Abdominal Compartment Syndrome
Moshe Schein, MD FACS

Outline adapted from a chapter from the book 'The Abdominal Compartment Syndrome',
edited by Rao Ivatury et al, and to be published by Landes Bioscience

 

“In four patients with ruptured abdominal aortic aneurysms increased intra-abdominal pressure developed after repair. It was manifested by increased ventilatory pressure, increased central venous pressure, and decreased urinary output associated with massive abdominal distension not due to bleeding. This set of findings constitutes an intra-abdominal compartment syndrome caused by massive interstitial and retroperitoneal swelling"

- Fielsam, 1989

Author's Note
The brief history of intra-abdominal hypertension and the abdominal compartment syndrome are typical of any medical innovation: described, forgotten, re-discovered, and faced with skepticisms and ridicule. Eventually, after being scientifically proven and re-proven and supported by “clinical leaders” and widely published in reputable journals—it is accepted as “truth”. This collection summarizes phases in the history of IAHT and ACS from the mid 19th century until today.
 

1863
First? description of the effects of intra-abdominal pressure
Étienne-Jules Marey
(b. March 5, 1830, Beaune, Ff. d. May 15, 1904, Paris)

Marey wrote in his paper “Physiologie médicale de la circulation du sang” that the 'effects that respiration produces on the thorax are the inverse of those present in the abdomen.' However, according to Emerson, Marey 'describes no tests and gives no records or figures.'

Marey was a physician, inventor, and photographer, noted for his contributions to experimental physiology and early cinematography. His doctoral dissertation of 1857 on the mechanical recording of the circulation of blood was followed by ten years of experimentation with various instruments used for monitoring the pulse and heart. He studied medicine in Paris and became a member of the Academy of Medicine and the Academy of Sciences, of which he was made president in 1895. He held the chair of "Natural History of Organized Bodies" at the College de France from 1868 and published more than 150 scientific papers. For many years he was president of the French Photographic Society.

He invented the odograph, similar to the odometer; the chronograph, an instrument for measuring time intervals; and "Marey's tambour", for noting subtle movements in human activity. Throughout his life he tried to simplify and standardize medical charting instruments so that they could be used without difficulty in clinical diagnostics.

But Marey's greatest achievement was his use of photography to study movement. His chronophotographs (multiple exposures on single glass plates and on strips of film that passed automatically through a camera of his own design) had an important influence on both science and the arts and helped lay the foundation of motion pictures.

1865
First measurement of intra-abdominal pressure
Braune, Germany
First measurements of intra-abdominal pressure. Braune measured IAP via the rectum.

1870 - 1900
Further developments in the understanding of intra-abdominal pressure

  • Paul Bert (1870) published a volume on “Physiologie comparée de la respiration.” Based on experiments in anesthetized animals, measuring thoracic and abdominal pressures through tubes inserted in the trachea and rectum, respectively, Bert described elevation of IAP on inspiration and the descent of the diaphragm.
  • Schroeder of Germany (1886) noted the slightly increased IAP in pregnancy, hypothesizing that there must be some adaptation of abdominal wall tension to the increasing size of the uterus.
  • Schatz of Germany (1872) used balloon tube connected to a mercury manometer to measure pressures within the gravid uterus. According to him IAP is positive and during pregnancy IAP rises slightly, though not in proportion to the increase in the size of the uterus, until the last month, when usually the abdominal muscles are stretched beyond their ability to respond, and there is then a fall of pressure below normal. He also noted that the pressure in the inferior vena cava must be at least as high as IAP to avoid obliteration of its lumen, and that a moderately positive IAP—increased in the erect position-- assists the return of blood flow, and the flow of chyle from the abdominal viscera.
  • Wendt of Germany (1873) measured IAP through the rectum, noting that the higher the abdominal pressure the less the secretion of urine.
  • Oderbrecht of Germany (1875) measured pressures within the urinary bladder, concluding that IAP is normally positive.
  • Wegner of Germany (1877) noted that the normal positive IAP aids absorption of fluids from the peritoneal surface.
  • Quinke of Germany (1878) noted in patients with ascites the obstructive effects of high IAP on venous return from abdominal viscera.
  • Mosso and Pellacani of Italy (1882) measured positive IAP through the urinary bladder.
  • Senator of France (1883) noted that IAP is much diminished by weakness of the abdominal walls.
  • Heinricius of Germany (1890) found that IAP’s between 27 to 46 cm. water were fatal to animals owing to prevention of respiration, decreasing cardiac diastolic distention and a low blood pressure. He also contended that rapid abdominal distention at low pressure is of much harm while gradually established high pressure may be well tolerated.

