Fascial Traction Technique in Closure of an Open Abdomen

Introduction:

In critically ill patients, damage control surgery (a surgery carried out to save a life rather than rectify or maintain the anatomy) is performed. It is a type of minimal intervention to maintain the life of the patient by relieving pressure in conditions of intra-abdominal hypertension. The abdomen can be left open so that a second look can be made to make sure that the needed changes, like stopping sepsis or bleeding, have been made. After inspection, the abdomen is temporarily sutured back using specific techniques. Fascial traction is one such technique used for the closure of the open abdomen.

What Is an Open Abdomen?

An open abdomen is a defect that can be caused on purpose by leaving an abdominal incision open during surgery or by opening the abdomen in emergencies like abdominal compartment syndrome or after an injury.

When Is an Open Abdomen Condition Considered?

• Edema (swelling) with decreased space in the abdomen.

• A deep infection in the abdomen necessitates drainage.

• The open abdomen is indicated as a damage control surgery to manage abdominal trauma and abdominal sepsis.

• The open abdomen is managed by a temporary abdominal closure technique. This closure is done by bringing the wound edges together. In conditions, when it is not feasible, simple coverage is done.

• Open Abdomen Treatment Can Be Used For:

  • Managing septic abdomen.

  • Abdominal compartment syndrome: Continuous intra-abdominal pressure above 200 mm Hg (millimeter of mercury) with at least one organ dysfunction.

• Complications of the Open Abdomen:

  • Enteroatmospheric Fistula - It is a communication between the digestive tract and the atmosphere.

  • Hernia - The bulge of tissue or opening through an opening.

What Are the Different Techniques Used in Closure of an Open Abdomen?

Various temporary abdominal closure techniques are available. Bogota bag (temporary mesh) placement was an older technique for temporary abdominal closure. Many new techniques have been introduced, including:

• Dynamic Therapies:

  • Dynamic fascial closure combined with negative pressure therapy.
  • Mesh-mediated fascial traction technique.
  • Dynamic retention sutures or abdominal reapproximation anchor (ABRA).
  • Vacuum-assisted wound closure and mesh-mediated fascial traction technique.

• Static Therapies:

  • Sequential primary closure.

  • Negative pressure wound therapy.

  • Mesh bridging.

What Are the Objectives of Abdominal Closure Techniques?

• To reduce the extent of initial surgery.

• To temporarily close the abdomen, maintain a sterile, tension-free environment.

What Is the Fascial Traction Technique for Closing an Open Abdomen?

• Primary fascial closure is the foremost thing to be done in open abdomen cases.

• Wound coverage can be done with the help of a Bogota bag or absorbable mesh.

• The goal of temporary abdominal closure is to maintain the structure and prevent shrinkage.

• A heavy-weight polypropylene mesh is divided into equal halves, and the first half of the mesh is sutured to one side of the incision edge. The same is followed on the other side of the incision, and the two mesh halves are brought together under tension and sutured at the midline.

• This tension prevents the retraction of lateral muscles, which will facilitate closure.

• A special foam with a tube connected to a negative pressure wound therapy device is placed through which the edges slide towards each other.

• Using negative pressure, the internal layers of the abdomen are tucked in to prevent any adhesion between the abdominal contents and the layers.

• A dressing is placed at the end, which is to be changed every 48 to 72 hours.

What Is Done During a Dressing Change?

1. Removing the special foam.

2. Opening the sutured mesh.

3. Collecting fluids for culture.

4. Washing out the abdominal cavity with a warm saline solution.

5. The extra mesh is cut and re-sutured.

6. A new special foam with a tube is placed.

Is the Fascial Traction Technique the Same for Critically Ill and Stable Patients?

The procedure can differ depending on the condition of the patient. For a stable patient, the procedure outlined above is followed. For a patient who is unstable (very sick), the procedure is broken up into the following two steps and carried out.

1. First Step: Only intra-abdominal dressing is applied along with special foam of the negative pressure wound therapy device.

2. Second Step: When the patient comes for a dressing change, the mesh is applied, and the dressing is changed.

What Is the Purpose of Various Techniques Used in the Treatment of Open Abdomen?

• Management of fascia (layers that cover the internal organs).

• Management of viscera (internal organs).

• Application of negative pressure wound therapy.

What Facilitates Fascial Closure?

1. Hypertonic Saline: Hypertonic saline is used for resuscitation, facilitating early closure.

2. Botulinum Toxin A: Chemical paralysis of the lateral abdominal wall having strong opposing forces helps in abdominal wall reconstruction.

What Are the Indications of Fascial Traction Technique?

• Indicated for closure of the open abdomen without tension.

• Indicated when the edges of the abdomen cannot be placed together.

What Are the Factors Affecting the Outcome of the Fascial Traction Technique?

• The clinical condition of the patient.

• Presence of intra-abdominal contamination: Any infection or sepsis persisting after the closure can lead the patient closer to the death bed.

• Polytrauma or injuries to multiple body parts or organs.

What Are the Contraindications of Fascial Traction Technique?

When abdominal surgery is done and the abdominal cavity needs to be closed, the fascial traction technique cannot be used.

What Are the Postoperative Complications?

• Wound Healing Problems (Infections): There are chances of developing infections at the surgical wound site, which delay the wound healing process due to many factors.

• Prolonged Healing Period: As the surgery is carried out in critically ill patients, the body may not perform its normal functions due to organ dysfunctions and a lack of the body's ability to heal the wound naturally.

• Pain: Though pain has been reported in a very less percentage of patients postoperatively, it can be relieved by using prescribed pain-relieving medications.

• Retracted Scar: Unavoidable scar at the end of the process.

• Mesh Infection: The mesh used to bring the edges together can also become infected, which can delay wound healing and increase pain. Chances of re-infection of the wound occur.

Conclusion:

The fascial traction technique, along with vacuum-assisted wound closure, is a promising treatment for open abdomen cases. Critically ill patients are recommended to undergo this surgery. This procedure has saved many lives. Nevertheless, some complications cannot be a reason for the denial of this surgery.