Vacuum-packing temporary abdominal closure in post laparotomy wound sepsis and wound dehiscence

Vacuum-packing temporary abdominal closure in post laparotomy wound sepsis and wound dehiscence

Mohammed A Hablus, MD

Department of General Surgery, Tanta University, Egypt.

Co"espondence:e-mail: mahablus@yahoo.com

Abstract

Background/Aim: Post-laparotomy wound sepsis and dehiscence occur in 0.25% to 3% of patients. Frequently, definitive fascial and/or cutaneous reconstructions cannot be performed in an immediate  setting due to the wound condition  or the general condition  of the patient. Commercial VAC (Kinetic Concepts, Inc, San Antonio, TX) have been predominantly used for treatment  of the open abdomen  and in abdominal  sepsis. However, commercial devices are either not available or prohibitively expensive for most patients in resource-poor regions. The method described herein is a relatively crude and low cost one applying the principals of topical negative pressure and temporary abdominal wound closure and our aim is to check its foasibility, safety and efficacy as a temporary abdominal closure method in post laparotomy wound sepsis and wound dehiscence.

Patients  and methods:  This prospective study included  17 patients  with significant post

laparotomy  wound dehiscence  admitted to surgery department  between June 2008 and  May

2011. Vacuum  packing  closure therapy  was administered  for the whole 17 patients. Eleven patients (64 %) had complete fascial dehiscence  with exposed bowel and six patients (36 %) had partial thickness fascial dehiscence. The evaluations included descriptive characteristics of the patients, rate of primary fascial closure and vacuum packing related morbidity and mortality.

Results: Of these 11 patients with full thickness wound dehiscence and bowel exposure, two patients died of vacuum packing unrelated problems, six patients underwent successful primary fascial closure. In those 6 patients with partial thickness wound dehiscence. vacuum packing therapy achieved satisfactory  wound healing in all the patients, Problems  related to vacuum packing therapy included necrosis of fascial edges (2 patients) and blister under the adhesive tape (2 patients). No variables had a significant  influence on vacuum packing wound therapy specific morbidity or primary closure rate in the univariate analysis. Three variables showed a significant influence on mortality: age (P<O.OOJ), adult respiratory distress  syndrome (P=O.Ol), multiorganfailure (P=O.Ol) andMPI(P=O.Ol).

Conclusion: Vacuum-packing therapy is safe and  effective temporary abdominal closure in post laparotomy wound sepsis and dehiscence. Its effectiveness is similar to the known commercial device but the cost is much less which could be advisable in health care systems with limited funds in poor developing countries.

Key words: Vacuum  wound therapy, open abdomen. temporary  abdominal  closure,  post laparotomy wound dehiscence.

Introduction:

Post-laparotomy wound dehiscence occurs in 0.25% to 3%  of patients, and multiple factors can contribute to its occurrence.I The

most common local factors associated with wound breakdown are wound infection, hematoma, and seroma. Regional factors include bowel edema and abdominal distention,

which may be caused by intra-abdominal infections,  hemorrhage,  and trauma, while systemic factors commonly associated with abdominal wound dehiscence are advanced age, malnutrition, pulmonary disease, renal failure, obesity, diabetes mellitus, steroid use, administration of radiotherapy, and/or administration  of chemotherapy. Imperfect surgical technique and emergency laparotomies are associated with an increased risk of wound dehiscence as well.2

Post-laparotomy wound dehiscence can range from a superficial, localized wound separation to complete fascial dehiscence. In the majority of cases with dehiscence of fascia, a  polymicrobial infection  is  present.3

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 dehiscence is addressed in parallel with the establishment of a supportive environment for wound healing.2,3

Frequently, definitive fascial and/or cutaneous reconstructions cannot be performed in an immediate setting due to the wound condition or the general condition of the patient. Inthese cases the closure of the wound is done in a delayed setting.4 This delay provides an opportunity for debridement of necrotic tissue if present, control of local infection, resolution of bowel edema,  and treatment of any associated intra-abdominal pathologic conditions. The "dressings" during this interval should provide adequate coverage of the abdominal wound, particularly when associated with exposed abdominal viscera, and promote healing of the abdominal wall.5

A method of temporary closure of these abdominal wounds that would promote wound healing, contain the abdominal viscera if exposed, reduce dressing change frequency, and reduce pain would be invaluable to both the patient and surgeon.  Saline-soaked gauze dressings, Bogota bag, towel packing with or without suction, absorbable or permanent mesh, and/or other prosthetic materials such as plastic, silastic  or silicone sheets had been used to provide a temporary abdominal closure  in cases   of  dehisced  abdominal wounds.6

