SURGICAL MANAGEMENT of OPEN ABDOMEN

Abstract

The open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. Benefits of maintaining an open abdomen include ease of re-exploration, control of abdominal contents, reduction of the risk of intra-abdominal hypertension and abdominal compartment syndrome, and fascial preservation for closure of the abdominal wall. Studying the layers of the abdominal wall, and knowing the anatomy of the anterior abdominal wall, its arterial and nerve supply is the corner stone in management of that surgical condition, and in finding the best way to temporary close the abdomen till reaching definitive closure of the abdominal fascia and abdominal wall. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has a several etiological and predisposing factors, so if they are kept in mind, we could avoid the occurrence of such problem. These factors include factors that increase intra-peritoneal volume including free blood and clots, bowel edema, vascular congestion, excessive crystalloid resuscitation, intraperitoneal packing, and nonsurgical bleeding . The prolonged exposure of abdominal viscera can result in high rates of complications, including infection, sepsis, and fistula formation. Restoration of the abdominal wall integrity is the paramount goal of treatment for this condition and can be achieved only if the underlying problem causing the intra-abdominal hypertension (IAH) and abdominal compartement syndrome (ACS) is addressed in parallel with the establishment of a supportive environment for wound healing. Patients with open abdomens initially require placement in the intensive care unit. This class of patients is at risk for bleeding, hypothermia, significant fluid losses, and respiratory dysfunction. Serial bladder pressure monitoring should be a part of post-operative management protocols in high-risk patients, and decompression of the abdomen with a pressure of > 25–30 mmHg should be considered even without clear clinical evidence of abdominal compartment syndrom( ACS). Techniques have evolved from a static approach of containing the abdominal viscera such as gauze packing, bogota' bag and mesh closure to more dynamic systems , such, as V.A.C. Therapy with the V.A.C. Abdominal Dressing System. Static techniques allows the abdominal wall to granulate followed by placing skin graft and developing an abdominal wall hernia . Dynamic closure device, such, as V.A.C. Therapy with the V.A.C. Abdominal Dressing System appears to have an advantage in meeting most requirements for managing an open abdomen. The benefits of vacuum assisted closure( V.A.C) Therapy with the V.A.C. Abdominal Dressing System includes protection of the intra-abdominal contents,control of peritoneal fluid, facilitatation of primary closure of the fascia and minimize the need for secondary repairs of ventral hernias and subsequent repair.