Investing abdominal fascia after surgery

Results: There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy. Conclusion: The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient.

For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place. The management of catastrophic abdominal injuries has been described in past military conflicts. One of the initial references of the use of open abdomen technique was by Ogilvie[ 1 ] in during World War II. A double sheet of this is cut rather smaller than the defect in the muscles, and sutured into place with interrupted catgut sutures.

This device is obviously temporary, but it prevents retraction of the edges of the gap, it keeps the intestinal contents from protruding during the early days when they are so difficult to retain, and it allows the abdominal wall to be used as a whole in respiration. Stone and Lamb,[ 2 ] Stone et al. In addition, the use of the open abdomen OA technique has been used in the management of emergency general surgery, vascular surgery, intra-abdominal sepsis, and acute pancreatitis.

Abdominal compartment syndrome ACS after ruptured abdominal aortic aneurysm rAAA or trauma has become one of the key life-saving indications for decompressive laparotomy and open abdomen technique. During the course of the past 30 years, several authors have contributed their clinical experience to the literature in an effort to define the clinical indications and to describe the various management strategies for the appropriate use of the open abdomen technique.

There has remained a great degree of heterogeneity in the patient populations, and the surgical techniques described. The OA approach is used in both military and civilian trauma, vascular emergencies, and emergency general surgery. Given the lack of consensus, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee convened a study group to establish the recommendations for the use of OA techniques in both trauma and nontrauma surgery and to provide guidelines regarding the following specific topics: Indications for OA technique in ACS, DC, general surgery, and vascular surgery.

Surgical technique for temporary abdominal closure TAC. Surgical technique for repeat laparotomy and staged abdominal reconstruction STAR. Nutritional aspects of open abdomen technique. The citations in English were identified during the period of through using the primary search strategies outlined.

Given the complexity of this literature, several strategies were necessary to appropriately capture the breadth of evidence on the topic. The search excluded case reports, reviews, letters or commentary, editorials, and articles focusing only on pediatric participants. The PubMed-related articles algorithm was also used to identify the additional articles similar to the items retrieved by the primary strategy, in addition to hand searching of the reference lists of key articles retrieved by the searches.

Of approximately 1, articles identified by these two techniques, only prospective or retrospective studies examining open abdominal management were selected, consisting of institutional studies evaluating open abdomen management strategies in the adult surgical or critical care population. Ninety-five articles pertained to the topics studied and were used to develop the recommendations. The articles were reviewed by a group of 18 surgeons who collaborated to produce this practice management guideline.

The chair, vice chair, and a committee member J. They were then distributed to all members of the study group for critical review. Each committee member has to answer the following four questions of each article reviewed: What is the class of evidence in the article? Are the results of the article valid based on the data presented? What is your conclusion based on the evidence the article provided?

Does the article supports the class of evidence? The correlation between the evidence and the level of recommendations is as follows: Level I This recommendation is convincingly justifiable based on the available scientific information alone. It is usually based on class I data; however, strong class II evidence may form the basis for a level I recommendation, especially if the issue does not lend itself to testing in a randomized format.

Conversely, weak or contradictory class I data may not be able to support a level I recommendation. Level II This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level III This recommendation is supported by available data but adequate scientific evidence is lacking. It is generally supported by class III data.

This type of recommendation is useful for educational purposes and in guiding future studies. Table 2. Figure 1. The management of the open abdomen in trauma, emergency general, and vascular surgery flow diagram. OA, open abdomen; PIP, peak inspiratory pressure. Damage Control There are no level I recommendations for DC in trauma, emergency general surgery, or vascular emergencies. In the cases of severe abdominal trauma because of penetrating or blunt injury involving hepatic, nonhepatic, or vascular injuries with intra-abdominal packing, the use of the OA technique should be considered, and an early decision to truncate a definitive operation should be made as soon as possible level II.

Source control remains the major predictor of outcome level II. The DC and open abdomen technique may be considered in the management of severe necrotizing pancreatitis level III. Temporary Abdominal Closure There are no level I recommendations for TAC in trauma, emergency general surgery, or vascular emergencies.

Any TAC technique must provide for easy re-exploration, a high rate of definitive closure, and be cost effective level II. All allow ready access for relaparotomy procedures and provide tension-free closure contributing to the prevention of IAH level II.

