W. M. Brigode1, M. Masteller3, K. Ansah4, J. Bean2, R. Sullivan2, A. Vafa2 1University of California – San Francisco – East Bay,Department Of Surgery,Oakland, CA, USA 2University of Illinois at Chicago – Mount Sinai Hospital,Division Of Trauma And Critical Care Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Trauma And Critical Care,Chicago, IL, USA 4Ross University School of Medicine,Miramar, FLORIDA, USA
Introduction: The development of damage control laparotomy has been advanced in the past several decades by the use of the Bogota Bag, Barker Pack, and Negative Pressure Wound Therapy. A skin-only sutured closure with fascia left in discontinuity has not been widely reported in the modern literature. Older sources cite wound complications and abdominal compartment syndrome as potential pitfalls of the technique. We hypothesized that in closely monitored patients by surgeons familiar with the technique, the use of this closure technique would improve fascial closure rate without an accompanying change in mortality or wound complications.
Methods: We performed a retrospective review of consecutive patients managed with an open abdomen after trauma laparotomy at a busy, urban, level I trauma center, over a seven year period from October 15, 2011 to June 15, 2018. Patients undergoing laparotomy for non-traumatic indications were excluded. Primary outcomes were mortality and fascial closure at the index admission. Secondary outcomes included enteral fistula development, fascial dehiscence, and skin dehiscence.
Results: During the study period, 76 patients underwent open abdominal treatment, 55 of which underwent a total of 67 skin-only closures. Use of a skin closure at the index operation was associated with an increased fascial closure rate (62% vs 30%, 88% vs 50% in survivors, p<0.05 for both) without a change in mortality (p>0.05). The measured secondary outcomes were rare and statistically similar (p>0.05). While its use at the index operation was beneficial, the use of skin closure overall was safe (p>0.05 for all complications) but was not associated with an increase in fascial closure (p>0.05). This is likely secondary to selection bias of survivors needing salvage skin closure with a planned ventral hernia.
Conclusion: Skin-only sutured abdominal closure is a viable alternative to more commonly used open abdominal management techniques. When faced with a damage control situation in a patient’s index operation, it can increase a patient’s chances at fascial closure in the index admission without an increase in mortality or wound complications. The intrinsic apposition of the muscular abdominal wall to the skin and subcutaneous tissues may prevent loss of abdominal wall domain, while allowing for the temporary increase in the abdominal visceral volume associated with trauma resuscitation. When used after index laparotomy it remains safe, but the benefit on fascial closure rate is lost. Further research should be done to elucidate the role of this forgotten technique in the trauma surgeon’s toolbox.