m ABDOMINAL COMPARTMENT

SYNDROME
m LAPAROSTOMY

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{ Normal intra-abdominal pressure is around 5 mm
Hg (range, 0.2-16.2 mm Hg).
{ Increased intra-abdominal pressure greater than
12 mm Hg associated with rising peak airway
pressure, hypoxia, difficult ventilation and oliguria
or anuria that improve on decompression
{ Most commonly encountered in the multiple
trauma and ICU setting.
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Ileus as a result of bowel edema and contamination,
Coagulopathy,
Packing used to control bleeding,
Capillary leak, and
Massive fluid resuscitation and transfusion.
In the nontrauma setting,
Ascites,
Retroperitoneal hemorrhage,
Pancreatitis after reduction of chronic hernias that have
lost their domain,
Repair of ruptured abdominal aortic aneurysms,
Complex abdominal procedures, and liver
transplantation
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Difficulty breathing and exhibit elevated peak
airway pressure, hypoxia, worsening
hypercapnia, and deteriorating compliance
Abdomen becomes distended and tense, cardiac
output is reduced
Neurologic deterioration may occur.
Central venous, pulmonary capillary wedge, and
peak airway pressure become elevated and
acidosis develops.
Anuria, exacerbation of pulmonary failure,
cardiac decompensation, and ultimately leads to
death.
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{ Urinary bladder catheter is the gold standard

indirect method used to measure intra-abdominal
pressure;
{ A regular Foley catheter, a three-way Foley
catheter with saline injected into one port and
pressure measured through the other, or
{ A regular Foley catheter serially connected to a
three-way stopcock and a transducer can be used
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I 10-14 

II 15-24 !"

III 25-35 "

IV >35  !
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Laparostomy
{ P. Fagniez of Paris has coined the term
Dzlaparostomydz which implies leaving the abdomen
open
{ Goal - peritoneal cavity could be treated like an
abscess cavity
{ An adjunct to the policy of repeated laparotomies;
indeed, if the abdomen is to be re-looked 48 hours
later
{ Allows viscera to expand and prevent abdominal
hypertension
{ Allows the patient to return to the critical care
setting for further resuscitation and restoration of
physiologic reserve, tissue perfusion,
normothermia, correction of acid base balance,
and normalization of coagulation
{ Allows the trauma team to further assess the
patient and to define other potential life- or limb-
threatening injuries
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After major loss of abdominal wall tissue following
trauma or debridement for necrotizing fasciitis
Extreme visceral or retroperitoneal swelling after
major trauma,resuscitation, or major surgery
Poor condition of fascia after multiple laparotomies
Uncertain viability of remaining bowel
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Planned re-operation within a day or two Ȃ why
lock the gate through which you are to re-enter very
soon?
Closure possible only under extreme tension Ȃ
compromising the fascia and creating intra-
abdominal hypertension (IAHT)
{ Advantages
Addition to damage control, it facilitates
frequent re-explorations.
Obviating the deleterious local and systemic
consequences of the abdominal compartment
syndrome obviating the deleterious local and
systemic consequences
     
 


