Subcutaneous Linea Alba Fasciotomy: A Less

Morbid Treatment for Abdominal

Compartment Syndrome
MICHAEL L. CHEATHAM, M.D.,* JESSICA FOWLER,t PETER PAPPAS, M.D.*

From the ^Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida; and the
f Florida State University CoUege of Medicine, Tallahassee, Florida

Abdominal compartment syndrome is a cause of significant morbidity and mortality among

surgical patients. It has traditionally been treated by abdominal decompression with the associ-
ated risks of chronic incisional hernia and enteroatmospheric fistula. Subcutaneous linea alba
fasciotomy has recently been described as a new surgical technique for the treatment of abdomi-
nal compartment syndrome secondary to acute pancreatitis. This technique reduces intra-
abdominal pressure and restores organ function while maintaining the skin and peritoneum
intact for visceral protection. We describe the application of subcutaneous linea alba fasciotomy
as a safe and effective alternative for the surgical management of abdominal compartment syn-
drome in a traumatically injured patient refractory to comprehensive medical interventions.

NTRA-ABDOMINAL HYPERTENSION (IAH) and abdomi-
I nal compartment syndrome (ACS) are commonly
encountered in the critically ill.'"'' IAH is defined as
the presence of a consistently elevated intraabdotninal
pressure (IAP) greater than or equal to 12 mmHg with-
out evidence of organ dysfunction.'-^ ACS occurs
when IAP exceeds 20 mmHg in association with the
development of new organ dysfunction or failure.'-^
ACS requires immediate attention and rapid treatment
to decrease the excessive IAP, restore organ perfusion
and oxygénation, and avoid morbidity and mortal-
ity.'-^
The traditional treatment for severe IAH and/or
ACS has been surgical decompression with subse-
quent management of the resulting "open" abdomen
using one of a vaiieîy of temporary abdominal closure
techniques.--^ If visceral edema resolves rapidly (i.e.,
within 7-10 days), primary fascial closute of the ab-
domen is usually pos.sible during either a single or
staged procedure(s).*' If the patient's critical illness
and third-space edema is more prolonged, pi imary clo-
sure is generally not feasible and split-thickness skin
grafting of the exposed viscera or a skin and subcuta-
neous tissue-only closure is performed.--^ Open ab-
Presented at the Annual Scientific Meeting and Postgraduate
Course Program, Southeastern Surgical Congress. Birmingham.
AL. Febmary 9-12. 2008.
Address correspondence and reprint requests to Michael L.
Cheatham. M.D.. Department of Surgical Education. Orlando Re-
gional Medical Center. 86 West Underwood Street, Suite 201.
Orlando. FL 32806. E-mail: michael.cheatham@orhs.org.
dominai decompression, although frequently life-
saving, is a potentially morbid procedure that is
associated with an increased risk of enteroatmospheric
fistula formation, significant Huid and protein loss,
and increased hospital length of stay.'-^ If primary
fascial closure cannot be achieved during the initial
hospital admission, the resulting incisional hernia
must be repaired at a later date with the patient fre-
quently being unable to resume normal activities and
employment in the interim.^
Leppäniemi et al. have recently described a new
surgical technique for the treatment of ACS secondary
to acute pancreatitis."' " Subcutaneous linea alba fas-
ciotomy (SLAF) releases fascial tension, thereby re-
ducing IAP while simultaneously maintaining the peri-
toneum, subcutaneous tissue, and skin intact as a
protective covering for the abdominal viscera. As
originally described, under general anesthesia, three
transverse 2 to 4 cm long skin incisions placed 10 cm
below the xiphoid and both 5 cm above and below the
umbilicus are created. The subcutaneous tissue and
linea alba are divided in the tnidline using scalpel and
scissors, leaving the peritoneum intact. The fascial di-
astasis created by SLAF is typically 8 to 10 cm with a
reduction in IAP of 10 to 15 mmHg. Patients who
continue to demonstrate evidence of IAH/ACS refrac-
tory to SLAF undergo traditional open decompression.
Using this technique. Leppäniemi et al. successfully
avoided traditional open abdominal decompression in
50 per cent of the patients in whom SLAF was per-
formed.' '

746
No. 8 SUBCUTANEOUS LINEA ALBA FASCIOTOMY Cheatham et al. 747

In patietits with acute pancreatitis. SLAF has been

demonstrated to represent an effeetive and less morbid
technique to reduce IAP, treat lAH-induced organ dys-
function and failure, and avoid the potential morbidity
of traditional open abdominal decompression. Based
on this successful approach, we sought to determine
whether SLAF could be applied to the traumatically
injured patient with IAH/ACS.

