Editing Open abdomen (section)

=== '''Phase 3: First re-operation''' ===

* '''Takebacks'''
** Washout and re-VAC every 1-3 days
** Only do it at the bedside if patient is unstable and can't go to OT
** Check for complications/problems that will delay closure and serial fascial tightening
** For first 24-72 hours after index operation, adhesions are soft and give way easily. Operating again between 1-4 weeks can be hazardous. Avoid using sharp dissection. Generally look for collections at the periphery, and try to leave the 'central visceral block' alone.
* '''Check for reasons to delay closure:'''
** Ongoing inflammatory response
** Visceral oedema
** Retraction of abdominal wall musculature
** Lack of source control
** Intra-abdominal abscess
** Enterocutaneous fistula
* '''Assess readiness for closure:'''
** Direct closure is usually possible when the fascial edges are 3-7cm apart
** Intra-abdominal pressure >20mmHg or a rise of peak inspiratory pressure of 10cm H2O during attempts to close fascia are warning signs
** Delayed fascial closure (phase 4) might be prudent in this group
* '''Choice of technique to close after relook laparotomy:'''
** Patients predicted to be uncomplicated and likely to close within 8 days: NPWT + sequential fascial closure
** Patients with risk factors for difficult abdomen: NPWT + serial fascial tightening
*** Direct serial suturing if feasible
*** Interposition polypropylene mesh protected by Ioban if abdomen is too tight for direct suturing