818979

research-article2018
SJS0010.1177/1457496918818979Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial tractionP. Petersson, et al.

SJS
SCANDINAVIAN
Original Research Article JOURNAL OF SURGERY

Vacuum-assisted wound closure and permanent onlay

mesh–mediated fascial traction: A Novel Technique for
the Prevention of Incisional Hernia after Open Abdomen
Therapy Including Results From a Retrospective Case
Series

P. Petersson1,2 , A. Montgomery1,2, U. Petersson1,2

1 Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden
2 Department of Surgery, Skåne University Hospital, Malmö, Sweden

Abstract

Background and Aims: Incisional hernia development is a frequent long-term sequel after
open abdomen treatment. This report describes a novel technique, the vacuum-assisted
wound closure and permanent onlay mesh–mediated fascial traction for temporary and
final closure of the open abdomen, with the intention to decrease incisional hernia rates.
Primary aim was to evaluate incisional hernia development and secondary aims to describe
short-term complications and patient-reported outcome.
Materials and Methods: The basics of the technique is an onlay mesh, applied
early during open abdomen treatment by suturing to the fascia in two rows with a
3- to 4-cm overlap from the midline incision, used for traction and kept for reinforced
permanent closure. A retrospective case series, including chart review, evaluation of
computed tomography/ultrasound images, and an out-patient clinical examination
were performed. The patients were asked to answer a modified version of the ventral
hernia pain questionnaire.
Results: A total of 11 patients were treated with vacuum-assisted wound closure and
permanent onlay mesh–mediated fascial traction with median follow-up of 467 days.
Fascial closure rate was 100% and 30 day mortality 0%. Two of nine patients, eligible for
incisional hernia follow-up, developed a hernia. Neither of the hernias were symptomatic
nor clinically detectable. Six of 10 patients eligible for short-term follow-up had a prolonged
wound-healing time exceeding 3 weeks. One of seven patients eligible for patient-reported
outcome have had pain during the last week.
Conclusion: The vacuum-assisted wound closure and permanent onlay mesh–mediated
fascial traction is a promising new technique for open abdomen treatment and reinforced

Correspondence: Scandinavian Journal of Surgery

Ulf Petersson 2019, Vol. 108(3) 216­–226
Department of Surgery © The Finnish Surgical Society 2018
Article reuse guidelines:
Skåne University Hospital sagepub.com/journals-permissions
205 02 Malmö DOI: 10.1177/1457496918818979
https://doi.org/10.1177/1457496918818979

Sweden journals.sagepub.com/home/sjs
Email: ulf.a.petersson@telia.com
 Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial traction 217

fascial closure. The results of the first 11 patients treated with this technique show a low
incisional hernia rate with manageable short-term wound complications and few patient-
reported disadvantages.
Key words: Open abdomen; permanent onlay mesh; incisional hernia

