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No such thing as an "open abdomen"

A term commonly used by surgeons for the treatment of major trauma cases
and abdominal compartment syndrome is "open abdomen." (This term may also
be used on someone with another type or surgery such as an aortic aneurysm
repair, but most commonly it refers to trauma.) This term means that the
surgeon operated on a patient's abdomen and did not sew them back shut
because they already had IAH or ACS and needed to be decompressed, they
had so much swelling in their abdomen that they could not tuck the guts back in,
or they were afraid that if they did tuck the guts back in, the patient would
develop abdominal hypertension and possibly abdominal compartment
syndrome. A common belief is that because the abdomen is left open, the
patient cannot develop IAH or ACS

Figure 1: This patient has an IAP of 33 mm Hg – he is suffering from organ


dysfunction due to abdominal compartment syndrome and needs a
decompressive laparotomy.[1]

Figure 2: This is the patient from figure 1 after his decompressive Laparotomy.
Note how dramatically the swollen intestines have bulged out of the abdominal
incision. You can imagine how this swelling led to a dramatic increase in the
IAP when the abdominal wall confined it. Now that it has been decompressed,
the patient's IAP has dropped to 15 mm Hg.

The result of a decompressive laparotomy, or of simply leaving the abdomen


"open" after a surgical case is that the volume of space available for the
abdomens contents is much larger – probably half again as large. Once the
abdomen is opened, the patients intestines are not left out in the open air
because this would result in them drying out and dying as well as becoming
infected by the external environment. For this reason, every "open abdomen" is
closed with a dressing.

Dressing closures are done in a variety of ways: Bogota bag, Ioban dressing,
Wittman patch, KCI Vac-pac, etc. One of the more common methods is using a
"Bogota bag" because it costs almost nothing.

Figure 4: A Bogota bag is simply a 3 liter IV plastic bag with 3 of the edges cut
off so it lies flat (Figures 3 & 4) It is put in a sterilizer in the operating room, then
given to the surgeon who stitches it over the guts to the sides of the abdominal
incision. This allows the clinician to be able to look through the clear window of
the plastic bag and see if the guts are healthy. Sometimes they pack gauze
under the bag to absorb fluid. The other methods are variations on the same
theme, some including suction that allows re-accumulated fluid to be suctioned
out of the abdominal cavity.
Figure 5: A commercially available temporary abdominal wall with Velcro to
allow gradual wound tightening

Figures 6a & 6b: KCI Vac-Pac – Sponge inserted over an internal dressing,
with suction in center, then covered again with outer dressing. 6a is early in the
course when abdomen is still widely open. 6b is later as the wound is partially
closed and the sponge is trimmed smaller.
The point of all the above discussion is this: There is no such thing as an open
abdomen after surgery. This would lead to desiccation (drying/mummification)
and death of the bowel plus internal infection. ALL open abdomens are closed
with an airtight dressing for protection. The result is a closed abdomen that has
a larger volume that the previous abdomen so the internal pressure is reduced.

However, the same processes that led to the accumulation of fluid and increase
in IAP in the first place are still present. If they continue and further edema
develops, the pressure within the abdomen can easily begin rising again and
ACS can recur. This has been described in many reports. The largest series, by
Gracias demonstrated that of all patients who had their abdomen left open to
prevent IAH / ACS and had a vacuum pack placed to suction out excess fluid,
still developed ACS (defined as IAP > 25 mmHg plus organ dysfunction).[2] The
mortality in those who developed ACS was 60% while it was only 7% in the
others.

The authors recommend that "treatment of IAH can be achieved by incising the
external antimicrobial drape to allow for further expansion of the abdominal wall
… Prior to placement of a new sterile drape."[2]

Their conclusion: "Management of the open abdomen with the vacuum-pack


closure technique does not obviate against the development of ACS. …
Ongoing vigilant monitoring of IAP is mandatory in this patient population to
recognize IAH and treat it expediently."[2]

More recent data out of Colombia confirm Gracia's observations: In a series of


79 open abdomens who were all serially monitored for IAP from the time of
surgery through their ICU stay, Ordonez et al found recurrent abdominal
compartment syndrome occurring in 8.9% of their study population - all who
required emergent reexploration and relief of the elevated pressure despite
having an "open" dressing.[3] The subgroup of patients who developed
recurrent ACS suffered a 78% mortality while those who did not had a 20%
mortality. Based on the enorous costs occuring when the patient is opened and
the ability to monitor and prevent ACS in many patients, these clinicians feel
aggressive bladder pressure monitoring of all open abdomens and early
intervention to reduce rising pressures is mandatory to avoid death and reduce
costs.