 
{ Towel Clipping the Skin Edges
{ Open Packing of the Abdomen
{ Zipper Closures
{ Wittmann Patch
{ Synthetic Mesh Closure
Polytetrafluoroethylene Closure
Marlex Mesh (Polypropylene)
Absorbable Mesh
Silastic (Plastic) Closures
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{ Simplest and fastest forms of temporary closure
{ Towel clips are placed 1 cm apart and 1 cm
away from each side of the skin edge.
{ The incision may then be covered with an
adherent plastic drape (eg, Vi-Drape, Steri-
Drape)
{ Used in the rapid temporary closure of thoracic
or groin incisions in patients with trauma
injuries who are in unstable condition and in
patients undergoing general surgery
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{ The abdominal wall defect and the exposed
viscera are covered with rayon cloth
{ Rayon cloth is then covered with gauze
dressing.
{ Widely spaced, retention-type sutures are
placed, encompassing all layers of the
abdominal wall, and tied above the gauze
packing
{ As bowel edema diminishes, the gauze dressing
is removed and the retention sutures are
gradually tightened until the incision can be
closed.
{ "")
Zipper closures were popularized by Stone et al
in their open abdomen approach for pancreatic
abscess.
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{ Tension closure is accomplished by the adherence
of the overlapping Velcro-like sheets.
{ As bowel edema resolves, the excess Velcro-
biocompatible patch material is removed and the
fascial edges are approximated.
{ Major advantage of this approach is the
{ Ease of access for repeated surgical
interventions
{ Capacity to apply tension to the midline fascia,
which helps prevent lateral retraction of the
aponeurotic edges, allowing for definitive
delayed primary closure in most case
{ Reduces need for hernia repair
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{ Polytetrafluoroethylene (PTFE) 2-mm
biocompatible prosthetic abdominal wall graft
is strong and watertight and creates a bed for
granulation tissue, which may be covered with a
split-thickness skin graft when the prosthesis is
removed.
{ PTFE is expensive, and similar outcomes may be
achieved with less costly absorbable mesh or
silastic (silo) dressing changes
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{ Reported the use of marlex mesh in the setting
of a contaminated wound (eg, fasciitis, intra-
abdominal sepsis).
{ Short-term successes have occurred, numerous
long-term complications have been reported
with marlex mesh
{ Complications include increased incidence of
postoperative wound sepsis, increased
incidence of enteric fistulas, and significant
decreased survivability of split-thickness skin
grafts
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{ Used extensively in TACs
{ Polyglactin (Vicryl) and polyglycolic acid
(Dexon)
{ Has been used in the repair of traumatic liver,
splenic, and renal injuries and in pelvic floor
repair in the setting of abdominal peroneal
resection of the rectum.
{ Although early burst strength (at 8 wk) is
comparable to that of permanent mesh, as the
mesh is absorbed (at 10-12 wk), hernias
inevitably develop in most patients
{ Mesh is applied loosely over the abdominal
contents and then covered with fine mesh gauze
packing, maintaining the bowel below the
absorbable mesh and within the abdominal
contents
{ This may decrease bowel wall distention,
thinning, and subsequent desiccation, which
may decrease the incidence of enterocutaneous
fistula
{ Choice of material on surgeons, use of Dexon
mesh-may allow for more efficient drainage of
intra-abdominal fluid and, thus, may decrease
potential delayed complications (eg, abdominal
distention, ileus, abscess)
{  )
{ A presterilized (gas), soft 3-L plastic cystoscopy
fluid irrigation bag is cut and shaped to cover
the abdominal incision and extruded viscera
{ This bag is either stapled or sutured to the skin
edges of the wound with a standard (wide) skin
stapling device or monofilament,
nonabsorbable suture, thus preserving the
fascia
{ Sterile, antibiotic-soaked towels (using Kantrex)
may be applied over the silo, which is then
covered with an iodine-impregnated adhesive
plastic drape.
The wound is inspected and the dressing is
changed every 24 hours (or as needed).
Intravenous (IV)/cystoscopy bag silos may be
replaced in the ICU setting using standard
sterile surgical technique and equipment.
IV bag closure (also known as the Bogotá Bag)
has been used extensively and successfully.
Fast and effective temporary closure modes and
have some significant cost benefits
Mogotá Mag closure
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{ Whichever TAC device you use, try to place it over
the omentum Ȃ if available
{ Suture the TAC device to the fascial edges. Just
placing it Dzon topdz will result in huge abdominal
wall defects because the midline-wound fascial
edges tend to retract laterally, The larger the
defect the more problematic its eventual
reconstruction
{ Using a permeable TAC device (e.g., mesh) as
opposed to a non-permeable (e.g.Bogota bag) has
the advantage of allowing the egress of infected
intraperitoneal fluids.
{ Try to adjust the tension of the TAC device to the
intra-abdominal pressure
{ If you plan another re-operation within a day or
two the type of TAC device you use is of little
importance: you can always replace it at the end of
the next laparotomy. The selection of TAC device
when no more re-operations are deemed
necessary is crucial;
{ Abdominal re-entry through the TAC device is
simple: divide it at its centre; with your finger
gently separate the omentum and viscera from the
overlying TAC devise.At the end of the procedure
re-suture the TAC device with a running suture.