The main indications for vacuum packing wound  therapy are  uncontrollable exudate

necessitating frequent  dressing changes, exposed bowel, significant abdominal wall defect with or without fascial dehiscence, and nonhealing wound many weeks after surgery.5,6

The abdominal wall integrity canbe restored by secondary healing, surgical closure of all or some of the abdominal wall layers, placement of a split-thickness skin graft (STSG) over the granulated bowel, and utilization of local or regional tissue flaps. When the fascia is involved, its closure can be achieved by delayedprimary closure, component separation, prosthetic mesh placement, and/or a local tissue flap.7

The vacuum-assisted closure system (VAC) was introduced in 1997 by Argenta  and Morykwas for the management of difficult-to­ treat wounds, and many applications of this negative pressure technique have been reported since then.8

Commercial VAC (Kinetic Concepts, Inc, San Antonio, TX) have been predominantly used for treatment of the open abdomen in trauma patients,  especially in abdominal compartment syndrome as a damage control strategy and in abdominal sepsis. Simple and easy application, low system-related morbidity, and a high rate of primary fascial closure are the described main advantages. However, commercial devices are either not available or prohibitively expensive for most patients in resource-poor regions.9,10

Two broad mechanisms of action of negative pressure therapy were proposed: removal of fluids  and mechanical  deformation. Fluid removal encompasses two beneficial effects in the process of wound healing. The first is a decrease in edema, leading to a decrease in interstitial pressure and a reduction in diffusion distance. The second is the removal of soluble factors such as cytokines, collagenases and elastases, which are primary inhibitors of fibroblasts and endothelial cell proliferation - essential to proper  wound healing. The relationship between mechanical deformation and increased growth is well known, as it is the basis of tissue expansion.ll

An altered wound environment promotes increased blood flow, angiogenesis and oxygen tension, decreased bacterial counts  and increased granulation tissue formation and the

induction  of cell proliferation resulting  in improved wound healing. It also induces a reduction in the wound surface area with a positive modulation of the inhibitory contents in the wound fluid.12

It is not yet clear whether the vacuum assisted wound dressing combined with gauzes as wound surface filler is as effective as the commercial VAC device using Polyurethane or Polyvinyl Alcohol sponges. To date, most studies were conducted using the commercial VAC device in combination with Polyurethane or Polyvinyl Alcohol sponges.

We applied a fenestrated nonadherent plastic liner composed of the inner surface of blood collection bag as compared to Bogota bag in full thickness wound dehiscence with fascial defect and exposed bowels and omentum, and we filled the wounds with highly absorbant sterile gauze instead of Polyvinyl Alcohol sponges.

Figure (1): Full thickness wound dehiscence with fascial defect and  exposed bowels and omentum.

Vacuum packing wound therapy were applied by staff members of the Gastrointestinal and Laparoscopic  Surgery Unit in a ward­ based setting or in the operating theatre. In all infected laparotomy wounds, adequate wound debridement and wound swabbing were done with sending for culture and sensitivity tests.

In full thickness wound dehiscence with fascial defect and  exposed bowels and omentum, a fenestrated nonadherent plastic liner composed of the inner surface of blood collection bag (JMS Singapore PTE limited

The method described herein is a relatively crude and low cost one applying the principals of topical negative pressure and temporary abdominal wound closure and our aim is  to check  its feasibility, safety  and efficacy.

Patients and methods:

This prospective study was carried out at

The Gastrointestinal and Laparoscopic Surgery Unit, General  surgery  Department, Tanta University Hospital and Tanta University Emergency Hospital from June 2008 to May

2011.  All  patients  with  significant post

laparotomy wound dehiscence that could not be immediately resutured because of severe wound sepsis or bad general condition  were included in  this  study. The  decision to administer vacuum packing closure  therapy was taken after considering the nature of the primary illness and coexisting  local, intra­ abdominal, and systemic factors that compromised wound healing.

Figure (2): Partial thickness wound dehiscence.

LTD) was used. It was moistened with 0.9% saline solution and tucked under the fascial edges and over the omentum and exposed intestines and extended laterally under the anterior abdominal wall to prevent the intestine from adhering to the abdominal wall and thus allow safe placement of fascial sutures, if and when required. When negative pressure was applied to the dressing, this material became semirigid, providing additional protection and containment of the intraabdominal contents.