Introduction 2. The incision is reinforced using an non-absorbable

When open abdomen (OA) treatment is needed, a
temporary abdominal closure (TAC) technique has to
be applied in order to protect the abdominal content
and facilitate fascial closure. In a review by Atema
et al. (1), it was concluded that a combination of nega-
tive-pressure wound therapy (NPWT) and fascial trac-
tion result in the highest fascia closure rates. The same
conclusion was drawn in two guidelines on OA ther-
apy published in 2018 (2, 3). The first technique utiliz-
ing this combination, the vacuum-assisted wound
closure and mesh-mediated fascial traction (VAWCM),
was described in 2007 from our institution (4). In this
technique, a large mesh is divided in two halves and
sutured to the fascial edge on each side of the incision.
After applying the intra-abdominal part of the NPWT
system, the meshes are sutured together under tension
pulling the fascia toward the midline. At definitive
closure, the meshes are removed and the facia was
closed with a running suture. This technique enables
fascia closure in 61%–100% reported in patients sur-
viving the OA period (5, 6). By utilizing the VAWCM
technique, the former problem with large ventral her-
nias can be avoided in most patients. However, more
recent studies evaluating long-term complications
after NPWT and fascial traction of any kind show inci-
sional hernia (IH) frequencies between 21%–54% (7–
11). Improvement of TAC techniques is desirable in
order to prevent IH formation and subsequent need
for additional surgery in these already severely
afflicted patients.
The vacuum-assisted wound closure and perma-
nent onlay mesh–mediated fascial traction (VAWCPOM)
technique was developed at our institution, utilizing
NPWT and permanent onlay mesh for fascial traction,
in order to prevent IH. When terminating the OA ther-
apy, the onlay mesh is left in place and used for fascia
reinforcement. Furthermore, the improved attachment
of the mesh to the fascia allows the applied traction to
be increased. This might result in fewer dressing
changes and shorter time to final closure.
The purpose of this report is to describe the
VAWCPOM technique and to retrospectively evaluate
short-term complications, IH development, and
patient-reported outcome.
Material and Methods
The Vawcpom Technique
The principles of the initial steps of the VAWCPOM
technique
1. The rectus fascia is dissected free from subcuta-
neous fat for a distance of 3–4 cm around the
incision.
2-0 suture (reinforced tension line, RTL) as
described by Hollinsky et al. (12) (Fig. 1A and 2A).
3. A 30 × 30 cm traction-resistant heavyweight poly-
propylene mesh is divided into two halves and
sutured at its lateral margin to the fascia with narrow
stitches using a non-absorbable running 2-0 suture,
with the mesh overlapping the fascial incision by
3–4 cm in both lateral and cranial/caudal directions.
4. A second line of a running 2-0 suture is applied to
the edge of the fascial incision including the RTL
suture in every stitch (Fig. 1B and 2B).
5. The same procedure is performed with the other
half of the mesh on the contralateral side where
after the RTL suture is tied.
6. The OA NPWT system is applied and tucked far
out intra-abdominally in all directions to prevent
adhesions between the abdominal wall and viscera.
7. The mesh halves are trimmed and closed under
tension over the intra-abdominal dressing, mini-
mizing the gap between the fascial edges (Fig. 1C
and 2C).
8. Perforated foam is applied above the closed mesh
and is kept narrow enabling medial sliding of the
skin (Fig. 1D).
9. The plastic drapes and the tubing set are applied.
The therapy unit is set to −125 to −150 mmHg with
continuous pressure. In patients with coagulopa-
thy, the pressure applied might be lowered to min-
imize the risk of bleeding (Fig. 1E and 2D).
Course of action at dressing changes performed every
48–72 h
1. Remove the subcutaneous perforated foam, open
the mesh, remove the intra-abdominal dressing,
take samples for bacterial culture, and perform
lavage with warm saline solution.
2. A new intra-abdominal dressing is applied.
3. Any redundant part of the mesh is trimmed, and
the mesh is tightened.
4. A new narrow subcutaneous foam, plastic drapes,
and tubing set are applied.
Abdominal wall/fascial closure when fascial edges can be
aligned
1. Remove the subcutaneous perforated foam, open
the mesh, remove the intra-abdominal dressing,
take samples for bacterial culture, and perform
lavage with warm saline solution.
2. Trim the mesh to the level of the fascial edges on
both sides (Fig. 2E).
3. Close the mesh with small and narrow stitches of a
non-absorbable running 2-0 suture taking care not
218 P. Petersson, et al.

Fig. 1. Schematic illustration describing the VAWCPOM technique: (A) the fascia is dissected free from subcutaneous fat on a distance of
approximately 3 cm from the incision on each side, as well as cranially and caudally, and a reinforced tension line (RTL) suture is applied
along the fascial edges. (B) The first half of the heavyweight polypropylene mesh is sutured to the fascia in double rows, one at the lateral
margin of the mesh and the other along the fascial edge including the RTL suture. (C) The other half of the mesh is sutured in the same
way, and the RTL suture is tied. The abdominal part of the NPWT system is placed as far out as possible before the two mesh halves are
sutured together in the midline under tension. (D) The subcutaneous NPWT perforated foam is cut narrower than the skin gap. (E) The
plastic drape and the tubing set is then applied, taking care to slide the skin edges medially. (F) When the fascial edges can be aligned,
the abdomen is closed. Trim the mesh along the fascial edges on both sides and suture the mesh with small and narrow stitches. It is not
necessary to suture the fascia. All suturing is done with non-absorbable sutures.
 Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial traction 219

