Numerous techniques have been described for handling the acute inability to close the abdomen. For detailed descriptions of how to temporarily “close” the abdomen, see extensive descriptions in various chapters throughout this book. However, the techniques discussed next merit special mention [5–7].

Although we rarely use towel clip closure (the senior author has used it only time), and we mention it as a possible technique only to condemn it, it is the most simple and can be rapidly performed for temporary closure of the abdominal skin and subcutaneous tissue in clinically hemodynamically unstable patients.

Depending on the length of the incision, up to 25–30 standard towel clips might be necessary to complete closure (Fig. 8.4). While some authors find the use of the towel clamp (or clip) beneficial, the authors of this chapter advise to use minimally.

All attempts should be made to cover over the viscera. Skin and subcutaneous tissue is the best choice and should be used whenever possible. The suture closure technique can be used with or without intra-abdominal packing. This technique has serious limitations and might not be applicable in patients with extensive edema of the retroperitoneum or of the viscera itself [5–7].

If we use this technique, some sort of wound VAC over the incision should be applied. An abdominal binder should be applied as well.

Retention sutures incorporating large portions of tissue tied under tension can forcibly contain the abdominal contents. Unfortunately, retention sutures exacerbate ACS and have been implicated in the development of enterocutaneous fistulas (ECFs), even when the sutures are placed extraperitoneally, so this technique should not be used for temporary closure. Instead, simple closure of the skin, if possible, should be performed. Better yet, we employ other techniques, such as vacuum-assisted closure (VAC), that protect the skin from injuries induced by large sutures.

Pliakos et al. [8] tested whether a modification of the VAC technique would facilitate primary fascial closure and reduce morbidity in patients who had severe abdominal sepsis. They randomized 53 patients into 2 groups. Thirty of these patients were analyzed. The VAC group had patients managed only with the VAC device. The other group was comprised of the retentions sutured sequential fascial closure (RSSFC) procedure . For the VAC group, the abdomen was left open for 12 days (P = 0.0001) with 4.4 ± 1.35 changes per patient (P = 0.001) and for the RSSFC group for 8 days with 2.87 ± 0.74 dressing changes. Abdominal closure was possible in 6 patients from the VAC group and for 14 patients in the RSSFC group. These differences were significant (p = 0.005). Planned hernia was exclusively decided in patients in the VAC group (P = 0.001). The hospital stay was 17.53 ± 4.59 days for the VAC group and 11.93 ± 2.05 days for the RSSFC group (P = 0.0001). The median initial intra-abdominal pressure (IAP) was 12 mm Hg for the VAC group and 16 mmHg for the RSSFC group (P < 0.0001). These results indicated that the RSSFC procedure compared to the single use of the VAC device was superior. Pliakos et al. [8] concluded that sequential fascial closure can begin once abdominal sepsis is controlled.

Atema et al. [9] conducted a systematic review and performed a meta-analysis on incidence of temporary abdominal closure (TAC) and open abdomen (OA) in peritonitis patients in order to assess delayed fascial closure, enteroatmospheric fistula, and mortality rate overall and per TAC.

Of 78 patient series, 5 of them, which included 77 patients, had dynamic retention sutures. Best results were produced by negative pressure wound therapy (NPWT) with continuous fascial traction; however, these authors concluded that the overall quality of available evidence was poor and recommendations could not be made.

Jannasch et al. [10] conducted a topic-related, selective, PubMed-based literature search on the options of temporary closure of the abdominal wall and found that procedures with the highest fascial closure rate (Wittmann patch, STAR, 75–93%; dynamic retention sutures, 61–91%; V.A.C., 69–84%) have the lowest mortality. Dynamic retention sutures rank as one of the procedures with the highest fascial closure and lowest mortality rate according to their findings.

With extensive edema and distention of intra-abdominal organs, an abdominal silo can be inserted to cover the exposed viscera. Some authors use plastic bags or silos sutured to the skin to allow the viscera to extrude from the peritoneal cavity. We do not prefer this technique because it involves suturing into the skin or fascia; doing so may cause recurrence of ACS. Instead, we cover the intestines with an “intestinal bag” and dressing. The surgeon must be aggressive about returning patients with temporary silos to the operating room as soon as possible, either to close the abdomen permanently or at least to cover the intestines with skin and subcutaneous tissue.

Performing DCS does not mean that you have committed the patient to long-term open abdomen management, and every attempt should be made to close the fascia primarily. A number of techniques and strategies have been described, but application of wound VAC has revolutionized the care of many surgical wounds in just about all surgical disciplines. The fundamental reasons for applying suction (via VAC) to an open wound are to allow for the rapid removal of peritoneal fluid and to collapse spaces between the viscera. Both steps will make the contents of the abdominal cavity smaller, resulting in a greater chance of subsequently performing a formal aponeurotic closure of the midline incision [11].