Case Report
A 46-year-oId morbidly obese (131 kg) man was brought
to our Level I tiuttnia center after a motorcycle crash. On
thorough evaluation, he was found to have significant tho-
racoabdominal trauma, including multiple rib fractures, a
flail chest, bilateral traumatic piieumothoraces. and multiple
spine injuries resulting in paraplegia. He required Ihoracot-
omy lor intercostal and spinal hemorrhage and .subsequently
developed acute respiratory distress syndrome necessitating
high-level mechanical ventilatory support with positive end-
expiratory pressure as high as 25 cm H^O. As a result of his
risk factors for IAH/ACS. IAP aiid abdominal perfusion
pressure (APP) (calculated as mean arterial pressure minus
IAP) were monitored serially and the patient was resusci-
tated in accordance with the World Society of the Abdomi-
nal Compartment Syndrome IAH/ACS management algo-
r i t h m . - ' - This included nasogastric decompression,
judicious goal-directed fluid resuscitation, continuous intra-
venous sedation and analgesia, pharmacological paralysis,
and va.sopressor support to maintain APP greater than 60
mmHg.
On hospital Day 21. the patient developed an aeute de-
terioration in his already critical illness marked by increased FiG. 1. Subcutaneous linea alba fasciotomy (SLAF) technique.
peak inspiralory and mean airway pressures to 57 and 37 cm
HjO. respectively, as well as anuria refractory to volume
resuscitation. His IAP rose to 27 mmHg with an inadequate
APP of 34 mmHg. He was diagnosed with secondary ACS
and open surgical decompression was strongly considered.
Given the patient's morbid obesity and the difficulty in both
managing and subsequently closing an open abdomen in
such patients, a decision was made to attempt SLAF with
the intent to proceed to traditional open decompression if
the procedure failed to sufficiently lower the patient's IAP.
The patient was steriiely prepped and draped for abdomi-
nal decompression at his bedside in the intensive care unit
(ICU). His continuous sedation, analgesia, and pharmaeo-
logical paralysis were continued. IAP was monitored con-
tinuously throughout the procedure to determine the pa-
tient's response to SLAF. Using a modification of the
Leppäniemi leehnique. two 4-cm long midline incisions,
one midway between xiphoid and the umbilicus and one
midway between the umbilicus and pubis, were made with
FIG. 2. Subcutaneous dissection between skin ineisions.
a scalpel (Fig. 1). The subcutaneous tissue was bluntly dis-
seeted down to the linea alba. Electrocautery was used for
henu)stasis. The fascia was carefully incised ai the base of riorly down to the pubis symphysis using electrocautery and
each ineision. The peritoneum was bluntly dissected away Metzenbaum scissors leaving the overlying skin and subcu-
from the underside of the fascia with a careful finger (Fig. taneous tissues intact {Fig. 3). The fascia audibly and visu-
2). With careful dissection around the umbilicus, the fascia! ally separated as SLAF was perfomied. The skin of each
incisions were extended superiorly to Ihe xiphoid and infe- small incision was closed using surgical staples and a sterile
748 THE AMERICAN SURGEON
FIG. 3. Performing subcutaneous linea alba fasciotomy.
dressing was applied. During the procedure, lAP decreased
from 27 to 11 mniHg. whereas APP increased from 34 to 65
mmHg. Urinary output increased from 10 to 60 mL per hour
and remained at this level. Over the next few days, his lAP
slowly rose back into the 20 to 25 mmHg range, but he
maintained an adequate APP > 60 mmHg, did not demon-
strate evidence of inadequate organ perfusion, and thus
avoided open abdominal decompression.
The patient recovered from his profound critical illness
over the ensuing 4 weeks and was discharged to an inpatient
rehabilitation facility. He demonstrated no evidence of com-
plications attributable to his SLAF. Given his morbid obe-
sity and paraplegia, a decision has been made to not repair
his incisional hernia at this time.
Discussion
IAH and ACS are frequent causes of morbidity and
mortality among critically ill patients of all disci-
plines.'-- Malbrain et al. in a multicenter trial found