Fig. 2. Operation photography describing the VAWCPOM technique: (A) the reinforced tension line (RTL) suture is applied along the
fascial edge after the fascia has been freed from subcutaneous fat. (B) The heavyweight polypropylene mesh halves are sutured to the
fascia in double rows, one at the lateral margin of the mesh and the other along the fascial edge including the RTL suture. (C) After the
abdominal part of the NPWT system is placed as far out as possible, the two mesh halves are sutured together in the midline under
tension. (D) The subcutaneous NPWT perforated foam is cut narrower than the skin gap, and the plastic drape and the tubing set are then
applied, taking care to slide the skin edges medially. (E) and (F) The mesh is trimmed along the fascial edges on both sides and sutured
with small and narrow stitches. It is not necessary to suture the fascia. All suturing is done with non-absorbable sutures.

to fold the mesh or creating a ridge of mesh in the
midline (Fig. 1F and 2F).
4. In case the conditions for skin closure is not opti-
mal, apply subcutaneous NPWT for a few days
before the skin is closed.
5. After closure of the skin, application of a NPWT
system for closed incisions can be considered for
an additional week.
save time and minimize the surgical trauma. The
NPWT system is applied during the first operation
without the onlay mesh, which instead is applied dur-
ing the first dressing change. In this way, it is possible
to stabilize the patient in the intensive care unit (ICU)
before the more time-consuming application of the
mesh is done. An algorithm for OA treatment used at
our institution is presented in Fig. 3.

The OA treatment with VAWCPOM can be initiated

using either of two ways. If the patient is stable the
onlay mesh and NPWT system can be applied at the
first operation. In case of an unstable critically ill
patient, a two-step procedure can be performed to
Included Patients and Study Design
Consecutive OA patients treated with the VAWCPOM
technique at the Department of Surgery, Skåne
University Hospital, Sweden, between December 2014
220
Fig. 3. Algorithm for open abdomen treatment with the VAWCPOM technique.
and December 2016, were included in this retrospec-
tive case series. Patients were identified by searching
the operation registers (surgical codes JAH30, JAH33,
and DQ023).
Chart review
A chart review was performed, and data retrieved
according to Tables 1 to 3. If patients had undergone
computed tomography (CT) or ultrasound during the
P. Petersson, et al.
follow-up time for other indications, the images were
examined in order to increase the possibility to diag-
nose clinically non-detectable IHs.
Assessment at OA initiation and during OA treatment
At OA initiation, the patient’s clinical status was eval-
uated with American Society of Anesthesiologists
physical status classification (ASA) and with the
Sequential Organ Failure Assessment (SOFA) score
 Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial traction 221

Table 1 was performed in upright and supine position during

Patient characteristics at OA.
Gender, male
Age (years), median (range)
BMI (kg/m2), median (range)
Chronic obstructive pulmonary disease
Coronary artery disease
Current cancer treatment
Immunosuppression
Diabetes mellitus (I or II)
Smoking
ASA score, median (range)
SOFA score, median (range)
Albumin (g/L), median (range)
ICU treatment
ICU treatment time, days (range)
relaxation, straining, and coughing. It was noticed
9/11 (82%)
whether the scar was stuck to the underlying fascia or
65 (24–82)
freely displaceable. The patients answer a modified
29.0 (21.6–44.5)
version of the Ventral Hernia Pain Questionnaire
3/11 (27.3%)
(VHPQ) (20), approved by the inventors. Patients not
4/11 (36.4%)
able to attend the clinical examination answered the
4/11 (36.4%)
questionnaire by mail or telephone.
2/11 (18.2%)
Patients operated with additional surgery through
1/11 (9.1%)
the onlay mesh was excluded from the out-patient
2/11 (18%)
clinical examination and from answering the pain
3 (1–4)
questionnaire. However, the presence of an IH was
3 (1–14)
evaluated at the additional surgical procedure.
25 (14–32)
Follow-up time was calculated from the day of fascial
7/11 (64%)
closure to the day of clinical examination, last chart
7 (3–19)
notation or day of the additional surgery, respectively.