1911
Haven Emerson publishes his treatise - 'intra-abdominal pressures'
Emerson conducted numerous experiments in dogs showing what was to be re-discovered again and again: that contraction of the diaphragm is the chief factor in the rise of IAP during inspiration; that anesthesia and muscle paralysis – with loss of muscle tone - decreases the IAP; that elevated IAP increases peripheral vascular resistance; that excessive IAP can cause death from cardiac failure even before terminal asphyxia develops: 'Pressure as high as 45 cm. Aq. Will kill a small animal'.

Emerson understood that elevated IAP decreases blood pressure because of diminish venous return to the heart as well as depressed cardiac contractility. He then provided amazingly relevant clinical correlation, which subsequently has been totally ignored by many generations of surgeons:

'…(in) excessive IAP, the difficulty in breathing is even more marked, and this often plays an
important role in the circulatory emergencies in infectious disease, where meteorism,
abdominal distention and interference with the descent of the diaphragm may determine cardiac failure.'

Emerson understood that the cardiovascular collapse associated with 'distention of the abdomen with gas or fluid, as in typhoid fever, ascites, or peritonitis' are caused by 'overloading the resistance in the splanchnic area' and that 'relief of the laboring heart is constantly seen after removal of ascitic fluid.'

Emerson H. Intra-abdominal pressures. Arch Intern Med 1911;7:754-784

Haven Emerson (1874-1957), physician and public health official, was educated at Harvard (1896) and received his M.D. in 1899 from the College of Physicians & Surgeons of Columbia University (P&S); he received an honorary doctorate from Columbia in 1954. Emerson was an associate in physiology and medicine at P&S, 1902-14, and was the first Director of Columbia's DeLamar Institute of Public Health (1922-1940), now the Mailman School of Public Health. He held numerous public health positions including Deputy Commissioner (1914-1916) and Commissioner (1916-1918) of the Department of Health of the City of New York, and served as a member of the city's Board of Health from 1938 until his death.

Emerson served in the U.S. Army Medical Corps 1918-19. Afterwards, he directed several health and hospital surveys including those in Cleveland, 1919-1920; Athens, Greece, 1921-1931; and New York City, 1935-1937. He also served as a member of the Community Expert Statisticians of the Health Section of the League of Nations, 1920-1940.

He is credited with helping to found the Hospital Council of Greater New York in 1938, was a member of numerous professional associations and societies, the recipient of various medals and awards, and was a prolific author and editor. He married Grace Parrish in 1901 with whom he had five children. He died at Greenport, NY on May 21, 1957.

1923
Thorington and Schmidt studied urinary output and blood pressure changes in experimental ascites.

Thorington JM, Schmidt CF. A study of urinary output and blood-pressure changes resulting in experimental ascites. Am J Med Sci 1923;165:880-90

1939
Bellis and Wangensteen demonstrated changes in venous flow in the abdomen and extremities associated with abdominal distention.

Bellis CJ, Wangensteen OH. Venous circulatory changes in the abdomen and lower extremities attending abdominal distention. Proc Soc Exp Biol Med 1939;4:490-498

1940
Ogilvie describes first Laparostomy
Ogilvie, in a paper to the Lancet, describes a 'dodge that has twice helped me out' in order to avoid closing a 'burst abdomen' under tension. He describes the use of Vaseline impregnated canvas or cotton cloth sutured to the wound edges in order to cover abdominal contents. After this he enhanced epithelialization with 'pinch grafts ... liberally sprinkled' on the granulating wound surface. He recommended a waiting period of several months to allow for wound contracture before any attempt at repair of the resultant ventral hernia.

Ogilvie WH. The late complications of abdominal war wounds. Lancet 1940;2:253-256

1947
Bradely and Bradely showed decreased glomerular filtration rate and renal plasma flow with increased IAP.

Bradely SE, Bradely GP. The effect of increased intra-abdominal pressure on renal function in man. J Clin Invest 1947;26:1010-1015

1948
First description of 'Staged Abdominal Repair'
Gross introduced the so-called “staged abdominal repair” in the management of omphalocele, thus acknowledging the importance of avoiding abdominal closure under excessive tension.

Gross RE. A new method for surgical treatment of large omphaloceles. Surgery 1948;24:277-292

1951
M. G. Baggot descibes 'Abdominal Blow-Out'
M.G Baggot, an anesthesist from Dublin (currently retired in Granite City, Illinois) who really saw the light. He suggested that forcing distended bowel back into the abdominal cavity of limited size might kill the patient.

