? Open abdomen techniques overused ? (Cross Posted)

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Ken,

Glad to see that I have good company in house!  

As to your questions:
1.    Are we all applying damage control, open abdomen  techniques, etc. too 
often?
    I think that we are.  I suspect that many may be using the technique to simplify their efforts to leave the OR in the face of a difficult closure.  In those cases, the only reason to leave an abdomen open would be if the peak pressures were too elevated after closure (or when attempting a closure) to allow for adequate ventilation.
    The only absolute need in the acute setting, as I see it, is in a trauma patient that is cold, coagulopathic, hypotensive, and who needs to be packed and moved to the ICU for resuscitation after all SURGICAL bleeding has been corrected.  The other acute need for an open abdomen is, of course, abdominal compartment syndrome (ACS) - NOT intra-andominal hypertention (IAH) - where the elevated intra-abdominal pressure is associated with decreasing cardiac output, decreasing renal function and increasing difficulty in ventilation.
2.    Are we increasing the number of enteric fistulas,  use of expensive 
secondary closure meshes and devices far too often?  
    YES.  I have been blessed with only one fistula, and that was when I used a vicryl mesh acutely.  Big mistake.  
    I have taken to using a "sandwich" using ioban sheets with a blue towel sandwiched between them.  I "piecrust" each side of the sandwich, and leave a large 360 degree flap that I will lay inside the abdominal cavity on top of the bowel, extending as far laterally superiorly and inferiorly as I can.  I lay a kerlex on the surface of the closure and 2 blake drains on top of that, then lay another ioban to seal the entire closure.  Allows for suctioning of abdominal edema, an easy removal, and replacement as needed.  And it is cheap!  Once I have gotten to the point that I think I can close the abdomen, I will close as much as possible, replace the sandwich, and come back again and again till closed - usually done over 4-5 days.
3.    Is there a need to return to a swinging back of a  pendulum?
    YES

Hope the day is quiet.  We have, unfortunately, had a very busy and lethal weekend here....

Best wishes,

Ron

PS - JoAnn sends her regards!


>>> <KMATTOX at aol.com> 9/15/2007 1:17 PM >>>
I find myself being reflective today while between cases while on in-house  
trauma call.    We just finished a take back on a patient with an  open 
abdomen, needing a washout, and assessment for continued  therapy.   We found what 
everyone is reporting, an enteric  fistula.  We all have seen enteric fistulas 
following trauma for a  long time, and I do not know if the incidence in the 
open abdomen cases is any  less or greater than prior to temporary closure 
methods.  
 
More than 12 temporary closure options now exist, and each has its  champion. 
   We are increasingly training  surgeons who are more comfortable with 
laparoscopic technology, and when  faced with even a relatively straight forward 
open trauma case, are applying  damage control.   Now my questions.
 
1.    Are we all applying damage control, open abdomen  techniques, etc. too 
often?
2.    Are we increasing the number of enteric fistulas,  use of expensive 
secondary closure meshes and devices far too often?
3.    Is there a need to return to a swinging back of a  pendulum?
 
K Mattox



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