BMI: body mass index; ASA: American Society of Anesthesiologists
physical status classification; SOFA: Sequential Organ Failure
Assessment; ICU: intensive care unit.
(13). When calculating the SOFA score, the worst value
for each organ system noted from 12 h before, up to
12 h after the OA initiation, was used.
Contamination grade at OA initiation was classi-
fied according to the Centers for Disease Control and
Prevention (CDC) classification for prevention of sur-
gical wound infections (14).
For every OA intervention, that is, the OA initiation
procedure, dressing changes and at fascial closure, the
OA status was classified according to the OA classifi-
cation system defined by the World Society of
Abdominal Compartment Syndrome (15–17).
Peritonitis, if present at OA initiation, was graded
according to the Mannheim Peritonitis Index (MPI)
(18). Causes for OA treatment were classified as fol-
lows: 1 = visceral edema and/or intra-abdominal/ret-
roperitoneal swelling, reducing intra-abdominal
space, making it mechanically impossible to close the
abdomen; 2 = intra-abdominal deep infection/perito-
nitis with need for drainage; 3 = damage control and/
or planned second look operation; and 4 = decompres-
sion in case of an abdominal compartment syndrome.
Patients may have more than one of the abovemen-
tioned causes. Complications occurring during the
OA treatment was noted.
Assessment of postoperative complications
Postoperative complications, that is, complications
occurring after fascial closure, were graded and classi-
fied according to Clavien–Dindo Classification (19).
Short-term wound complications were evaluated, and
the wound-healing time was calculated from chart
notations made by wound-specialized nurses.
Prolonged healing was defined as healing time exceed-
ing 3 weeks and chart notation stating wound-healing
problems.
Clinical out-patient follow-up
Patients alive in August 2017 were invited to a clinical
follow-up. A protocol-based clinical hernia examination
Ethical approval
Ethical approval for this retrospective case series was
not needed, as it is classified as a clinical quality evalu-
ation according to the Regional Ethics Committee at
Lund University, Sweden (2012/726). Patients were
informed in writing and approved participation by
answering the questionnaire.
Results
Assessment at Oa Initiation and During Oa
Treatment
A total of 11 patients treated with VAWCPOM were
identified and included. Patient characteristics at the
OA initiation are presented in Table 1. VAWCPOM
treatment details for each patient are presented in
Table 2. Fascial closure rate was 100%.
One patient developed an anastomotic leakage dur-
ing the VAWCPOM treatment that transformed into
an enteroatmospheric fistula (EAF). Due to its loca-
tion, deep down in the right side of the abdomen, it
was impossible to locate during dressing changes. The
fistula was managed successfully by drainage with a
transcutaneous catheter placed as far out to the right
side and as close to the fistula as possible, with contin-
ued VAWCPOM treatment. Adhesions were allowed
to develop around the catheter, thereby creating a fis-
tula separated from the OA, making it possible to
close the fascia despite the fistula. Shortly thereafter,
the fistula effluent ceased.
Mortality
There was no 30-day mortality. However, two patients
died during follow-up. One patient was discharged to
a nursing home but was re-admitted a few days later
due to aggravation of heart insufficiency and died
48 days after fascial closure. The second patient died
due to a septic condition not related to the VAWCPOM
treatment after 299 days.
Assessment of Postoperative
Complications
Postoperative short-term complications are presented
in Table 3. One patient was lost to follow-up after
 Table 2
222

VAWCPOM treatment details.

