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bdominal compartment syndrome (ACS) results fromelevations in intra-abdominal pressure (IAP) to a point

here blood flow to end organs is compromised, culminatingn organ dysfunction and failure.1-3 Although it was originallyescribed in patients sustaining severe trauma, ACS is nowecognized to occur in patients with other critical diseasend/or major intra-abdominal operations.1-8 The causes ofCS were examined in multiple intensive care units (ICUs)ithin teaching hospitals compared with general hospitals

ssisted in Table 1.9 In teaching hospitals, ACS was mostommonly associated with vascular surgery, whereas in gen-ral community hospitals ACS was more often associatedith small or large bowel procedures.9

A multicenter study from 13 ICUs across six countriesstablished that 41.2% of critical care patients had a normalAP less than 12 mm Hg, 58.8% had intra-abdominal hyper-ension (IAH) above 12 mm Hg, 28.9% had IAP above 15m Hg, and 8.2% presented with IAP greater than 20 mmg.10 This study has also identified the prevalence of IAH,hich is defined as IAP � 12 mm Hg, to be between 2% and3%, whereas ACS, defined as IAP � 20 mm Hg with one orore organ failures, to be between 1% and 15%.10 The rela-

ive frequency of IAH and ACS, which is associated withortality rates ranging from 25% to 100%, argues for in-

reased vigilance and more frequent monitoring in patients atisk for developing high IAP. The keys to prevention anduccessful management of IAH and ACS are maintaining aigh index of suspicion, obtaining serial IAP measurements,nd intervening early.

AP and Abdominalerfusion Pressure (APP)

AP is the pressure located within the abdominal cavity and isormally �5 mm Hg, but can vary from 0.2 mm Hg to 16.2m Hg according to one study.11 Additionally, IAP increasesith increasing body mass index but generally pressuresreater than 15 mm Hg over a sustained period of time haveeen associated with impairment of cardiac, pulmonary, re-al, gastrointestinal, and/or central nervous system function.AP is determined by abdominal organ volume, presence of

epartment of Surgery, Lehigh Valley Hospital, Allentown, PA.ddress reprint requests to Michael D. Pasquale, MD, FACS, Associate Pro-

fessor of Surgery, Penn State College of Medicine, Lehigh Valley Physi-cian Group, 1240 S Cedar Crest Boulevard, Suite 308, Allentown, PA

I18103-6218. E-mail: [email protected]

524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.oi:10.1053/j.optechgensurg.2008.04.001

pace occupying substances, and abdominal wall compli-nce.

APP is defined as mean arterial pressure (MAP) minus IAPnd assesses not only the severity of IAP, but also the patient’serfusion status.12 Therefore, it is important to control hem-rrhage, ensure adequate resuscitation, and prevent hypovo-emia. APP has been shown to be superior to both IAP and thelobal resuscitation endpoints base deficit and lactate in pre-icting outcome in patients with ACS.12,13 Failure to maintainn APP of at least 60 mm Hg in a patient with IAH is associ-ted with increased mortality.13

The diagnosis of IAH and ACS is difficult because clinicalndings have been found to be poor predictors of IAP. Usinglinical examination alone, ICU physicians have been showno have less than a 50% chance of correctly identifying in-reased IAP.14 Currently, the most common recommendedethod for measurement of IAP is the utilization of an in-welling transurethral catheter to measure the intravesicularbladder) pressure.11 The standard technique outlined is torst drain residual urine from the bladder, clamp the Foleyag drainage tube distal to the access port and then infuse 50L of sterile normal saline into the urinary catheter via the

ccess port. This amount (50 mL) has been shown to providehe most accurate and valid assessment of IAP; measurementhould be done with the patient in a supine position at end-xpiration.15 A transducer is attached to the access port of theatheter and 30 to 60 seconds are allowed for equilibrationith the pubic symphysis used as the zero.16