He had conceived that the factor leading to the high mortality rate associated with abdominal wound dehiscence is not the dehiscence itself but the emergency procedure to correct it --that produces high IAP. He termed such abdominal dehiscence “abdominal blow-out” and concluded that the ensuing death is due to respiratory dysfunction.

Baggot also coined the term “acute tension pneumoperitoneum” believing that excessive free air trapped in the abdomen during its closure increases IAP. Significantly, he recommended avoiding abdominal closure under tension, leaving instead such abdomens open, using a technique described over a decade earlier by the great British surgeon Sir Heneage Ogilvie.

Baggot MG. Abdominal blow-out: a concept. Current Research Anesthesia Analgesia 1951;30:295-8

1960
Gordon provides supporting evidence to the clinical significance of elevated IAP was provided in studies in patients with ascites, the amount of which correlated with cardiorespiratory morbidity –the later reversed by paracentesis. Several later papers support this work.

Gordon ME. The acute effects of abdominal paracentesis in Laennec’s cirrhosis upon changes of electrolytes and eater, renal function and hemodynamics. Am J Gastroenterol 1960;33:15-37
Suazzi M, Polese A, Magrini F, et al. Negative influence of ascites in the cardiac function of cirrhotic patients, Am J Med 1975;59:165-170
Cruikshank DP, Buschsbalm HJ. Effects of rapid paracentesis, cardiovascular dynamics and body fluid composition. JAMA 1973;225:1361-1362
Knauer CM, Love HM. Hemodynamics in cirrhotic patient during paracentesis. N Engl J Med 1967;276:491-496

1969
A growing number of papers supporting leaving the abdomen open in newborns with omphalocele and gastroschisis.

Ravitch MM. Omphalocle: secondary repair with the aid of pneumoperitoneum. Arch Surg 1969;99:166-170
Allen RG, Wrenn EL, Jr. Silo as a sac in the treatment of omphalocele and gastroschisis. J Ped Surg 1969;4:3-8

1970
Sönderberg and Westin correlated IAP directly measured during laparoscopy, to that measured through the urinary bladder.

Sönderberg G, Westin B. Transmission of rapid pressure increase from the peritoneal cavity to the bladder. Scan J Urol Nephrol 1970;4:155-165

1972
Shenansky and Gillenwater showed how increased IAP generated by applying abdominal counterpressure (i.e. the MAST suit) depresses cardiac and renal function.

Shenansky JH, Gillenwater JY. The renal hemodynamic and functional effects of external counterpressure. Surg Gynecol Obstet 1972;134:253-258

1973
Early experience with laparoscopy led to recognition of the adverse effects of pneumoperitroneum-associated increase in IAP: Ivankovich et at described cardiovascular collapse during gynecological laparoscopy and studied the physiology of the phenomenon.

Ivankovich AS, Albrecht RF, Zahed B et al. Cardiovascular collapse during gynecological laparoscopy. Ill Med J 1974;145:58-61
Motev M, Ivankovich AD, Bieniarz J et al. Cardiovascular effects and acid base and blood gas changes during laparoscopy. Amer J Obstet Gynecol 1973;116:1002-1012

1976
Lenz et al, studying cardiovascular changes during laparoscopy, pointed out the dangers of pneumoperitoneum in patients with cardiovascular dysfunction, anemia or hypovolemia.

Richardson and Trinkle studied hemodynamic and respiratory alterations with increased intra-abdominal pressure.

Lenz RJ, Thomas TA, Wilkins DG. Cardiovascular changes during laparoscopy. Anaesthesia 1976;31:4-12
Richardson JD, Trinkle JK. Hemodynamic and respiratory alterations with increased intra-abdominal pressure. J Surg Res 1976;20:401-404

1981
Kashtan et al rediscovered the hemodynamic effects of increased IAP

Kashtan J, Green JF, Parson EQ et al. hemodynamic effects of increased abdominal pressure. J Surg Res 1981;30:249-255

1982
Harman et al as well as Richards et al (1983) demonstrated how elevated IAP adversely affects renal function and how abdominal decompression improves it, and Le Roith et al studied the effects of increased IAP on plasma antidiuretic hormone levels.