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closure, vacuum packing-specific morbidity, and mortality was conducted: age, sex, ASA score, BMI,  origin of  abdominal sepsis (colorectal, small bowel, stomach, unknown), MPI  index, number of vacuum packing changes, time  after  initial  operation when abdominal sepsis  was under  control, and medical comorbidities. Univariate regression using  Fisher's exact  test  and  v2  test  for dichotomous data and Mann-Whitney U test for continuous data were performed. Results are shown as odds ratio (OR) with 95% confidence  interval (CI). Statistical  analysis was performed  by using SPSS® version 13 (SPSS Inc., Chicago,  IL). Regardless  of the statistical tests selected, the level of significance was defined as P0.05.

Results:

During the 36-month  study period 17 (11 male, 7 female) patients with a median age of

46 (12-67) years underwent vacuum packing wound therapy for  the  management of abdominal wounds sepsis and dehiscence. All the patients had wound dehiscence of varying depth and extent following laparotomy. Eleven patients (64%) had complete fascial dehiscence with exposed  bowel and six patients (36%) had  partial thickness wound dehiscence.

The initial laparotomy was performed  as an emergency procedure in 13(76%) patients, while the rest underwent a planned laparotomy. A  midline incision was  performed in  13 patients, lower right paramedian in two patients and 2 patients had transverse incisions. A single laparotomy was performed  in 13 patients,  3 underwent two operations and 1 underwent 3 operations. The median duration  of hospital stay was 32 (19-63) days and 6 patients (35%) spent  a median  of 27 (15-27) days  in the intensive care unit. The laparotomy wound was present for a median of 7 (6-19) days prior to  instituting vacuum packing therapy.

The median duration of vacuum packing therapy was 19 (8-29) days. In those 6 patients

with  partial thickness wound  dehiscence, vacuum packing therapy achieved satisfactory wound healing in all the patients, with healthy granulation  tissue covering  a flat contracted wound. Secondary skin sutures were performed in 4 patients and the other two patients there were no need to take further sutures   as the wound  was   cosmetically satisfactory.

Of these 11 patients with full  thickness wound dehiscence  and bowel exposure , two patients died of vacuum packing unrelated problems , six  patients  underwent successful primary fascial closure with secondary suturing of the skin prior to discharge. In the remaining three  patients with  full  thickness wound dehiscence and  bowel exposure, fascial reconstruction was not  undertaken mainly because of the patients not being fit for further surgery at this  stage  and   the  wound  was allowed to heal by second intention culminating with planned incisional hernia accepted with stoppage of vacuum packing wound therapy.

The median duration of vacuum packing therapy was 23 (13-29) days with a frequency of change of3 (2-5) days. A subsequent wound breakdown was not reported in any of these patients during follow-up. In 3 patients (17%) vacuum packing  therapy was stopped due to poor patient compliance (1 patient), and death not related to vacuum packing   therapy (2 patients). Problems related to vacuum packing therapy included necrosis of fascial edges (2 patients) and blister under the adhesive  tape (2 patients).

Three patients  were discharged home on vacuum packing  therapy and were followed up in the outpatient  clinic periodically until cessation of therapy. The median duration of follow-up after hospital discharge was 14 (13-

35) months with loss of follow up of one patient. The eventual outcome after follow-up is outlined  in Table(2). Two  patients  died during their hospital stay  due to adult respiratory distress syndrome (1 patient) and multiorgan failure (2 patients).

Table (1): Descriptive characteristics of the patients (n = 17).

Table (1): Final outcome.

No variables had a significant influence on vacuum packing wound therapy specific morbidity or  primary closure rate  in  the univariate analysis. Three variables showed a significant influence on  mortality: age (P<O.OO1), adult respiratory distress syndrome (P = 0.01), multiorgan  failure (P = 0.01) and MPI (P = 0.01).

Discussion:

The vacuum assisted wound dressing is an established method  of wound  management. Recent  studies  and publications have  been limited to the highly sophisticated equipment marketed by the KCI.13 Unfortunately the cost of equipment is a great hurdle to its use in the developing world where the cost of treatment has to be borne by the patient  and relatives and there is limited healthcare funding or poor financial status. We describe a new method of wound  topical  negative pressure   dressing application  without using the standard  VAC equipment, from material readily available to any surgeon applying the same principle with much lower costs.

The vacuum assisted wound   dressing has

been used in a wide variety of cases of acute and chronic wounds, open fractures, infected wounds, radiation ulcers, sternotomy wounds, degloving injury, open  abdomen, severe abdominal sepsis, abdominal compartmental syndrome, enterocutaneous fistula, congenital abdominal wall defects, diabetic foot, post operative chest wall dehiscence and  pressure sores.14

We describe a simple, low-cost and effective method  of vacuum assisted  wound dressing for treatment of abdominal wound sepsis and dehiscence which  should  benefit  the larger population where the standard  equipment  is not available.

