Temporary Abdominal Closure Techniques - Advantages, Disadvantages, and Complications

Introduction

Emergency surgeries are performed immediately after a traumatic event or injury to save the patient's life and control the damage. Sometimes, the wound is left open for some days to monitor the condition just after the surgery. For instance, after emergency surgery on the abdomen, it is left open or temporarily closed. This surgical technique is called temporary abdominal closure.

The main goal of temporary abdominal closure is to control the infection and excessive bleeding within the body's internal structures or hemorrhage. There are various techniques available to close the abdomen temporarily. These techniques aim to prevent the side movement or displacement of the oblique muscles of the abdomen from the original location. However, every technique has its advantages and disadvantages. Therefore, it is crucial to identify the goals (which vary from patient to patient) before selecting a closure technique.

What Is Temporary Abdominal Closure?

When the abdomen or belly of the patient is closed temporarily after emergency surgery, it is called temporary abdominal closure.

Why Is Temporary Abdominal Closure Done?

It is done to:

• Manage an open abdomen (intentionally leaving the abdomen open after surgery).

• Avoid complications, especially abdominal compartment syndrome (abnormal increase in the abdomen pressure).

• Prevent fistula (an abnormal connection between internal structures or organs).

• Protect the fascia of the abdomen.

• Manage the bleeding and infection.

When Is Temporary Abdominal Closure Indicated?

It is done after damage control laparotomy. Damage control laparotomy is an emergency surgery done for severely traumatized or injured patients; it is done to control the infection and excessive bleeding within the body's internal structures or hemorrhage. Other indications are:

• Infection of the abdomen.

• Necrosis and infection of the pancreas.

• Internal bleeding in the abdomen.

• Necrosis or death of tissues in the abdominal wall.

• Transplantation (replacing a damaged or diseased organ with a healthy organ from another patient or person).

What Are the Temporary Abdominal Closure Techniques?

The main aim of the temporary abdominal closure technique is to prevent the side movement or displacement of the oblique muscles of the abdomen from the original location. There are various types of abdominal closure techniques, such as:

1. Primary Closure of the Viscera-

• It is the standard gold technique.

• The abdomen is closed with a simple packing method.

• It is indicated for patients who have abscess formation.

• This technique aids in peritoneal drainage - drain of fluids from spaces between organs and abdomen wall.

• Wet gauze pieces or zinc-oxide-based dressings are placed directly on the open abdomen. These dressings absorb the fluids and help in fluid removal or drain.

• The patient remains in the intensive care unit, and every day, the dressing is changed.

Advantages of Primary Closure of the Viscera-

• Results in low disease or death rate.

• Good recovery.

• Provides good drainage.

Disadvantages of Primary Closure of the Viscera-

• Fistula formation.

• Loss of proteins.

2. Skin Only Closure-

• Skin is used to close the abdomen temporarily.

• Towel clips are placed to the skin 1 cm away.

• The towel clips are covered with a plastic drape to avoid contamination of the wound.

• This technique is no longer used because of the high risks of complications.

Advantages of Skin Only Closure-

• Easily available.

• Inexpensive.

• Reduces loss of heat and fluids from the body.

Disadvantages of Skin Only Closure-

• Increases risk of infection.

• May result in abdominal compartment syndrome.

3. Bogota Bag-

• A Bogota bag is a large sterile plastic bag attached to the abdomen through sutures or stitches.

• Generally, 3-L IV Bogota bags are cut into an oval or round shape as per the shape of the abdomen.

• The monofilament suture is used - a single-thread suture that has a low risk of infection and quickly passes through the tissues.

• Towels soaked in antibiotics are also placed over the abdomen.

• Adhesive drapes soaked in iodine are placed to cover the wound; these drapes prevent bacterial infection.

• This dressing is changed every day.

Advantages of Bogota Bag Technique-

• Maintain heat or temperature of the body.

• Reduce loss of fluids.

• Easy to use and apply.

• Skin-friendly.

• Decreases renal and respiratory failure.

• Bogota bags are cheaper than other techniques.

Disadvantages of Bogota Bag Technique-

• Fails to prevent vertical tension on the oblique muscles of the abdomen.