Numerous studies have demonstrated the effectiveness of various VAC techniques. For example, Padalino et al. [12] demonstrated that the VAFC-KCI was associated with a high fascial closure rate after conducting a prospective observational study of nine patients with a mean Acute Physiology and Chronic Health Evaluation II score of 22.62 and a Sequential Organ Failure Assessment score of 10.62. All patients had abdominal compartment syndrome (ACS) and a sepsis source that was difficult to control. However, as stated previously, Pliakos et al. [8] found significant differences in wound closure rate between patients who received RSSFC versus VAC. Their results indicated that the RSSFC procedure compared to the single use of the VAC device was superior, but other studies provide evidence for the usefulness of VAC.

Cothren et al. [13] performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, in order to achieve a higher rate of primary fascial closure. This procedure is similar to the one performed by Burlew et al. [14], which is presented later in this chapter. The steps include: [1] initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for ACS, [2] cover the bowel with white sponges overlapping like patchwork, [3] place the fascia under moderate tension over white sponges with #1-PDS sutures, [4] place large black VAC sponges on top of the white sponges, affixed with occlusive dressing and standard suction tubing, [5] then patient is returned to the OR for sequential fascial closure and replacement of the sponge sandwich every 2 days. Cothren et al. analyzed differences in 14 patients who underwent SAC. Nine were due to damage control and five were due to secondary ACS. Average time to closure was 7.5 ± 1.0 days (range 4–16) and average number of laparotomies to closure was 4.6 ± 0.5 (range 3–8). All patients attained primary fascial closure. The authors concluded that this technique achieves 100% fascial approximation [14].

Roberts et al. [15] conducted a systematic review of published and unpublished studies that compared the effectiveness and safety of negative pressure wound therapy (NPWT) versus alternate TAC techniques in critically ill adults with open abdominal wounds. Of 2715 citations, they found two RCTs and nine cohort studies that met inclusion criteria. One RCT observed an improved fascial closure rate (relative risk [RR], 2.4; 95% confidence interval [CI], 1.0–5.3) and length of hospital stay after addition of retention sutured sequential fascial closure to the Kinetic Concepts Inc. (KCI) vacuum-assisted closure (VAC). Another reported a trend toward enhanced fascial closure using the KCI VAC versus Barker’s vacuum pack (RR, 2.6; 95% CI, 0.95–7.1). One prospective cohort study observed improved mortality (RR, 0.48; 95% CI, 0.25–0.92) and fascial closure (RR, 1.5; 95% CI, 1.1–2.0) for patients who received the ABThera versus Barker’s vacuum pack. Another noted a reduced arterial lactate, intra-abdominal pressure, and hospital stay for those fitted with the KCI VAC versus Bogotá bag. Roberts et al. stated that the majority of the retrospective studies exhibited low methodological quality and reported no mortality or fascial closure benefit for NPWT [15].

Failure to close the abdomen and loss or retraction of abdominal wall laterally will require a skin graft, which should be placed as soon as possible. In such patients, the wound is covered with absorbable Vicryl^® (Ethicon, Somerville, NJ) mesh (Fig. 8.5), which eventually is allowed to granulate (Fig. 8.6), and a split-thickness skin graft technique is applied (Fig. 8.7). Then, at a later date (usually more than 6 months), the abdominal incisional hernia is addressed [16, 17].

Removing the skin of the intestines is not an easy task and may be associated with new injuries to the intestines that if not recognized and repaired may cause another catastrophe in these patients.

Barnes et al. [18] reviewed whether the skin component would be beneficial as an immune-monitoring tool and found that skin transplanted as part of the abdominal wall or as a separate vascularized sentinel skin flap may aid in the diagnosis of rejection. This has the potential to improve graft survival and reduce immunosuppressive morbidity.