Permanent mesh i. The 3-layer VP protective barrier against the viscera, surgical towel, drains, and occlusive adhesive drape is considered the current standard by which to measure other devices level III. Primary closure of the abdominal wall should be performed when possible. On-demand laparotomy is associated with a reduction in relaparotomies and negative laparotomies that may reduce healthcare utilization and medical costs level II.

Planned and on-demand relaparotomy can be considered in both abdominal sepsis and necrotizing pancreatitis. When primary closures can be achieved, on-demand relaparotomy has been associated with decreased mortality level III. The trends in clinical parameters are predictive of ongoing sepsis or inflammation and failed source control.

STAR is indicated or should be considered when there is an inability to eliminate or adequately control the source of infection, incomplete debridement of necrotic tissue, excessive visceral edema, questionable bowel viability, or critical patient condition precluding definitive repair level III. STAR of intra-abdominal injuries should take place after physiologic normalization, i.

After STAR, delaying primary fascial closure should be considered in light of intra-abdominal findings i. STAR should be considered after bowel injury with massive fecal contamination or hemorrhagic or septic shock. Staging the gastrointestinal GI reconstruction when the patient is hemodynamically stable allows for possible primary bowel anastomosis to be performed with decreased reliance on creating an obligate ostomy level III.

Nutrition Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen level II. Enteral access and feeding of the patient with an open abdomen with an intact GI tract should be instituted as early as possible, as this may improve the rate of early primary bowel wall closure, fistula formation, and hospital charges level III.

Scientific Foundation Indications Table 3. Indications for the Use of the Open Abdomen Technique in Trauma and Emergency General Surgery continued Forty-two articles were reviewed with multiple, worldwide indications for the management of the open abdomen Table 3. More than 1, patients were included.

The evidence identified is either observational or retrospective in nature, spanning more than 20 years of experience, and as such, it is difficult to link clinical action with event outcome. However, the management of the open abdomen in trauma, transplant, emergency general surgery, and vascular surgery has found a role, and that role seems to be expanding. Indications have included ACS in its various forms; DC surgery; trauma to include hepatic, severe nonhepatic, and penetrating abdominal trauma, necrotizing pancreatitis, intra-abdominal sepsis, emergent vascular surgery, and recently, orthotropic liver transplantations.

ACS is not necessarily an end-stage process, but a continuum of disease, which might be amendable to medical management at an earlier stage. Medical therapies should be instituted at this point: positioning, negative fluid balance, and drainage of intra-abdominal fluid collections. Other measures that have been mentioned and that have yet to be studied include neuromuscular blockade, increase sedation, diuresis, evacuation of intraluminal contents, and hemodialysis or hemofiltration in the attempt to decrease IAH.

Raeburn et al. Studies attempting to identify the risk factors for ACS suggest that shock, mechanical ventilation, and aggressive fluid resuscitation are common. Recurrent ACS occurs after DC in a patient with an open abdomen with either ongoing hemorrhage or massive volume resuscitation. IAH developed in Classic triggers for DC surgery, which have been described in three phases, have been described and may include acidosis with a pH of 7. The design looked more at packing as a technique, but did some analysis of management of the abdominal wall.

Also noted were better peak airway pressures in mesh patients, although these findings were not statistically significant. Protocols to pursue DC should take into account the development of acidosis, hypothermia, and massive transfusion or resuscitation. Groups were compared in a sequential time study before and after protocol. Although mortality was similar between these two groups, the postprotocol group was found to have decreased operative time, transfusions, length of stay, blood loss, infectious complications, and visceral edema.

Surgical approaches included using the OA technique, laparotomy with continuous postoperative lavage, minimally invasive procedures, and laparotomy with primary abdominal closure. The authors concluded that the OA strategy in this patient population should be considered obsolete. The majority of the literature has described an OA technique with serial laparotomies for patients with necrotizing pancreatitis as safe and effective at decreasing intra-abdominal postoperative infectious complications.

On average, six operations were required to control infection. Four different techniques of abdominal closure were used. Certain clinical parameters may suggest which patients have ongoing evidence of sepsis or inflammation after closure of the abdominal wall after planned repeat laparotomy for peritonitis.