Case Case description Indication for CDCa Peritonitis MPI Worst OA Time Number Max Fascia closure NPWT Closed Complications
OA treatment at OA classb of OA of dressing diastase sc after incision during OA
initiation treatment changes (cm) fascial NPWT treatment
(days) (mean days closure
between)

1 Sigmoid cancer Peritonitis and 4 Yes 27 1B 14 5 (2.8) 6.0 Yes Yes No Respiratory
op. Postoperative edema insufficiency
anastomotic insufficiency
2 Self-inflicted knife wound Edema 3 No – 1B 9 2 (4.5) 5.0 Yes No No None
in present IH with colo-
cutaneous fistula
3 Adhesion ileus op. Peritonitis and 4 Yes 28 1B 8 1 (8.0)c – Yes Yes No Aggravation of
Postoperative wound edema heart insufficiency
dehiscence
4 Laparoscopic Bile peritonitis 3 Yes 26 1B 10 3 (3.3) 4.0 Yes Yes Yes None
cholecystectomy and edema
for cholecystitis.
Postoperative bile-
leakage
5 Carcinoid tumor. Second look 2 No – 4 20 7 (2.9) 3.0 Yes Yes Yes EAF
Postoperative ileus and and edema
ischemic bowel
6 Hip-replacement Decompression 1 No – 1A 9 2 (4.5) 9.5 Yes Yes Yes None
op. Retroperitoneal (ACS)
hematoma, hypovolemic
shock and ACS
P. Petersson, et al.

7 Colo-vesical fistula op. Edema 3 Yes 20 1B 8 3 (2.7) 10.0 Yes Yes Yes None
Postoperative wound
dehiscence
8 Abdominal gunshot Second look 3 Yes 17 2A 14 4 (3.5) 5.0 Yes No Yes None
trauma. Small and edema
bowel resection and
retroperitoneal hematoma
9 Cecal cancer op. Peritonitis and 4 Yes 32 1C 10 3 (3.3) 8.0 Yes Yes No None
Postoperative edema
anastomotic insufficiency
10 Hysterectomy, SOE and Peritonitis and 4 Yes 39 1C 13 4 (3.3) 9.0 Yes Yes Yes None
IH repair. Postoperative edema
sepsis due to small bowel
perforation
11 Sigmoid cancer op. Oedema 3 No – 1A 14 3 (4.7) 10.0 Yes Yes Yes None
Postoperative wound
dehiscence
All – – Range: 1–4 7/11 (64%) 27 (17–39) Range:1A–4 10 (8–20) Median: 3.3 Median: 7 11/11 (100%) 9/11 (82%) 7/11 (64%) –
(2.7–8.0) (3–10)

OA: open abdomen; CDC: Center for Disease Control: MPI: Mannheim Peritonitis Index; NPWT: negative-pressure wound therapy; IH: incisional hernia; EAF: enteroatmospheric fistula; ACS: abdominal compartment
syndrome; SOE: salpingo-oophorectomy.
aCDC classification for prevention of surgical wound infections: 1 = clean wound; 2 = clean-contaminated wound; 3 = contaminated wound; 4 = dirty or infected wound.
bWorst OA classification during OA treatment (according to the World Society of the Abdominal Compartment Syndrome).
cThe patient was severely ill and treatment was palliative for several days until the condition improved and the abdomen successfully closed after 8 days without dressing change.
 Table 3
Short- and long-term follow-up.

Case Patient Death cause Wound Delayed Wound Clavien– IH IH at clinical IH at Follow-up, Retracted VHPQ: VHPQ: scar VHPQ:
diseased (days healing healing infectionb Dindoc examination CT/UL daysd scar pain last cosmetically scar
after closure) problemsa time, days week disturbing socially
limiting

1 No – No – No IIIa No No No 350 – No Yes No

2 No – No – No – No No No 210 – – – –
3 Yes (48) Heart Yes 43 No V – – – – – – – –
insufficiency
4 No – No – No – No No No 534 No No Yes No
5 No – Yes 35 No I No No No 610 Yes No No No
6 No – No – No – No No – 467 No No Yes No
7 No – Yes 35 No I Yes No Yes 549 No No No No
8 No – – – – – – – – – – – – –
9 Yes (299) Sepsise Yes 91 Yes II No No – 210 – – – –
10 No – Yes 33 No I No No No 456 No No Yes No
11 No – Yes 75 No I Yes No Yes 257 No Yes Yes Yes
All 2/11 (18%) – 6/10 (60%) Median: 38.5 1/10 (10%) – 2/9 (22%) – – Median: 467 1/6 (17%) 1/7 (14%) 5/7 (71%) 1/7 (14%)

