INTRODUCTION

The open abdomen (OA) is defined as the separation of all layers of the abdominal wall, with controlled exposition of the entrails, after a laparotomy. This technique is employed in critical patients who require specialized handling, particularly in cases of abdominal sepsis, compartment syndrome risk and other conditions that compromise the patient’s stability. The main indications for OA include severe visceral edema, damage control, fecal peritonitis and the presence of large parietal defects, such as those usually present in patients with extensive burns.1,2 Open abdomen (OA) is divided into three periods: initial, middle, and final. During the initial period, the abdomen’s opening is performed along with a temporary abdominal closure (TAC). Its main objectives are:

Temporal abdominal closure (TAC) entails a series of methods designed to protect abdominal entrails while the patient remains with an open abdomen (OA). Literature offers diverse TAC options, making it essential to choose the most adequate technique to maximize the abdominal wall’s definitive closure and minimize associated complications. Among the main complications that are to be avoided with adequate use of TAC are enteroatmospheric fistulas, intraabdominal abscesses, frozen abdomen and planned hernias³. The second treatment period corresponds to the phase in which the patient remains with the open abdomen (OA) without the possibility of definitive closure. During this time, the patient may be placed in the Intensive Care Unit (ICU) or in-patient room, depending on the clinical state. In this stage, it’s possible that the patient requires multiple additional surgical interventions, including re-explorations, abdominal cleanings and adjustments in the temporary closure’s handling, with the objective of preserving the viability of the organs and to prevent complications until sufficient stabilization for definitive closure is achieved^2,3,4. The third treatment period starts when the patient’s clinical and surgical conditions allow for the definitive closure of the abdominal wall. Elapsed time between the first intervention and recovery varies significantly according to the open abdomen’s (OA) indication and general patient state. In prolonged evolution cases, such as in abdominal sepsis patients, several complications may arise, such as:

MATERIALS AND METHODS

Retrospective, observational, descriptive, cross-cut study, with non-probabilistic sampling, patients of both genders with OA, employed techniques in their handling and temporary closure were included, from March 2023 to February 2024, in the Clinical Surgery’s 2nd Subject. Data collection was done through clinical files’ revision, and with the creation of a questionary to gather information with the study variables (age, gender, temporary closure technique, definitive closure technique, death) to be investigated in this work. All ethical and confidential principles were upheld.

RESULTS

28 patients were included, of which 77% were man and 23% were women. The average age was 49 years old. The techniques employed were: Table I. Distribution of Temporary Abdominal Closure (TAC) Techniques

Definitive closure of the abdominal wall was achieved in 4 patients (14.3%), while in 4 cases (14.3%) only the skin closure was performed. In 16 patients (57.2%), closure was done through scarring by second intention. The mortality rate was 14.2%.

Figure 1.  Open abdomen with vacuum-assisted closure. 

Figure 2.  Abdomen opened by Bogota’s bag 

Figure 3.  Dynamic traction with retention sutures and VAC. 

DISCUSSION

OA is defined as a clinical situation where the abdominal wall is left unclosed after surgical intervention, and it’s handled with temporary abdominal closure (TAC). In certain situations, it’s due to an intervention or surgical complication, such as a partial resection of the abdominal wall due to necrosing infection, trauma or tumor, but can be a technique employed to treat critical abdominal cases, situations in which the abdomen is left open due to several causes like damage control, or an important visceral edema just as published by Leppäniemi⁷. Bjorck8 published a modification of the open abdomen’s classification which characterizes the different stages according to the infection and fixing grade, from a clean, open, nonadhering abdomen to a frozen abdomen with one or more enteroatmospheric fistulas. In some patients, open abdomen is used as a treatment technique and it’s combined with some form of TAC, it can be divided into static or dynamic, with or without negative pressure, static temporary abdominal closures without negative pressure are found in the unused skin closure, the use of meshes that are already contraindicated due to fistula emergence, and Bogota’s bag which is still a handling option for OA, used on a majority of patients in this investigation^2,3. All patients in this study received vacuum pressure therapy, nowadays there are several studies that recommend the use of negative pressure, given its beneficial effects: such as reduction of intra-abdominal liquids, visceral edema’s decrease, favoring the tissue granulation process, favoring irrigation and neovascularization, contamination control and elimination of intra-abdominal cytokines, as per the research done by Petersson, Tolonen and Cheatham^9,10,11,12. Dynamic closure (DC) is a technique that consists in the progressive closure of the abdominal wall through a TAC that allows traction for abdominal wall’s muscles towards the medium line, sequentially, during each surgical intervention until a primary fascial closure (PFC) is achieved, using, in some cases, a negative pressure system. A TAC that allows the association of dynamic closure and negative pressure counters the OA complications, given that it avoids muscle retraction and dominance loss from the beginning and allows the visceral blockade to develop in a controlled manner; this way, it allows for definitive closure of the abdominal cavity when conditions are met in most cases. In a small percentage of subjects submitted to this study were handled with dynamic traction, due to the learning curve to reproduce the techniques^13,14,15. International guides recommend the use of TAC with dynamic techniques over static ones, performing definitive abdominal closure as soon as possible with the goal of reducing mortality, complications and in-patient stay related to OA, negative pressure techniques must always be used if available, performing means to prevent enteroatmospheric fistula, such as not applying negative pressure directly over the entrails, nor placing gauzes in contact or compressing with them, it’s possible to apply Bogota’s bag in low resource contexts, taking into account that a lower late fascial closure rate and higher intestinal fistula rate will occur, if there are no other available methods, or if a dynamic closure technique isn’t an option, a TAC with negative pressure therapy in a static closure OA must be performed, similar to the results obtained in this study^15,16. Lastly, it’s important to perform an OA indication with much character, knowing all modern TAC methods, learning to properly use them, understanding what is fundamental for the multidisciplinary treatment of severe patients, favorable evolution will depend on antibiotic therapy run by isolated germ, correction of metabolic and systemic disorders such as anemia or hipoalbuminemia^17).

CONCLUSION

The most frequently used temporary closure technique for OA handling was Bogota’s bag and vacuum-assisted closure. Wall closure was achieved in 4 patients. 4 deceased were registered.