A continuous intra-abdominal pressure (CIAP) measure-ent technique has been studied and proposed as a means ofonitoring patients at high risk for the development of ele-

ated IAP and ACS. This method utilizes a three-way urethralatheter with continuous saline infusion via the irrigationort and is connected through a two-way stopcock for con-inuous transduction (Fig 1). This method has been shown toe equal to intermittent clamping of the collection bag tubingnd transducing the drainage port.17 It has been recom-ended that patients in the ICU who are at high risk for IAH

nd ACS have IAP measurements done every 4 to 6 hours.18

his would include burn patients, those with massive ab-ominal trauma or extensive abdominal bleeding, patientsith coagulopathies, patients who have bowel ischemia or

equire packing, patients with severe pancreatitis or pancre-tic abscess, and patients with other conditions requiringassive volume resuscitation.IAH is defined by either one or both of the following: (1) an

AP of 12 mm Hg or greater, recorded by a minimum of three

39

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tandardized measurements conducted 4 to 6 hours apart;2) an APP of 60 mm Hg or less, recorded by a minimum ofwo standardized measurements conducted 1 to 6 hourspart.19 APP has been shown to assess not only the severity ofhe patient’s IAH, but also the adequacy of abdominal bloodow, and been proposed as a more accurate predictor ofisceral perfusion.20 The classification of the IAH gradingystem is shown in Table 2.20

Computed tomography (CT) of the abdomen can providevidence of rising IAP in those patients at risk of developingAH and ACS. CT features that have been evaluated includeompression of the inferior vena cava, renal compression,levation of the diaphragm, bowel wall thickening with en-ancement, bilateral inguinal herniation, and the “roundelly sign.”21 In a recent study, Bahrani and co-workershowed that the round belly sign and bowel wall thickeningere found to be significantly more common in patients whoeveloped IAH when compared with those who did not.22

he round belly sign is defined as an increase in the ratio ofnterorposterior to transverse diameter greater than 0.8. Thiss measured at the level where the left renal vein crosses theorta and does not include subcutaneous fat (Fig 2). Bowelall thickening is defined as a thickness of 0.3 mm with

ontrast enhancement (Fig 3). Bahrani and colleagues foundhat individuals with a round belly sign had a 6.78 relative

igure 1 Three-way urethral catheter, with continuous saline infusionia irrigation port, is connected through a two-way stopcock for con-

able 1 Procedures Associated with ACS*

TeachingHospitals

n � 31

GeneralHospitals

n � 69

ynecologic surgery 2 (6.7) 5 (7.2)epatobiliary surgery 9 (30.0) 1 (1.4)mall/large bowel obstruction 8 (26.7) 29 (42.0)mall/large bowel surgery 17 (54.8) 50 (72.5)rauma 16 (53.3) 44 (63.8)rological surgery 2 (13.3) 6 (8.7)ascular surgery 21 (70.0) 41 (59.4)ther 6 (19.4)† 15 (21.7)‡

Percentage given in parentheses.Includes pancreatitis, liver failure, and patients on extracorporeal

membrane oxygenation.Includes pancreatitis, ascites, intra-abdominal sepsis, and pseudo-

obstruction.

inuous transduction. (Color version of figure is available online.) F

isk of developing IAH whereas those with bowel wall thick-ning had a 13.38 relative risk of developing IAH (Figs 2 and).22 In a separate study, the presence of the round belly signnd bowel wall thickening with enhancement were morerequently detected with elevated IAP, but only bowel wallhickening with enhancement was observed in the presencef ACS.23

bdominalompartment Syndrome

levated IAP with systemic signs and symptoms of that pres-ure results in ACS. Although ACS was first described in the890s, only over the last several years have surgeons begun tolearly define the pathophysiology and resultant disordersssociated with excess IAP. ACS is likely to develop after anyvent that leads to an acute increase in the volume of abdom-nal contents sufficient to cause pressure-related dysfunctionf the end organs. As such, ACS can result from trauma,ajor surgery, and numerous other conditions requiring

arge volume resuscitation. The critical IAP in the majority ofatients lies in the range of 10 to 15 mm Hg.24 ACS is defineds the presence of an IAP of at least 20 mm Hg with or withoutn APP less than 60 mm Hg, recorded by a minimum of threetandardized measurements conducted 1 to 6 hours apart,nd a new single or multiple organ system failure.18 Becausehese patients are repeatedly resuscitated, they enter a cyclef ischemia-reperfusion resulting in the development of aystemic inflammatory response syndrome (SIRS). Reduc-

able 2 Grading of Intra-Abdominal Hypertension

GradeIntra-Abdominal Pressure

(mm Hg)