IH: incisional hernia; CT/UL: computed tomography/ultrasound; VHPQ:Ventral Hernia Pain Questionnaire;
aDefined as a healing time more than 3 weeks and a chart notation stating wound healing problems.
bCulture-confirmed wound and/or mesh infection.
cClavien–Dindo classification: Grade I = any deviation from normal postoperative course, including wound infections opened at the bedside but not treated with antibiotics; Grade

II = requiring pharmacological treatment, e.g. antibiotic treatment, blood transfusion, or parenteral nutrition; Grade IIIa = requiring surgical, endoscopic, or radiologic intervention without
general anesthesia and Grade IIIb under general anesthesia; Grade IVa = life-threatening complication requiring IC/ICU management with single organ dysfunction and Grade IVb with
multiorgan dysfunction; Grade V = death of patient.
dFollow-up days for all modalities of IH diagnosis.
eDeath unrelated to the OA treatment.
Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial traction
223
224 P. Petersson, et al.
discharge. Prolonged wound healing was seen in 6/10
patients. One patient developed a mesh infection
treated conservatively with antibiotics for a prolonged
period of time before a small part of the onlay mesh
was extirpated, where after the wound was treated
with NPWT until healing. Another patient was subject
for a longer period of conservative wound treatment
without NPWT. The remaining four patients’ delayed
wound healing was due to a planned approach, where
a shorter part of the midline incision was left for sec-
ondary healing after finishing NPWT. These patients
were managed at the out-patient clinic by a nurse until
the wound was healed. The average wound-healing
time just exceeded 4 weeks in the patients with pro-
longed healing.
Clinical Out-Patient Follow-Up and the
Modified Vhpq
Long-term complications, together with answers to
the VHPQ are shown in Table 3. Nine patients were
eligible for IH evaluation (one early death and one
patient was lost to follow-up) and two (22%) devel-
oped an IH. None was detectable at clinical examina-
tion but diagnosed by CT or ultrasound performed for
other reasons. Both hernias were located either in the
upper or lower part of the midline above or below the
onlay mesh. None of the patients reported any symp-
toms related to the hernia, and none had undergone
IH repair during the follow-up period.
Seven patients answered the modified VHPQ. One
patient was lost to follow-up, and three patients were
not eligible (two deceased and one re-operated for
stomal reversal with a midline incision). One patient
(14%) had experienced pain during the last week. Five
of seven (71%) found their scar cosmetically disturb-
ing, and one (14%) also found it socially limiting.
Discussion
We describe a novel TAC technique for management
of OA with vacuum-assisted wound closure combined
with the application of a permanent onlay mesh for
fascial traction and IH prevention (VAWCPOM). The
results of the 11 first patients treated with the tech-
nique are promising with fascial closure in all patients,
a relatively low IH rate without serious short-term
wound complications or patient-reported disadvan-
tages.
In this report, 9 of 11 patients were eligible for fol-
low-up concerning IH formation, showing an IH rate
of 22% after a median of 467 days. In comparison with
the older VAWCM technique, this is a considerably
lower incidence. None of the two patients had a symp-
tomatic IH and none had undergone surgical repair. In
both cases, the hernia was located above and/or below
the mesh, and from the patient’s chart, we suspect that
the cranial/caudal mesh coverage in these patients
might have been insufficient. This stresses the need for
good mesh coverage with at least a 3-cm overlap on
healthy non-incised fascia both cranially and caudally,
a fact we have become aware of during this retrospec-
tive evaluation. In the systematic review by Acosta
et al. (5) from 2017, IH rates reported in two prospective
and one retrospective study ranged between 21%–
54%. Our result is in the lower part of this range, and
we assume it may be further decreased as the treat-
ment protocol for VAWCPOM is further implemented
among surgeons.
In this small case series of patients, the mesh/fascia
closure rate was 100%, but much larger numbers of
patients are needed to determine the actual closure
rate for the technique. However, there is no reason to
believe that the new technique should perform worse
than the old. With improved attachment of the mesh,
a greater fascial traction can be applied, possibly
increasing fascial closure rates. Another potential ben-
efit when the fascial traction is increased is shorter
time to fascial closure.
The use of a permanent mesh in contaminated surgi-
