KEY WORDS
Abdominal compartment syndrome - abdominal hypertension - bogota - burn abdomen -
component separation - goretex mesh - Intra-abdominal hypertension - mesh repair -
open abdomen - postburn - Rives-Stoppa - PTFE mesh - polytetrafluoroethylene
INTRODUCTION
Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS)
commonly occurs in major burns due to extensive fluid resuscitation, thick eschars
over the abdomen and sepsis.[[1]] To relieve the excess pressure, decompressive laparotomy is done which can lead
to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very
difficult with bowel oedema and expedient closure results in increased pressure again
and multi-organ failure. Keeping the abdomen open is fraught with fluid loss, temperature
loss, desiccation of the bowels leading to enterocutaneous fistula and loss of abdominal
domain, thus increasing the morbidity and mortality for the patient. We describe how
we managed a major burn with IAH and a combination of techniques for safe closure
of an open abdomen after the decompression of IAH.
CASE REPORT
A 20-year-old woman sustained 48% deep burns with inhalational injury while cooking.
She was resuscitated, and the all deep burns were excised and allografted on the 3rd day. She later underwent sandwich grafting on days 6, 18 and 27 post-burns. Most
of the grafts had obtained except for a few areas which healed conservatively. She
developed pain and tenderness in the right upper quadrant of her abdomen 32 days after
the burn. Contrast-enhanced computed tomography (CECT) scan showed free fluid in the
abdomen. As the pain increased, CECT scan was repeated on day 37 post-burns which
showed bowel and mesentery oedema and increased free fluid in the abdomen. Gastroscopy
and colonoscopy were not contributory. Hence, diagnostic laparoscopy was then planned.
On inserting the trocar into the abdomen, insufflation of pneumoperitoneum could not
be done, as the intra-abdominal pressure (IAP) was 22 mm Hg indicating IAH. Decompressive
laparotomy was done immediately to prevent the ACS. Laparotomy revealed bowel and
mesentery oedema and an old perforation in the stomach which was sealed by the omentum.
Colonic biopsies revealed cytomegalovirus infection of the colon. The abdomen was
temporarily closed by negative-pressure wound therapy (NPWT). Peritoneal lavage was
done twice later due to persistent necrotic tissues in the abdomen. 14 days after
laparotomy, the oedema settled and she was considered fit for closing the abdomen.
Gore-tex mesh was sutured on the fascia both sides, pulled together (PTFE - polytetrafluroethylene)
and sutured in the midline. NPWT was applied over this to approximate the wound [[Figure 1]].
Figure 1: (a) Photograph of the open abdomen after release for intra-abdominal hypertension.
(b) Coverage of the open abdomen with a sheet of Gore-tex mesh with suturing to the
edges of the separated muscle. (c) Application of a vacuum-assisted closure dressing
over the Gore-tex mesh as a temporary closure method
The patient was taken to the theatre every week, the mesh was progressively approximated,
and NPWT applied over this for 4 weeks. Serial weekly excision of the Gore-tex mesh
was performed with gradual advancement of the muscles and fascia to the midline on
either side. After the fascia and the skin could be approximated, a definite closure
was done using the Rives-Stoppa technique. Here, both the posterior rectus sheaths
were brought together and sutured in the midline. A prolene mesh was placed below
the rectus muscles, and the anterior rectus sheath and the skin were sutured in the
midline. At 1 year after the last operation, all her wounds healed and she had no
hernia [[Figure 2]].
Figure 2: (a) Serial weekly excision of Gore-tex mesh and advancement of edges of muscle in
keeping with the patient constitution and stability. (b) Final component separation
using the Rives-Stoppa technique in combination with ultrapro mesh for reinforcement
in a subrectus fashion with approximation of the tissues. (c) Photograph of the abdomen
at 1-year follow-up
DISCUSSION
Ivy et al.[[2]] have noted IAH in 70% of patients with major burns. Increase in IAP occurs when
there is an increased intra-abdominal content (free fluid and bowel oedema due to
inappropriate resuscitation and sepsis) and due to a decrease in abdominal wall compliance[[3]] (abdominal eschars and agitation). Increase in IAP usually occurs early due to
over-resuscitation, abdominal eschars and agitation. In our case, it was late due
to sepsis. The normal IAP is between sub-atmospheric levels to 0 mm Hg and can rise
to 5–7 mm Hg in the critically ill. IAH is defined when there is a sustained rise
in IAP >12 mm Hg. ACS is defined as a sustained increase in IAP >20 mm Hg with the
organ failure.[[4]] ACS can lead to decreased venous return and cardiac output, reduced blood flow
to the kidneys leading to oliguria and anuria, reduced blood flow to the bowels resulting
in increased translocation of bacteria from the gut into the blood, reduced gut motility
and liver dysfunction. It also increases intrathoracic pressure and intracranial pressure,
hypoxia and hypercarbia leading to death.[[5]] Thus, IAP needs to be measured at least every 2 h in major burns. They can be done
directly by an intra-abdominal catheter inserted for ascites drainage, peritoneal
dialysis or laparoscopy or they can be done indirectly through the urinary bladder,
rectum and uterus. Detecting IAH necessitates treating the cause, namely, paralysing
the patient with agitation, diuresis with increased fluids, escharotomies with abdominal
eschars and treating sepsis. When the patient is refractory to the above treatment,
decompressive laparotomy is done.
To prevent fluid loss, temperature loss, enterocutaneous fistula leading on to desiccation
of bowels and loss of abdominal domain, the abdomen needs to be closed soon. The methods
to close the open abdomen can be broadly divided into those that do not close the
fascia and those that aim for a delayed fascial closure.[[6]] The former includes NPWT, skin approximation with towel clips, allowing for granulation
and grafting. These techniques are used when the patient is in poor health and aim
to treat a planned ventral hernia later. However, repair of a ventral hernia later
can be difficult due to the retraction of the fascia and loss of tone of the rectus
muscle. The latter techniques include dynamic retention sutures, Wittmann Patch, Bogota
bag technique and using a Gore-tex mesh. The former techniques involve suturing material
to the fascia both sides and closing progressively in the midline. NPWT is usually
applied over it. Dynamic retention sutures can lead to fascial necrosis.[[7]] Wittman patch is a Velcro-like device that can be easily closed in the middle.[[8]] This is quite costly and not available everywhere.
The Bogota technique involves suturing a plastic sheet to the fascia and progressively
closing in the midline and is commonly used as it is very cheap.[[9]] We used Gore-tex mesh because it can be safely applied over the bowels and is stronger
than the plastic sheet used in Bogota technique.[[1]] NPWT above it helps to get the skin together and eases nursing care. After the
fascia comes together, a definitive abdominal closure is done as the Gore-tex mesh
left alone will cause infection. Rives-Stoppa technique[[10]] is a gold standard technique for the closure of ventral abdominal defects. As the
posterior rectus sheath is closed, a prolene mesh can be used instead of this technique.
CONCLUSION
This article highlights the need to watch out for IAH and highlights a possible method
of closing an open abdomen after a decompressive laparotomy for ACS after a severe
burn.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patient has given her consent for her images and other clinical information
to be reported in the journal. The patient understand that name and initial will not
be published and due efforts will be made to conceal identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