I 12-15II 16-20III 21-25IV >25

igure 2 CT scan showing round belly sign.

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Abdominal compartment syndrome 41

ion in microcirculatory blood flow generally follows, andhere is progression from SIRS to organ dysfunction. The

ODS and death that may follow are the result of the perfu-ion deficiency caused by the ACS.

ACS may be classified as primary, secondary, or recurrentCS as shown in Table 3.25 Primary ACS is a condition asso-iated with injury or disease in the abdominopelvic regionhat generally requires surgical or radiological intervention.rimary ACS is characterized by the presence of acute orubacute IAH occurring as a result of an intra-abdominalause including abdominal organ injuries that require surgi-al repair or damage control surgery, secondary peritonitis,r conditions associated with large retroperitoneal hemor-hage. Secondary ACS refers to conditions that do not origi-ate from the abdominopelvic region characterized by theresence of subacute or chronic IAH that develops as a resultf an extra-abdominal cause such as sepsis, major burns, orther conditions requiring massive fluid resuscitation. Recur-ent ACS refers to the condition where ACS redevelops afterurgical or medical treatment of primary or secondary ACS.his can occur with either persistence of ACS after decom-ressive laparotomy or development of new ACS after defin-

tive closure of the abdominal wall after utilization of a tem-orary abdominal wall closure method.

athophysiologic Changesssociated with IAH and ACSardiovascular

n IAP greater than 20 mm Hg has an important influence onhe cardiovascular system.26 The hemodynamic compromiseeen in ACS is because of alterations in preload, afterload,nd intrathoracic pressure. Preload is reduced because ofena caval compression which results in decreased cardiacutput. Furthermore, a high IAP causes compression of ab-ominal vascular beds which will in turn cause an increase infterload. The increased IAP will cause an elevation of theiaphragm and an increase in the intrathoracic pressure caus-

ng a compression of the pericardium and decrease in leftentricular end-diastolic volume. The increased intrathoracic

igure 3 CT scan showing bowel wall thickening with enhancement.

ressure seen with ACS can cause indirect measurements of

ardiac performance, such as central venous pressure andulmonary artery occlusion pressure, to become falsely ele-ated, even in a profoundly hypovolemic patient. The de-rease in cardiac output caused by ACS is worsened by hy-ovolemia and volume resuscitation leads to an

mprovement in cardiac output.27

ulmonaryncreased IAP and ACS can cause respiratory failure as theigh abdominal pressures cause the diaphragm to elevate andecrease thoracic volumes and chest wall compliance. Thesehanges may result in the need for mechanical ventilation asell as the requirements for high peak airway and plateauressures. The higher airway pressures are necessary for ad-quate ventilation and prevention of compressive atelectasishat, if untreated will result in ventilation-perfusion mis-atch, hypoxia, hypercarbia, and acidosis.28

enaln IAP of 15 to 20 mm Hg has been shown to result inliguria by lowering renal blood flow and glomerular filtra-ion rate, which can progress to anuria with an IAP above 30m Hg.29 This is because of compression of the renal paren-

hyma and veins causing increased renal vascular resistance,s well as decreased renal perfusion secondary to the de-reased cardiac output previously described. Plasma levels ofenin, aldosterone, and antidiuretic hormone are elevated inCS, resulting in sodium and water retention, reduced urineodium and chloride concentrations, and increased urine os-olality.30 This implies that renal hypoperfusion is the major

ause of renal failure in ACS.

able 3 Consensus Definitions According to the World Soci-ty of Abdominal Compartment Syndrome

Term Definition

AH Sustained increase in IAP of >12mm Hg, recorded by a minimum ofthree standardized measurementsconducted 4 to 6 hours apart, withor without an APP <60 mm Hg.