In conclusion, the decision to close the abdomen may not only be based on intraperitoneal findings but also based on the existence and level of organ failure. Late mortality because of MOF may also be reduced with delayed abdominal closure. Greater intraoperative blood loss, longer cross clamp times, and longer operative time were risk factors for IAH, which often resulted in colonic ischemia. Earlier decompression and treatment of colonic ischemia may improve mortality.

OA management proved extremely useful for monitoring blood flow to the anastomotic site and for allowing complete drainage into the abdominal space. Using this method would assist in leaving as much remnant bowel as possible after resection for superior mesenteric artery occlusion. These methods of closure have wide support in the literature and are considered safe. All allow ready access for relaparotomy procedures and provide a tension-free closure, obviating IAH.

A mesh zipper was reported as one of the earliest methods of TAC[ 49 ] in the s. The sterilized zipper was sewn directly to the abdominal fascia. Repeat operations could be performed by removing the outer dressings and unzipping the fascia. Burch et al. At the time, DC procedures were considered highly unorthodox. This series reported a good survival rate for a critically ill group of surgical patients. The complications included skin necrosis, fascial dehiscence, and fascial necrosis.

Recognition of the negative effects of forced fascial closure and IAH caused gradual abandonment of the zipper closure technique and replacement with tension-free closure techniques allowing expansion of intra-abdominal contents. Likewise, towel-clip closure of the skin and running suture closure of the skin, while fast and effective, do not allow sufficient fascial expansion to avoid IAH and ACS. These techniques have largely been replaced.

Ten of the 15 survivors had the mesh removed and were able to undergo primary fascial closure. The five remaining patients had the mesh removed and a split-thickness skin graft applied. No complications resulted from mesh placement. No descriptions of complications were reported. Purported benefits of PPE were its porous nature allowing the egress of fluids as well as low cost. The technique involves sewing a sterile plastic 3-L urologic irrigation bag to the fascia to form a fascial bridge.

This technique is simple and inexpensive. It has been used extensively for traumaindications[ 50 ] and for abdominal sepsis. Gortex W. Nagy et al. Ciresi[ 63 ] reported use of Gortex in patients having laparotomy for trauma and ruptured AAA. The study noted a low rate of reactivity to the Gortex, making re-exploration uncomplicated because of minimal adhesions. The subsequent closure rate was high and fistula rate was very low.

The high cost of Gortex, lack of fluid egress, and the potential fascial trauma from suturing the TAC in place have limited the use of Gortex as a TAC. There were no enterocutaneous fistulas reported and no cases of fascial necrosis with the WP when compared with zipper closure or closure with retention sutures. Aprahamian et al. Fifteen of the 16 survivors underwent primary fascial closure at subsequent operation. In one patient, the device was removed due to fascial infection requiring surgical debridement.

In a small series of patients developing ACS, WP was associated with no complications, and all survivors were able to undergo primary fascial closure. The hook-and-burr are then overlapped with limited tension to provide a secure TAC. Gauze is used to pack the subcutaneous tissue. At the completion of the subsequent operations, the patch can be tightened to keep fascial tension.

Repeated tightening of the patch allows for a gradual sequential closure of the fascia. Brock et al. A larger study with a combined population of traumaand emergent general surgical patients was reported in Barker et al. The same group reported their experience using VP with destructive bowel injuries requiring resection.

Next, a surgical towel is placed under the fascia followed by two silicone drains Jackson-Pratt Drain, Allegiance, McGaw Park, IL , which are placed on top of the towel. Paul, MN is placed over the skin laterally to the anterior axillary lines to seal the wound.

The surgical drains are connected to a Y-connector, and wall suction is applied. This dressing has gained wide acceptance because it is fast to apply, inexpensive, atraumatic and allows for excellent control of abdominal fluids. It is the current standard of care for TAC. In a series of patients, 11 9. Two of the small bowel fistulae and the gastric fistula occurred in patients who had an intestinal resection and anastomosis at their primary operation.

All these techniques are safe and allow ready access for relaparotomy. VP has the added advantage of not needing to be sutured to the fascia, saving time, and potential tissue destruction. There does not seem to be a single TAC that is superior to the others commonly in use.