In this  study,  two  patients died  due  to problems not related to vacuum packing wound dressing and the primary fascial closure rate was 6 out  of nine  patients (66%). In a retrospective study by Wild  et al.,  (2006)20 in patients with open abdominal wounds after surgery for peritonitis, a reduced mortality rate was found compared with conventional open wound packing.

Nine different techniques were compared

in a systemic review comparing  all literature until  December 2007 (57 case  series)15 on delayed primary fascial closure in patients with an open abdomen. The vacuum assisted wound dressing together with  the  artificial burr technique (biocompatible material  sewn  to midline fascia for stepwise approximation) were associated with the lowest mortality rate and the highest facial closure rate. It was stated in the consensus document  released  by the World Union ofWound Healing Societies that extra care has to be taken in patients with bowel anastomoses or enterotomy repairs.16

In a systematic review by Hensbroek et al.,

(2009)17 on the treatment of the open abdomen, the highest weighted delayed  primary fascial closure rates were seen in the series with the artificial burr, the commercial VAC  device and   dynamic  retention  sutures.  These techniques  might simply have been superior to  the  other   techniques. However, little information was available on the severity  of the underlying condition. Therefore, the higher closure rates might have been due to less severe disease (inclusion bias). An indication for this could be the low mortality rates in these series; however,  this  remains  speculation.IS A consensus document for the management

of the open abdomen  was launched  in 2005 by an expert advisory panei.19 In this document,

7 retrospective studies were analyzed on the

performance of the commercial VAC device versus other  temporal abdominal closure techniques (static [e.g.,  absorbable mesh, Wittmann patch, and  running suture] or dynamic [eg, BogotD bag and vacuum pack]). These other techniques  all use some kind of biologically inert material (eg, 3 L intravenous bag  [Bogota bag], Marlex with  zipper [Wittmann patch],  fenestrated polyethylene sheet, and moist towels, and some combined with wall suction [Bogota bag and vacuum pack]). Primary fascial Closure rates between

78%  and  93%  were  achieved with  VAC

therapy, and  the incidence of fistulas  was measured (2.6% for VAC vs. 7% for vacuum pack and 13% for Bogota).2o

In this study,  V.A.C.-specific morbidity was rather low. No patients developed fistulas, which is comparable to the rate in the literature of  0-20%. Rao  et  al.,21  described an enterocutaneous fistula rate of 20% in a group of  patients with  predominantly abdominal sepsis and concluded that V.A.C. dressings should be used with caution in patients with

abdominal sepsis. Other authors22 supported

this conclusion. However, the fistulas might not have been caused by the V.A.C. system or the  negative pressure itself  but  rather by manipulation of the surgeon during dressing changes. V.A.C. system changes in patients with abdominal sepsis and associated fragile bowel should be performed by an experienced surgeon.23

Other  vacuum  packing wound  therapy­ related complications in  this  study were necrosis at the fascial edges and blister under the  adhesive tape. Necrosis needing debridement might not be related to the vacuum packing wound therapy itself but rather caused by ischemia or ongoing infection of the fascial edges. Blisters occurred in one patient and might be related to tension between the skin and the adhesive tape.In our view, the majority of  the  mentioned vacuum  packing  wound therapy-related complications may be avoided by correct surgical technique.

There  is a discussion  on the intensity of negative pressure (ranging from 40 mm Hg to

150  mm  Hg),  the  use  of  intermittent or continuous pressure,  and the filler  material

recommendation is  to adjust  the  negative pressure settings according to the location and depth of the wound.24  Microvascular blood flow  measurements using  laser Doppler  in humans showed that the  superficial/ subcutaneous wounds may be best treated with pressures of around  75 mm Hg and muscle tissue around 100 mm Hg.25

Generally, lower pressure settings than the standard 125 mm Hg negative pressure are recommended to minimize possible ischemic effects.26 There is a great need for basic research in human subjects and confirmed with histological findings to enable a definite recommendation on  the  pressure settings. However, patients often  experience more discomfort, which reduces  compliance.27,28

Like in every study, several limitations have to be considered when interpreting its results. The qualitative value of the current  trial is without doubt; however, the limited number of  patients involved limits  its potential to generalization. Another  parameter that we should potentially keep in mind is the exact calculation of the costs.

In this study, the end results were gratifying.

We in no way claim that the method described here is better or worse thanthe system provided by  KCI  the   method obviously lacks standardization or pressure regulation but it works pretty well and we recommend its use in  situations where  standard equipment is awaited  or   is   simply  not   available.

