcutaneous  tissue.  Unfortunately,  there  is no proper follow-up in this study.24 The SAC procedure is a new technique developed by Kafie et al., done only in 3 patients, and needs further evaluation.25

Themostimportantaspectofreconstructing a functional abdominal wall is the recreation of the linea alba and achieving midline closure.9,10,13 This allows the abdominal wall to be encompassed by functional muscular components in a manner similar to normal anatomy. As opposed to an inert material, the abdominal musculature provides dynamic support of innervated tissue to redistribute the stress applied from intra-abdominal  forces.l4

The component separation technique not only

allows for local tissue transfer but allows for enough  midline  advancement  to close large and complex defects_9,15

As to incisional hernia, whatever the surgical suture technique used to close burst abdomen, the incidence is between 34% and

43% in techniques  where the skin and fascia is being  closed.26 The incidence  of  ventral hernia from the  different techniques  that do not  involve  closure  of the fascia  is 100%.8

Even in planned ventral hernias, the resulting hernia is unsightly huge and difficult to repair.3,6 But in our study only one patient (patient of bile duct injury) had incisional hernia (5.5%) and was treated later on by surgical repair with synthetic mesh.

None      of      our      patients      developed

gastrointestinal fistula, but in other studies gastrointestinal  fistulas  that  occurred  in relation to abdominal wall closure procedure was about 5%3 and may range from 9%-20% in cases  where  a prosthetic  mesh  is  used.6

One patient had a biliary fistula, which was related to the original problem and primary procedure. Although there was a high output biliary  leak into the abdominal  wound  over the abdominal  repair, reburst did not occur, but incisional hernia developed later on.

No single case of reburst occurred in our

study  in  contrast  to the  study  of Tremblay et  al.,  reburst  may  occur  in  a  significant number   of   patients   (5%),   even   in   open abdomen techniques, skin only, silo method or mesh application.3 Other procedures using myocutaneous advancement and primary skin closure gave a 13% incidence of reburst.8

3 patients out of 19 (16%) in our study developed wound  complications  in the form of subincisional abscesses (2 patients) who were  drained  under  general  anesthesia  and skin  necrosis  (1  patient)  who  was  treated by debridement and secondary suture. But Karem and Michael in their study show high wound   complications   rate  (52%)   in  open group  and  (27%)   in  endoscopic   group. 28

Intra-abdominal   abscess  is  an  unavoidable

complication,  even in temporary  abdominal closure   techniques    (4.5%)27,  but   in   our study there was no case of intra-abdominal abscess. However in the study of Levy et al., recurrent intra-abdominal abscess formation was around 13%; a minority usually drained spontaneously, and most patients required reoperation, with a mortality rate of 55%.8

Only   one   patient   died   in  the   fourth postoperative day from pulmonary embolism

Am-Shams] Surg 2014; 7(14):1-10

(mortality 5%) that was not related to the technique.  The   problem    is  that   mortality varies with the underlying disease. According to   the    available   literature,   mortality    of patients   with  parenchymatous liver  disease who  develop  burst  abdomen, although few, was   100%.3   Mortality   in  such   patients   is due to abdominal  compartment syndrome, reburst   with  ascitic   leak,  wound   infection, and hepatorenal failure.  Other  references did not mention the survival  rate of patients  with hepatic    insufficiency  among   their   groups of  burst  abdomen, nor  did they  mention  the degree  of insufficiency (whether the patients were ascitic or not).s

It should  be  noted  that  the  vast  majority of published studies are retrospective, discuss a single technique and include  fewer than  15 patients a year. As no prospective randomized trials exist, it remains unclear, given the small number   of  patients   in  the  various   studies, what the rate of mortality,  incidence of complications and rate of fascial  closure  are with the various techniques. 3

Concerning cost, our method  is a simple, one-stage procedure  without  prosthesis or multistage surgery. Also, the hospital stay usually  does not exceed  3 weeks unless there is  an  associated clinical   problem.   None  of the  patients  needed  re-exploration for  intra­ abdominal sepsis and subsequently low cost.

Conclusion:

As the ideal technique for closure of burst abdomen  should   be  technically  so  simple that   the  results   are  as  good  in  the  hands of  the  trainee   as  in  those   of  the  surgical master, it should  be free from complications, comfortable to the  patient  and  leave  a reasonable  aesthetic   scar.  These  criteria  fit with the  component separation technique in which the peritoneal integrity and defenses are maintained, postoperative care is simplified with comparable mortality  and morbidity for closure  of burst abdomen.

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