Harman PK, Kron IL, McLachan DH et al. Elevated intra-abdomial pressure and renal function. Ann Surg 1982;196:594-597
Richards WO, Scovill W, Shin B et al. Acute renal failire associated with increased intra-abdominal pressure. Ann Surg 1983;197:183-187
Le Roith D, Bark H, Nyska M et al. The effect of abdominal pressure on plasma antidiuretic hormone levels. J Surg Res 1982;32:65-69

1984
First description of the Abdominal Compartment Syndrome* (actual term not mentioned)
Kron, Harman and Nolan (1984) which is considered by many as a “benchmark” in the clinical perception of intra-abdominal hypertension. In this combined clinical and experimental study the authors showed that IAP could be used as a criterion for life-saving abdominal re-exploration and decompression.

*Interestingly, many claim that the term Abdominal Compartment Syndrome (ACS) was first used by Kron et al. However, I could not find such term used within their paper. This reflects the dangers of citing from secondary sources rather than reading the primary, original ones.

Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressures a criterion for abdominal re-exploration. Ann Surg 1984;199:28-30

1985
Smith et al reported reversal of postoperative anuria by decompressive laparotomy, Barnes et al (1985) studied cardiovascular responses to elevated IAP.

Smith JH, Merrell RC, Raffin TA. Reversal of postoperative anuria by decompressive celiotomy. Arch Intern Med. 1985;145:553-4.
Barnes GE, Laine GA, Giam PY et al. Cardiovascular responses to elevation of intra-abdominal hydrostatic pressure. Am J Physiol. 1985;248:R208-13.

1987
Caldwell and Ricotta measured changes in visceral blood flow.

Caldwell CB, Ricotta JJ. Changes in visceral blood flow with elevated intraabdominal pressure. J Surg Res. 1987;43:14-20.

1988
Jacques and Leereported improvement in renal function after relief of raised IAP due to retroperitoneal hematoma

Jacques T, Lee R. Improvement of renal function after relief of raised intra-abdominal pressure due to traumatic retroperitoneal haematoma. Anaesth Intensive Care. 1988;16:478-82.

1989
Cullen et al reported on surgical decompression of the abdomen in critically ill patients to reverse cardiovascular, renal and respiratory compromise. Around the same time people started measuring IAP through the urinary catheter in their intensive care units re-inventing a method reported by Oderbrecht more than 100 years earlier.

Cullen DJ, Coyle JP, Teplick R, Long MC. Cardiovascular, pulmonary, and renal effects of massively increased intra-abdominal pressure in critically ill patients. Crit Care Med. 1989;17:118-21
Iberti TJ, Lieber CE, Benjamin E. Determination of intra-abdominal pressure using a transurethral bladder catheter: clinical validation of the technique. Anesthesiology. 1989;70:47-50.

1989
First use of the term 'Abdominal Compartment Syndrome'
in 1989 the term abdominal compartment syndrome wad finally coined. It may well be that different people begun to use such term before but the first publication mentioning it was that by Fietsam et al from the William Beaumont Hospital, Royal Oak, Michigan. 35 The authors wrote:

“In four patients with ruptured abdominal aortic aneurysms increased intra-abdominal pressure developed after repair. It was manifested by increased ventilatory pressure, increased central venous pressure, and decreased urinary output associated with massive abdominal distension not due to bleeding. This set of findings constitutes an intra-abdominal compartment syndrome caused by massive interstitial and retroperitoneal swelling

…four patients received more than 25 liters of fluid resuscitation (electrolyte and blood) during and within 16 hours after operation and had massive abdominal distension. Decompressive laparotomies were performed in the Intensive Care…Opening the abdominal incision was associated with dramatic improvements in central venous pressure, urinary output, ventilatory pressure, arterial carbon dioxide tension, and oxygenation.”

Fietsam R Jr, Villalba M, Glover JL, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. Am Surg. 1989;55:396-402

Author's Note:
Thus, by the end of the 1980’s people new how to measure IAP, what damage elevated IAP can produce and how to treat it. They also defined the clinical syndrome and named it. But commonly people look at truth but refuse to acknowledge it and so it took a few more years for the concept to penetrate our surgical minds.

1995-1997
Abdominal compartments syndrome comes of age
Two “collective reviews” of ACS appeared in 1995 and 1996 - opening the gate to numerous publications, recognizing IAHT/ACS in a large number of surgical-- abdominal and extra-abdominal, traumatic and non-traumatic scenarios—and providing an ever growing list of complications and consequences.

Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: the physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg. 1995;180:745-53
Burch JM, Moore EE, Moore FA, Franciose R. The abdominal compartment syndrome. Surg Clin North Am. 1996;76:833-42.