Editing Open abdomen (section)

=== '''Phase 4: Management of open abdomen''' ===

* '''Techniques for definitively closing the difficult open abdomen'''
** Serial fascial suturing in combination with NPWT
** Gradual fascial tightening via trans-fascial tension-bearing closure techniques
*** Principle is to redistribute tension lateral to rectus sheath, theoretically lengthening lateral wall musculature
*** Techniques
**** Wittman Patch (artificial burr)
**** Transabdominal wall traction (TAWT)
**** Mesh-mediated fascial traction
***** Protect viscera with a polyethylene sheet or double-sided Ioban
***** Suture in an oval-shaped inlay polypropylene mesh
***** Apply VAC over the top (Abthera)
***** Takeback every 2-3 days: exchange the protective sheet, and serially tighten the mesh, until it can be removed
** Biosynthetic mesh - avoid in acute setting due to risk of infection
*** Options - human acellular dermal matrix (HADM), absorbable mesh like Vicryl, composite meshes
*** Techniques - two options
**** Underlay - if skin is lax enough to close but fascia not, you can place the mesh as underlay and directly close the skin. The mesh would typically be placed intra-peritoneal and secured with transfascial sutures.
**** STSG - if neither skin nor fascia can close, the mesh is placed underlay intra-peritoneal with standard saline moist to dry dressings BD for 2-4 weeks until satisfactory granulation has appeared in the wound bed. Then STSG can be placed. Will then need definitive component separation and delayed closure in 6-9 months. See bottom of page for a description of how to definitively close this type of abdomen.
** Component separation - full component separation is not recommended in acute setting - makes future hernia repairs much harder
* Pharmacologic adjuncts
** Continuous neuromuscular blockade doesn't make a difference
** Botox injection has been shown to help in both elective and acute setting