Open-Abdomen Approach

Second-look surgery
In certain situations, staging the operative approach to intraperitoneal
infections is appropriate. Staging may be performed as a scheduled
second-look operation or through open management, with or without
temporary closure (eg, with mesh or vacuum-assisted closure [VAC]). [10, 11]
Second-look operations may be employed in a damage-control fashion. In
these cases, the patient at initial operation is severely ill and unstable from
septic shock or coagulopathy (eg, mediator liberation or disseminated
intravascular coagulation [DIC]). The goal of the initial operation is to
provide preliminary drainage and to remove obviously necrotic tissue. The
patient is then resuscitated and stabilized in an intensive care unit (ICU)
setting for 24-36 hours and returned to the operating room for more
definitive drainage and source control.
In conditions related to bowel ischemia, the initial operation aims to remove
all frankly devitalized bowel. The second-look operation serves to
reevaluate for further demarcation and decision-making regarding
reanastomosis or diversion.
Closure of abdomen
Temporary closure of the abdomen to prevent herniation of the abdominal
contents and contamination of the abdominal cavity from the outside can
be achieved by using gauze and large, impermeable, self-adhesive
membrane dressings; mesh (eg, Vicryl, Dexon); nonabsorbable mesh (eg,
GORE-TEX, polypropylene), with or without zipper or Velcrolike closure
devices; and VAC devices (see Table 1 below). [12]  The advantages of this
management strategy include avoidance of ACS and provision of easy
access for reexploration. The disadvantages include significant disruption
of respiratory mechanics and potential contamination of the abdomen with
nosocomial pathogens.
Table 1. Options for Temporary and Permanent Closure After
Celiotomy (Open Table in a new window)
Closure
Description Advantages Disadvantages
Technique

Self-adhesive Abdominal Inexpensive Difficult to

impermeable dressing with Easy maintain seal
membranes gauze and application Potentially large
coverage of the volume losses
entire wound Fistula
with formation
impermeable
 membrane with
and without
placement of
drains between
the layers

Rapid loss of
tensile strength
(in the setting of
infection)
Can be
Potentially large
Suturing of the applied
volume losses
mesh to the directly over
Higher
Vicryl or fascial edges; bowel
incidence of
Dexon mesh different Allows for
later ventral
options for drainage of
hernia
dressing peritoneal
development
fluid
No reopen-and-
close option
Fistula
formation

Risk of
intestinal
erosion when
Suturing of the Good tensile
applied directly
mesh to the strength
over bowel
Polypropylene fascial edges; Allows for
Potentially large
mesh different drainage of
volume losses
options for peritoneal
High risk of
dressing fluid
mesh infection
Fistula
formation

GORE-TEX Suturing of the Good tensile Potential fluid

mesh mesh to the strength accumulation
fascial edges; Reopen and underneath the
different close option mesh
options for Limited tissue
dressing integration and
granulation
tissue formation
over the mesh
 Risk of mesh
infection
Fistula
formation

Expensive
Human Suturing of the
Good tensile Needs 10
acellular mesh to the
strength minutes of
dermis fascial edges
rehydration

Controlled
drainage of
secretions
Cost
Accelerated
Sponges Risk of
granulation
applied over intestinal
Vacuum- tissue
mesh and erosion when
assisted formation
attached to applied directly
closure device Wound
controlled, low- over bowel
debridement
level suction Fistula
Can remain in
formation
place for
longer than
48 hours

Suturing of Good tensile

artificial burr strength
(ie, Velcro) to Allows for
fascia, staged easy
Wittmann Fistula
abdominal reexploration
patch formation
closure by and eventual
application of primary
controlled fascial
tension closure

For delayed primary closure (permanent), our experience with the use of

human acellular dermis (commercially known as AlloDerm) has been
satisfactory, though this option has the disadvantage of being more
expensive than others.
A study by Mutafchiyski et al included 108 patients with diffuse peritonitis
and open abdomen who were treated either with mesh-foil laparostomy
without negative pressure or with VAC. [13] The investigators found VAC to
be associated with higher overall and late primary fascial closure rates,
a lower incidence of necrotizing fasciitis, fewer intra-abdominal abscesses
and enteroatmospheric fistulas, reduced overall mortality, and shorter ICU
and hospital stays.
In a study that involved 53 patients with peritonitis who underwent open-
abdomen management, Willms et al found that regardless of the process
underlying the peritonitis, the use of a combination of VAC and mesh-
mediated fascial traction (MMFT) was able to achieve high rates of fascial
closure. [14]
In a study that involved 152 patients who underwent open-abdomen
therapy at a single center, more than half of whom had sepsis (33.3%) or
peritonitis (24.2%) as the indication, Berrevoet et al found that patients who
started open-abdomen management with MMFT and negative-pressure
wound therapy (NPWT) from the initial surgery had a significantly better
fascial closure rate than those who started 3 or more days later. [15] The use
of VAC in conjunction with MMFT yielded high rates of fascial closure.
Absence of initial intraperitoneal NPWT and delayed initiation of MMFT
were risk factors for nonfascial closure.