• Does not drain the fluids completely.

• Requires additional surgery to remove the bag.

• Leads to the development of a hernia - abnormal bulging of the part of the internal organ on the skin.

• Higher rate of death.

4. Mesh Technique-

• A mesh is a synthetic material used for wound repair. Once placed within the wound, it remained permanently.

• Mesh is sutured to the edges of the abdomen.

• It protects the tissues from damage.

Advantages of Mesh Technique-

• Improves wound closure rate.

• Easy to give shape or trim as per the size and shape of the wound.

• Infection resistant.

Disadvantages of Mesh Technique-

• Wrinkles after wound contracture (a process in which the skin constricts).

• Increased risk of infection because of pores in the mesh.

• Hernia.

• Exposure of the mesh.

• Fistula formation.

5. Wittmann Patch-

• It has two sheets that are detachable - loop and closure sheet.

• Firstly, a looped sheet is placed, and then a closure sheet is placed over which gentle pressure is applied to penetrate the free ends of the sheet.

• The patch after the application is tightened every one to two days.

Advantages of Wittmann Patch-

• Provides firm closure of the abdomen.

• Prevents fistula formation.

• Prevents hernia.

• Requires less operative time.

• Easy to detach and reapply.

• Decreases pressure or ballooning of the abdomen.

Disadvantages of Wittmann Patch-

• It is expensive.

• It includes suturing or stitches within the abdominal skin edges.

• Increases risk of trauma to the skin and/or tissues.

• Increases the risk of necrosis.

• A hernia may develop in the future.

• Fails to drain the fluid completely.

6. Vacuum-Assisted Closure-

• It is based on negative pressure therapy - reverse air or suction is used to remove the fluids and infection.

• Four-layered dressing is used as a vacuum pack.

  • First Layer - Made of polyethylene sheet; prevents damage to internal organs.

  • Second Layer - Contains suction drains and sterile towels.

  • Third Layer - It has silicone drains.

  • Fourth Layer - Made of an adhesive sheet; covers the wound and skin around it; makes the vacuum seal.

Advantages of Vacuum-Assisted Closure-

• High rate of fascial closure.

• Improves nutrition supply to the wound.

• Improves granulation tissue growth, resulting in faster healing.

• Decreases count of infection-causing bacteria in the wound.

• Reduces the chance or risk of bowel edema - a collection of fluid in stomach tissues.

Disadvantage of Vacuum-Assisted Closure-

• Expensive technique.

7. Vacuum-Assisted Wound Closure and Mesh Mediated Fascial Traction-

• A sterile sheet is placed over the abdomen to cover and protect the internal organs.

• Propylene mesh is sutured with the skin edges.

• A monofilament suture is used to attach the mesh to the skin.

• Laparotomy pads are placed over the sheet.

• Sterile gauze is placed over the pads.

• Two drainage tubes made of silicone are placed and covered with laparotomy pads.

• The wound is sealed with an adhesive dressing.

• Suction is performed through the drainage tubes.

• This is changed every three days.

Advantages of Vacuum-Assisted Wound Closure and Mesh Mediated Fascial Traction-

• High closure rate of the wound.

• Lower occurrence of complications.

Disadvantage of Vacuum-Assisted Wound Closure and Mesh Mediated Fascial Traction-

• There is a high occurrence of a hernia within the first year of closing the abdomen.

What Are the Complications of Temporary Abdominal Closure Techniques?

The possible complications are:

• Enteroatmospheric Fistula - Abnormal communication between gastrointestinal tract and atmosphere.

• Hernia - Protrusion or bulging of part of an internal organ such as the intestine on the skin surface.

• Acidosis - Increases levels of acid in the body fluids.

• Hypothermia - Quick dropping of the temperature of the body.

Conclusion

Temporary closure of the abdomen is now a commonly used technique in severely ill patients and/or requires monitoring of the abdomen after trauma or injury. It is especially indicated after undergoing a laparotomy procedure to control the damage to the abdomen. There are many complications associated with these closure techniques, out of which fistula formation between the gastrointestinal tract and atmosphere is the most dangerous. The doctor must take special care to provide nutritional support to the patient for better health outcomes.