cal fields has been advised against, since the dominat-
ing previous experience has been that an infected mesh
could seldom be salvaged (21). However, there are data
indicating that the use of NPWT in case of mesh infec-
tions may provide a solution to this problem (22, 23). In
addition, data from studies on prophylactic mesh in
clean-contaminated situations, for example, for rein-
forcing incisions after colorectal surgery or for preven-
tion of parastomal hernias, does not indicate crucial
drawbacks concerning mesh-related complications (24).
In our report, 9 of 11 patients had a contaminated or
dirty/infected wound according to the CDC classifica-
tion, and seven of those had peritonitis at OA initiation.
We even experienced the development of an EAF dur-
ing the VAWCPOM treatment in one patient. The fis-
tula originated from a leaking anastomosis and was
located deep in the abdomen, far from the applied
intra-abdominal part of the NPWT system. It is impos-
sible to say if the negative-pressure treatment caused
the leakage and the formation of the EAF or not, but
earlier research implicates that the negative pressure
applied during VAWCM treatment does not propagate
far beyond the intra-abdominal visceral protection
sheet (25). Furthermore, a systematic review by Atema
et al. (1) from 2015 showed that NPWT with mesh trac-
tion had a lower incidence of fistula formation in com-
parison with the other TAC techniques. The fortunate
outcome in our patient with a closed abdomen, mesh in
place, no mesh infection, and a closed fistula demon-
strates that situations earlier believed to be deleterious
can now be treated successfully. In our report, the
majority of patients were contaminated when the syn-
thetic mesh was applied. Only one patient developed a
postoperative mesh infection and one had a noticeably
prolonged healing time. In both patients, a substantial
part of their wound-healing time was treated without
NPWT. A more active approach could possibly have
reduced the healing time for these two patients.
In an upcoming prospective study, there is an evi-
dent need for a defined protocol on how to handle
wounds at OA termination and how to handle post-
operative wound complications in VAWCPOM
patients. Furthermore, it is important that the
VAWCPOM technique is utilized in an optimal way
for prevention of wound complications. A subcutane-
ous exposed mesh is known to cause significantly
more wound complications, especially seroma forma-
tion, compared to fascia-covered meshes (21, 26–29).
 Vacuum-assisted wound closure and permanent onlay mesh–mediated fascial traction
Despite this, the VAWCPOM technique advocates the
onlay mesh position. The key for its success is that the
onlay mesh is granulated before skin closure. Often,
this is obtained during the OA treatment, but other-
wise achieved by utilizing prolonged NPWT on
closed mesh/fascia if needed. An alternative to the
onlay position could be a retromuscular mesh, but for
many of the patients in need of OA, this would have
been an unnecessary additional surgical trauma. We
have therefore chosen the simpler onlay position as
the standard mesh placement.
In the patient-reported follow-up, one of seven
patients had experienced pain during the last week,
but the pain could easily be ignored and did not
affect daily activities. The majority of the patients
reported that they found their scar cosmetically dis-
turbing, and a part of that group also found it
socially inhibiting. After OA treatment, “ugly”
abdominal scars are hard to prevent, but one effort
that might be important is to routinely plan for sec-
ondary suture if subcutaneous NPWT is used after
fascial closure.
This is a retrospective case series including 11
patients and interpretation of the results should be
done with caution due to the retrospective context and
few patients included. Discrepancies in pre-, peri- and
postoperative management is expected and might
influence the results. However, there were no opera-
tive data missing, and only one eligible patient was
lost to follow-up.
In summary, this retrospective case series, includ-
ing the first 11 patient treated with the novel
VAWCPOM technique shows promising results with
100% fascial closure rate, no OA treatment–related
mortality, manageable short-term wound complica-
tions, a low IH rate, and low incidence of long-term
abdominal wall pain. Further evaluation, preferably
in a prospective study, is needed before this novel
technique can be introduced as a standard treatment
regime.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
P. Petersson https://orcid.org/0000-0003-0250-1004
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Received: August 5, 2018
Accepted: November 13, 2018