CS Sustained increase in IAP of >20mm Hg, with or without APP <60and single or multiple organsystem failure not previouslypresent.

rimary ACS A condition associated with injury ordisease in the abdominopelvicregion that frequently requiresearly surgical or radiologicintervention or a condition thatdevelops following abdominalsurgery.

econdary ACS Caused by conditions that do notoriginate in the abdomen butresults in signs and symptomsassociated with primary ACS.

ecurrent ACS Develops following prophylactic ortherapeutic surgical or medicaltreatment or primary or secondary
ACS.

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astrointestinalncreased IAP has injurious effects on the splanchnic perfu-ion with decreased blood flow and tissue hypoxia. Experi-ents have shown that hepatic arterial and portal blood flowrogressively decrease as IAP increases above 10 mm Hg.31

Reduced flow to all abdominal viscera, with the exceptionf the adrenal glands, has been demonstrated when IAP isncreased to greater than 20 mm Hg.32 Decreases in bowelissue oxygenation leading to bowel ischemia and mucosalcidosis have been demonstrated with IAP greater than 40m Hg.33 This progressive ischemia can eventually lead toesenteric thrombosis.

eurologicalt has been established that IAH is a risk factor for the devel-pment of secondary brain injury in patients with traumaticrain injury. Increases in IAP in patients with closed head

njury have been shown to increase intracranial pressure via

igure 4 Enterocutaneous fistulas resulting from prolonged openbdomen. (Color version of figure is available online.)

Figure 5 Loss of domain secondary to prolonged open abd

ncreased central venous pressure and functional obstructiono cerebral outflow.34

One can see from the pathophysiology that the classicigns of ACS are decreased arterial oxygenation, elevations inhe partial pressure of carbon dioxide, high peak inspiratoryressures, oliguria or anuria, and a massively distended ab-omen. Confirmation of the diagnosis, of course, is madehrough measurement of the IAP as described previously.

reatment for ACSCS is characterized by IAH that leads to organ dysfunctionnd failure, and, therefore, the treatment involves decom-ression of the abdominal cavity. The simplest manner ofecompression is to open the abdomen through a midline

aparotomy incision. It is important to realize that complica-ions may arise from sudden decompression such as a reper-usion syndrome that could result in severe hypotension andven cardiac arrest. To prevent this, one must ensure ade-uate volume resuscitation before opening the abdomen. De-pite the potential complications, decompressive laparotomyas been shown to be very successful in restoring normalhysiologic function. Guidelines for management of IAH andCS have been suggested based on the aforementioned IAHrading system:

Grade 1 IAH: Normovolemic resuscitation and continuedmonitoring

Grade 2 IAH: Hypervolemic resuscitation, continued monitor-ing, ensure adequate oxygenation and ventilation, and con-sideration of decompression

Grade3IAH:Hypervolemicresuscitation,anddecompressionatthe bedside or in the operating room

Grade 4 IAH: Hypervolemic resuscitation and decompres-sion in the operating room

ubsequent to decompressive laparotomy, the surgeon isonfronted with dealing with the complexities of the openbdomen.

omen. (Color version of figure is available online.)