Conclusion:

Vacuum-packing therapy is safe  and effective method of temporary abdominal closure in post laparotomy wound sepsis and dehiscence. Its effectiveness is similar to the known commercial device but the cost is much less. Therefore vacuum wound packing could be an useful adjunct in treating post laparotomy wound sepsis and dehiscence when defmitive fascial and/or cutaneous reconstructions cannot be performed  in an immediate setting due to the wound condition or the general condition of the patient. The benefits of negative pressure dressing could  be advisable in health  care systems with limited funds in poor developing countries.

References:

1- Cothren CC, Moore EE, Johnson JL, Moore JB, Burch JM: One hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Am J Surg

2006; 192: 238-242.

2- Miller PR, Meredith JW, Johnson JC Chang MC: Prospective evaluation of vacuum­ assisted fascial closure after open abdomen: Planned ventral hernia rate is substantially reduced. Ann Surg 2004; 239: 608-716.

3- Suliburk JW,  Ware  DN,  Balogh  Z, McKinley BA, Cocanour CS, Kozar RA, et  al:  Vacuum-assisted wound  closure achieves early  fascial closure of  open abdomens after severe trauma. J Trauma

2003;55: 1155-1160.

4- Koss W, Ho HC, Yu M, Edwards K, Ghows M, Tan A, et al:Preventing loss of domain: A management strategy for closure of the "open abdomen" during the  initial hospitalization.J  Surg Educ 2009; 66:89-

95.

5- Navsaria PH, Bunting M, Om.oshoro-Jones J: Temporary closure of abdominal wounds by the modified sandwich vacuum  pack technique. Br J Surg  2003; 90: 718-722.

6- Barker DE, Kaufman HJ, Smith LA, et al: Vacuum pack  technique of  temporary abdominal  closure: A 7-year experience with 112 patients. J Trauma 2000; 48: 201-

207.

7- Miller PR, Meredith JW, Johnson JC, et al: Prospective evaluation of vacuum-assisted fascial closure after open abdomen. Ann Surg  2004:239:608-616.

8- Cipolla J, Stawicki SP, Hoff  WS, et al:  A proposed algorithm for managing the open abdomen. Am Surg 2005;  71: 202-207.

9- Kaplan  M, Banwell  P, Orgill  DP, et al:

Guidelines for the management of the open abdomen. Wounds 2005; 17(suppl): 1-24.

10-Kaplan M: Negative pressure wound therapy in the management of abdominal compartment syndrome. Ostomy Wound Manage 2004; 50(11): 20-25.

11-Suliburk JW, Ware DN, Balogh  Z, McKinley BA, Cocanour CS, Kozar RA, et  al:  Vacuum-assisted wound  closure achieves early  fascial closure of  open

2003;55: 1155-1160.

12-de Lange MY, Schasfoort RA,  Obdeijn MC, van der Werff JFA,  Nicolai JPA: Vacuum-assisted closure: indications and clinical experience.Eur JPlast Surg 2000;

23: 178-182.

13-Boele van Hensbroek P, Wind J, Dijkgraaf MG, et al: Temporary closure of the open abdomen: A systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg  2009; 33:

199-207.

14-Labler  L, Zwingmann  J, Mayer D, et al: V.A.C. abdominal dressing system. Eur J Trauma 2005; 5: 488-494.

15-Fleischmann W, Strecker W, Bombelli M, et al: Vacuum sealing as treatment of soft tissue damage in open fractures. Unfall chirurg 1993; 96: 488-492.

16-Starr-Marshall K: Vacuum-assisted closure of abdominal wounds and entero-cutaneous fistulae: The  St  Marks experience. Colorectal Dis  2007; 9:573.

17-Boele van Hensbroek P, Wind J, Dijkgraaf

MG, et al: Temporary closure of the open abdomen: A systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg 2009; 33:

199-207.

18-Miller PR, Thompson  JT, Faler BJ, et al: Late fascial closure in lieu of ventral hernia: The  next step in  open abdomen management. J Trauma.

19-Expert Working Group: Vacuum assisted closure: Recommendations for  use.  A consensus  document. Int Wound J 2008;

5(4): iii-19.

20-Wild  T, Stortecky  S, Stremitzer  S, et al: Abdominal dressing-a new  standard in therapy  of the open abdomen  following secondary peritonitis? Zentralbl Chir2006;

131(1): 111-114.

21-Rao M, Burke D, Finan PJ, et al: The use of vacuum assisted closure of abdominal wounds: A word of caution. Colorectal Dis

2007; 9: 266-268.

22-Moues CM, Heule F, Hovius SER: A review of topical  negative pressure therapy  in wound healing: Sufficient evidence? Am Journal of Surg 2011;  201(4):544-556.