Burlew et al. conducted a comparison study of patients who underwent damage control surgery between 2005 and 2010 at their institution. They compared patients who were operated on using a systematic protocol versus those who were not [14]. The systematic protocol, similar to the one conducted by Cothren et al. [13], was implemented in order to achieve a higher rate of primary fascial closure than what had been described previously in the literature. The procedure involved the following steps: [1] VAC white sponges were used to cover the bowel [2]. Next, the fascia was placed under moderate tension over the white sponges with no. 1-polydioxanone sutures [3]. Then, the black sponge was placed on top with the standard occlusive dressing. [4] Finally, patients underwent partial fascial closure and replacement of the sponge sandwich every two 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 h were excluded from reported results. Over the course of 5 years, 51 patients required an open abdomen after the second laparotomy. Eighty percent of these patients were men with a mean age of 34.7 ± 2 years. The mean injury severity score (ISS) was 37.1 ± 2.4, mean abdominal trauma index (ATI) of 26.4 ± 2.1. The average initial base deficit was 15.7 ± 0.6 and 24-hour red cell transfusions were 20.4 ± 2.4 units. Twenty nine followed the protocol and twenty two did not follow the protocol. Of the 29 who did follow protocol, 100% had fascial closure. Of the 22 who did not follow protocol, only 55% (N = 22) achieved fascial closure. There were no significant differences in ISS, ATI, initial base deficit, or red cell transfusions. They concluded that a methodological approach with sequential fascial closure achieves 100% fascial approximation as well as reducing the morbidity of the open abdomen and the cost of complex abdominal reconstruction or biologic mesh insertion [13].

An important question in the management of patients undergoing DCS or damage control laparotomy (DCL) in particular is when to use mesh repair and when to use lateral component separation (CS). To answer this question, Sharrock et al. [19] conducted a systematic review and meta-analysis of studies that compared methods of restoration of fascial continuity when primary closure was not possible following DCL for trauma. They included randomized controlled trials (RCTs), cohort studies, and case series’ that reported temporary abdominal closure (TAC) and early definitive closure methods in trauma patients undergoing DCL. In all, they reviewed 26 studies, with mortality, days to fascial closure, hospital length of stay, abdominal complications, and delayed ventral herniation as outcomes. Estimates for abdominal complications in delayed primary closure (DPC), mesh repair (MR), and component separation (CS) groups were 17%, 41%, and 17%, respectively, while estimates for mortality in DPC and MR groups were 6 and 0.5%. Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI = 5.10–7.51) and 15.90 (95% CI = 9.22–22.58) days, respectively. Sharrock et al. [19] concluded that component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL.

Fantus et al. [20] used the controlled fascial tensioning device (Wittmann Patch, Starsurgical, Inc., Burlington, WI) in combination with an adhesion preventing barrier to allow for unhindered sequential medial advancement of the fascia toward the midline. The use of these two devices together may lead to a higher incidence of fascia-to-fascia abdominal wall closure than the use of fascial tension alone [20]. Frazee et al. [21] conducted a retrospective review of 37 open abdomen patients who had temporary abdominal closure. They compared 37 patients who had temporary abdominal closure with a commercial negative pressure device (ABThera, KCI) to 37 patients who had open abdomen management with the Barker technique. Patients were compared using the chi-square, t-test, and logistic regression analysis with a significance level of p < 0.05. Mean age and BMI were significantly higher in the ABThera patients. No statistically significant differences were seen in male:female ratio, indication for open abdomen management, preoperative albumin, number of operations, and use of sequential closure. In 33 patients (89%) ultimate midline fascial closure was achieved with the ABThera vs in 22 patients (59%) using the Barker technique (p < 0.05). Logistic regression analysis was performed on the three significant variables identified on bivariate analysis. Only the type of temporary abdominal closure proved significant, with an odds ratio of 7.97 favoring ABThera (95% CI 1.98 to 32.00). Frazee et al. [21] concluded that the ABThera had significantly greater success with ultimate closure compared to the Barker technique.

Although other chapters will describe details of definitive surgical repairs, following DCS we will briefly mention here few elements of this management. Once patients have survived the acute stage—which may last for weeks or, worse, for months—deciding whether and when to reconstruct the abdominal wall defect is next major challenge. The main indication for reconstruction is a large hernia or the development of multiple fistulas enterocutaneous fistulas (ECF) or enteroatmospheric fistulas (EAFs) (Fig. 8.8). Reconstruction may also be mandated after failed attempts to close a celiotomy wound or when components of the abdominal wall, for whatever reason, are either injured or absent.

Specific criteria have been suggested to identify patients who may require special closure techniques, including one or more of the following: large defect size (>40 cm²); absence of stable skin coverage; hernia recurrence after prior closure attempts; infected or exposed mesh; systemic compromise (concurrent malignancy); local abdominal tissue compromise (irradiation, corticosteroid dependence); and concomitant ECFs [22–24]. Other indications for reconstruction are to improve the quality of life, inability to work or to exercise, pain, and recurrent obstructions requiring hospitalizations and frequent surgeries.

Identifying a bona fide indication for reconstruction might seem simple, but it is not an easy task in patients with massive hernias or complex abdominal wall defects. Many surgeons do not consider the mere presence of a hernia to be a sufficient indication for major surgery. But, we believe that large defects should be repaired unless a serious contraindication exists or unless surgery would put the patient at major risk. So, the decision will be between the patient and the surgeon on how they will proceed.