Laparoscopic Approach
Laparoscopic surgery is commonly used in the treatment of uncomplicated
appendicitis, though there is evidence to indicate that it can yield positive
outcomes for complicated appendicitis as well. [16]
For both complicated and uncomplicated appendicitis, the laparoscopic
approach is associated with a shorter length of hospital stay and fewer
wound infections than is the open approach. However, laparoscopic
surgery may be associated with a higher rate of intra-abdominal abscess.
Laparoscopic diagnosis and peritoneal lavage in patients with peritonitis
secondary to diverticulitis has been shown to be safe and has helped to
avoid the need for colostomy in many patients in small clinical trials. [17]
In a prospective study comparing laparoscopic peritoneal lavage with
an open Hartmann procedure for perforated diverticulitis with generalized
peritonitis, peritoneal lavage without operative intervention was found to be
feasible, with a comparable mortality and a low risk of short-term
recurrence. Successful laparoscopic repair of perforated gastric and
duodenal ulcers has also been reported.
A study by Illuminati et al found laparoscopic lavage/drainage (LALA) to be
a potentially effective as a bridge treatment before endovascular aneurysm
exclusion and elective colon resection in patients presenting with
perforated diverticulitis with purulent peritonitis associated with an
uncomplicated abdominal aortic aneurysm. [18]
No definitive guidelines have been established regarding the optimal
selection of patients for successful laparoscopic repair. Studies have
investigated scoring systems (eg, APACHE II, Boey score) for patient risk
stratification, in order to allow better selection of patients for laparoscopic
repair.
The treatment of perihepatic infections via the laparoscopic approach has
been well established in acute cholecystitis, where laparoscopic
cholecystectomy has become the mainstay of therapy. Primary treatment of
subphrenic abscesses and laparoscopic ultrasonography (US)-assisted
drainage of pyogenic liver abscesses have also been performed
successfully.
Individual reports also describe successful drainage of peripancreatic fluid
collections and complicated intra-abdominal abscesses that are not
amenable to percutaneous drainage guided by either computed
tomography (CT) or US.

Multiple Reexplorations
In severe peritonitis, particularly when it includes extensive retroperitoneal
involvement (eg, necrotizing pancreatitis), open treatment with repeat
reexploration, debridement, and intraperitoneal lavage has been shown to
be effective.
The decision to perform a series of reexplorations may be made during the
initial surgery if additional debridement and lavage are needed beyond
what can be achieved in the first procedure. Indications for planned repeat
laparotomy may include failure to achieve adequate source control, diffuse
fecal peritonitis, hemodynamic instability, and intra-abdominal
hypertension.
Multiple reoperations may be associated with significant risks, including
those from a substantial inflammatory response, fluid and electrolyte shifts,
and hypotension; however, these must be balanced against the risks of
persistent necrotic or infectious abdominal foci.
The open-abdomen technique allows thorough drainage of the intra-
abdominal infection, but the specific indications are not clearly defined.
Many trials lack control groups or use historical controls; outcome variables
(eg, mortality) are often not specific enough, and data on resource use are
limited.
To date, no conclusive data suggest a clear advantage for the open
approach over the closed approach in the treatment of severe abdominal
sepsis; however, in the author's experience, bowel edema and subsequent
inflammatory changes limit the use of the closed-abdomen technique.
Secondary ACS may ensue if abdominal closure is performed before the
inflammatory process has resolved.
In some cases, staged operative interventions will be planned. In other
cases, patients may present with continued peritonitis or abscess formation
requiring "on-demand" relaparotomy.
A 2004 study suggested that the mortality of on-demand laparotomy is
higher for those patients receiving intervention more than 48 hours after
their index operation.
Surgical-Site Infection and Delayed Healing
Patients requiring surgical intervention for peritonitis demonstrate a
significantly increased risk for surgical-site infection (SSI) and failed wound
healing; they should therefore be closely monitored for these potential
complications.
The incidence of SSI increases with the degree of contamination; therefore,
SSI occurs at much higher rates after operations for peritonitis and
peritoneal abscess (ie, 5-15%, compared with < 5% for elective abdominal
operations for noninfectious etiologies).
SSI may be expected if the wound is closed in the setting of gross
abdominal contamination (see Table 2 below). Perioperative systemic
antibiotic therapy, wound-protector devices, and wound lavage at the end
of therapy do not reliably prevent this complication. These wounds should
be left open and should be treated with wet-to-dry dressing changes
several times a day, or VAC dressing should be applied.
Table 2. Wound Classification and Risk of Surgical-Site Infection
(SSI) (Open Table in a new window)
Incidence
Classification Examples
of SSI  (%)

Elective surgery without violation of

Clean <2
the gut or infected spaces

Clean- Elective bowel surgery (prepared

5-15
contaminated bowel, mechanical and antibiotic)

Emergency bowel surgery

Contaminated (unprepared bowel, minor spillage), 15-30
drainage of infected spaces

Grossly contaminated traumatic

wounds, significant intestinal spillage,
Dirty >30
grossly infected and devitalized tissue
(necrotizing infection)

The same factors that impair the clearance of the abdominal infection
contribute to increased problems related to wound healing (eg, malnutrition,
severe sepsis, MODS, advanced age, and immunosuppression) and
should be addressed aggressively.