It is largely a matter of surgeon preference, and without direct comparison of the commonly used techniques a single method cannot be recommended. Relaparotomy and STAR should be performed when the patient has been adequately resuscitated as demonstrated by correction of hypothermia, acidosis, and coagulopathy. However, in high risk patients, ostomy remains the most conservative approach.

It has been well tolerated with few GI complications. Several authors have suggested decreased mortality. Patients in the on-demand group had shorter median ICU stays 7 vs. On-demand relaparotomy did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, healthcare utilization, and medical costs. Nutrition Support of the Open Abdomen Early nutritional support is well described in surgical literature.

Evidence that it is safe, well tolerated, decreases hospital length of stay, and may reduce infectious complications is clear. However, the idea of early enteral nutrition in the management of the open abdomen is relatively poorly investigated Table 6. We can infer from a relatively recent study that the OA represents a significant source of protein or nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a negative effect on patient outcome.

Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen. A special note should be made of the extremely rare occurrence of nonocclusive bowel ischemia because of early and aggressive enteral feeding.

Conclusion Through its various evolutions, the techniques of OA management have demonstrated usefulness in surgery. From life-saving decompression of ACS in vascular surgery and DC to providing ready and repeated access for source control in abdominal sepsis, the last 30 years have provided a substantial body of clinical experience to guide our endeavor to decrease morbidity and mortality.

There remains a great degree of heterogeneity in the patient populations and the surgical techniques described. We hope these recommendations provide a means to guide the indications, use, and early management of open abdomenin both trauma and nontrauma surgery. References Ogilvie WH. The late complications of abdominal war-wounds. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg Gynecol Obstet. Management of the major coagulopathy with onset during laparotomy.

Layered anatomy of the anterior abdominal wall Rectus sheath: Invests the rectus abdominis muscle; craniad to the midpoint between the umbilicus and pubic symphysis, the sheath divides into an anterior and posterior lamina. The posterior lamina ends there in the shape of the arcuate line; craniad to this line, the abdominal external oblique inserts in the anterior lamina of the rectus sheath, the abdominal internal oblique in both the anterior and posterior laminae, and the transverse abdominal muscle in the posterior lamina.

Semilunar Spigelian line: Transition zone between the aponeuroses of the lateral abdominal muscles and the lateral edge of the rectus sheath. Linea alba: About 1 cm wide firm band of connective tissue between the right and left rectus sheaths, extending from the sternum to the pubic symphysis. Transversalis fascia: Craniad to the arcuate line, it covers the posterior lamina of the rectus sheath, while caudad it is in intimate contact with the rectus abdominis.

Lateral umbilical fold: Paired folds of peritoneum; on each side craniad to the inferior epigastric artery, with its two accompanying veins each. Vessels and nerves a Arteries Superior epigastric artery: Extension of the internal thoracic artery, anastomoses with the inferior epigastric artery at the level of the umbilicus. Inferior epigastric artery: Arises from the external iliac artery and courses, just like its superior counterpart, within the rectus sheath on the posterior surface of the rectus abdominis.

Superficial epigastric artery: Arises from the femoral artery and, after passing over the inguinal ligament, radiates into the subcutaneous tissue of the anterior abdominal wall. Posterior intercostal arteries VI-XI and subcostal artery: Arise from the thoracic aorta; their terminal segments course obliquely caudad between the abdominal internal oblique and transverse abdominal muscles, and coming from the lateral aspect they extend into the rectus sheath, where they join with the superior and inferior epigastric arteries.

Inferior epigastric vein: Branches into veins accompanying the inferior epigastric artery and empties into the external iliac vein. Superficial epigastric vein: Parallels the eponymous artery see above c Lymphatics Superficial lymphatics Craniad to the umbilicus, they course to the axillary lymph nodes and caudad to the inguinal lymph nodes.

Deep lymphatics Usually parallel the blood vessels, pass into the parasternal, lumbar, and external iliac lymph nodes. Iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve: Involved in motor and sensory innervation of the inferior abdominal region and genitals. Physiology of the abdominal wall Function and tension systems of the abdominal wall Due to their distance from the spine, the straight muscles of the abdominal wall can exert considerable leverage on the spine.