the prevalence of lAH to be 54 per cent among pa-
tients in the medical ICU and 65 per cent among those
in the surgical ICU.'' Independent risk factors for the
development of IAH include abdominal surgery; high-
volume fluid resuscitation (greater than 3500 mL/24
hours); ileus; and pulmonary, renal, or liver dysfunc-
tion.- As a result, the World Society of the Abdominal
Compartment Syndrome advocates in their consensus
recommendations that patients should be screened for
these risk factors on ICU admission and in the pres-
ence of new or progressive organ failure.- When such
risk factors are present, serial IAP measurements
should be performed throughout the patient's critical
illness to detect the presence of IAH and potential
progression to ACS.
Serial IAP measurements are essential to the diag-
nosis and management of both IAH and ACS because
clinical examination is insensitive in detecting the
presence of elevated I A P . ' - Abdominal perfusion
August 2008 Vol. 74
pressure has been identified as a useful resuscitation
end point with maintenance of APP greater than 60
mmHg being prognostic of survival.^ APP assesses
not only the severity of IAH. but also the adequacy of
systemic perfusion and is superior to IAP alone.'"
Although surgical decompression is the most well-
known and frequently practiced treatment for ACS.
the medical treatment options for reducing elevated
IAP must not be forgotten because their application
can reduce the need for open decompression.- These
nonoperative alternatives include improving abdomi-
nal wall compliance through .sedation, analgesia, and
pharmacological paralysis; evacuating intraluminal
contents through nasogastric and/or rectal decompres-
sion; evacuating abdominal tluid collections through
percutaneous drainage; correcting positive fluid bal-
ance through hypertonic fluids, colloids, and careful
diuresis; and supporting organ function with vasopres-
sors and goal-directed resuscitation.- When all pos-
sible medical treatments have been implemented and
prove unsuccessful within a reasonable period of time,
surgical decompression with temporary abdominal
closure is indicated. Such patients are then at risk for
enteroatmospheric flstula formation, fluid and protein
loss, and prolonged hospital length of stay.
Leppaniemi et al. have described a novel technique
for the treatment of ACS secondary to acute pancrea-
titis. SLAF releases fascial tension and reduces IAP
while maintaining the peritoneum, subcutaneous ti.s-
sue, and skin intact to serve as a protective barrier for
the abdominal viscera, thus minimizing the complica-
tions of the open abdomen. They have demonstrated
success in avoiding open abdominal decompression in
50 per cent of patients demonstrating an average IAP
of 33 mmHg before SLAF. Minor breaches of the
peritoneum commonly occur but appear to have no
clinical significance. Continuous IAP monitoring dur-
ing SLAF performance is critical to confirm the ad-
equacy of decompression and resolution of the pa-
tient's excessive IAP.
It is important to recognize that patients with severe
IAH/ACS are unlikely to benefit from this less inva-
sive alternative and SLAF should always be performed
with the intent to convert to open decompression if
IAP does not respond as desired. Furthermore, like
traditional open abdominal decompression, SLAF re-
sults in an incisional hernia that will require subse-
quent repair. In our experience with skin-only abdomi-
nal wall closures, however, subsequent repair is
markedly easier than in patients who have undergone
split-thickness skin grafting of their exposed vi.scera.
This is the first reported case of SLAF after a trau-
matic injury. It was of particular value in this morbidly
obese patient, avoiding the creation of a complex ab-
dominal wall wound that would tTiost certainly have
No. 8 SUBCUTANEOUS LINEA ALBA FASCIOTOMY
required split-thickness skin grafting. SLAF represents
a safe, effective, and less morbid alternative for the
surgical management of primary or secondary ACS
refractory to comprehensive medical interventions.
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