When bending forward, the four oblique abdominal muscles act in unison and synergistically, thereby supporting the rectus abdominis muscles. The Valsalva maneuver or abdominal press involves the synchronous contraction of the abdominal muscles, diaphragm, and pelvic diaphragm.

Since the diaphragm is much weaker than the abdominal muscles, effective Valsalva maneuver necessitates closing the glottis and retaining air in the lungs which, when filled with air, buttress the diaphragm.

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What is Fascia? Fascia is a thin casing of connective tissue that surrounds all of our body parts including our organs, muscles and even blood vessels. Fascia allows independent movement between tissue layers and makes our motions fluid and uniquely "human". Imagine many thin layers of saran wrap encasing these internal body parts and you will get a better idea of what fascia is and how it works.

These thin layers of tissue do more than provide internal structure; fascia has nerves that make it almost as sensitive as skin. Fascia can become tight and restrictive due to poor posture, scoliosis, trauma, repetitive strain, chronic inflammation and surgical scars. Fascia and Scarring After Surgery When you have surgery, there are the scars that you see on the surface of your skin and then there are underlying scars that are not visible to the eye.

This underlying scar tissue can be uncomfortable, firm, and tight and thus restrict your movement. The good new is that if you have scars from surgery or other reasons, it is never too late to improve them! You can start treating scars years after they have fully healed and still see great improvement in the way they look, their texture and movement that may have been restricted due to scar tissue.

What does this have to do with fascia? As you now know, fascia is made up of layers of connective tissue which encase our muscles, organs etc. What often happens after top surgery and other procedures is that due to a lack of massage and movement, your fascia will adhere to the underlying scar tissue which is overlying the muscle underneath.

If the muscle is restricted this will ultimately lead to painful or restricted movement. It takes your body around 6 weeks to fully heal in cases without any complications. However, I recommend that at around weeks, you start to incorporate gentle touch and massage into your daily healing regimen. This enables your nerve endings to wake up and find their way out to the skin in a normal way. The deep layer fascia of Scarpa is thinner and more membranous in character than the superficial, and contains a considerable quantity of yellow elastic fibers.

It is loosely connected by areolar tissue to the aponeurosis of the Obliquus externus abdominis, but in the middle line it is more intimately adherent to the linea alba and to the symphysis pubis, and is prolonged on to the dorsum of the penis, forming the fundiform ligament; above, it is continuous with the superficial fascia over the rest of the trunk; below and laterally, it blends with the fascia lata of the thigh a little below the inguinal ligament; medially and below, it is continued over the penis and spermatic cord to the scrotum, where it helps to form the dartos.

From the scrotum it may be traced backward into continuity with the deep layer of the superficial fascia of the perineum fascia of Colles. In the female, it is continued into the labia majora and thence to the fascia of Colles. The transversalis fascia is a thin aponeurotic membrane which lies between the inner surface of the Transversus and the extraperitoneal fat. In the inguinal region, the transversalis fascia is thick and dense in structure and is joined by fibers from the aponeurosis of the Transversus, but it becomes thin as it ascends to the diaphragm, and blends with the fascia covering the under surface of this muscle.

Behind, it is lost in the fat which covers the posterior surfaces of the kidneys. Below, it has the following attachments: posteriorly, to the whole length of the iliac crest, between the attachments of the Transversus and Iliacus; between the anterior superior iliac spine and the femoral vessels it is connected to the posterior margin of the inguinal ligament, and is there continuous with the iliac fascia.

Medial to the femoral vessels it is thin and attached to the pubis and pectineal line, behind the inguinal aponeurotic falx, with which it is united; it descends in front of the femoral vessels to form the anterior wall of the femoral sheath. Beneath the inguinal ligament it is strengthened by a band of fibrous tissue, which is only loosely connected to the ligament, and is specialized as the deep crural arch.

The spermatic cord in the male and the round ligament of the uterus in the female pass through the transversalis fascia at a spot called the abdominal inguinal ring. This opening is not visible externally, since the transversalis fascia is prolonged on these structures as the infundibuliform fascia. Between the inner surface of the general layer of the fascia which lines the interior of the abdominal and pelvic cavities, and the peritoneum, there is a considerable amount of connective tissue, termed the extraperitoneal or subperitoneal connective tissue.

The parietal portion lines the cavity in varying quantities in different situations.

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