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emporary and Definitivelosure of the Open Abdomen

he concept of an open abdomen is not new and its use isncreasing in surgical patients. Reasons for not closing anbdomen are complex and multifactorial in major trauma oreptic patients. Some reasons include massive intestinal

Figure 6 Example of “frozen” abdomen when no bowelonline.)

online.)

dema, risk of, or treatment for, ACS, rapid conclusion of aamage control operation, need for additional re-explora-ions, and fascia and abdominal wall preservation. As an ad-unct to damage control laparotomy, and as part of the pre-ention and treatment of ACS, the practice of leaving thebdomen open has become more common. In fact, approxi-ately 15% to 18% of trauma patients who undergo laparot-

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Figure 7 Patient approximately 7 months post-skin grafting for open abdomen. (Color version of figure is available

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my have their abdomen left open at the time of initial oper-tion.35 However, management of the open abdomenequires meticulous attention to detail, with a plan to achieveascial closure as soon as it can be done safely. Before defin-tive closure, temporary abdominal closure will be requirednd this practice is generally performed in the ICU with mostare being delivered at the patient’s bedside. This care is trulyteam effort between the nursing staff and the physicians.After traumatic or septic insult, the open abdomen should

e considered a “hostile” environment.36 Extensive tissue de-truction, contamination, hematoma, and inflamed friableissue that require debridement are often present. The intensenflammatory response mediated by shock, ischemia-reper-usion injuries, and massive fluid resuscitation are all gener-lly associated with the care of these very sick patients.37

ccumulation of bowel wall edema, ascites, and third spaceuid certainly puts the patient at risk for the development ofAH and ACS. Although the open abdomen is designed torevent this, these physiologic derangements contribute tohe hostility of this environment and render the bowel andther organs prone to injury if not handled judiciously.

omplicationsot surprisingly, open abdomen patients experience a higher

ncidence of overall complications, including SIRS, MODS, fis-ulas, postoperative ileus, and third space losses, as comparedith other abdominal trauma patients. These complicationsay develop as a result of the underlying pathophysiology,

everity of trauma, wound packing, bowel manipulation, ab-ominal pressure changes, or multiple surgical and nonsurgicalrocedures. The abdominal wall cannot be closed in a ten-ion-free manner in this environment, and these factorsust be recognized and addressed or they can lead to

urther complications and death.

istulaistula formation rates vary from 2% to 25% in open abdo-en patients. Most would agree that fistula formation is theost dreaded complication of the open abdomen (Fig 4).xposed bowel can desiccate, deserosalize, or abrade in theetting of the open abdomen. Additionally, fistulas may beaused by biomaterial adherence to the bowel causing trans-ural change. As the bowel becomes more fixed in the open

bdomen, sudden changes in pressure or mishandling may

able 4 Ideal Qualities of a Temporary Abdominal Closure

Protects abdominal contentsCan loosen and open quicklyCan be re-accessed every 24 to 48 hoursMinimizes loss of domainPrevents eviscerationPreserves fasciaMinimizes desiccation and damageThird space fluid can be quantifiedAllows for selective tamponadeLowers bacterial counts and infectionKeeps patient (and nurses!) dry and intactNonadherent, pliable, permeable, conformable

esult in bowel disruption and fistula formation. Our group o

ecently reported only three fistulas formed in 79 (3.8%)onsecutive open abdomen patients.38 We attribute this rel-tively low fistula rate to our large experience with a stagedbdominal closure technique combined with meticulous at-ention to detail, the advent of vacuum-assisted wound ther-py, and the development of biologic mesh. Of course, it haseen shown that earlier fascial closure results in less fistulaormation.3 Fistulas often result in large amounts of contam-nated bowel contents spilling into the wound causing localnfection, intra-abdominal abscess, or systemic infection. Fis-ulas resulting from an open abdomen rarely close spontane-usly and are an enormous challenge to control. We haveound that teamwork among the various wound care special-sts is extremely helpful in managing these exceedingly diffi-ult and hostile wounds. Enterostomal therapy and somereative techniques are often necessary to exclude the fistulautput from the rest of the wound until it is safe to resect thestula.

nfectionhe open abdomen has a high potential for infection, either

rom fistula formation, anastomotic breakdown, or exposureo the environment. Traditional treatment with moist gauzeressings will almost universally result in wound contamina-ion or infection. Strict sterile technique is required wheneverrocedures are being performed in the open abdomen.

leedingiven the rich blood supply of the intestine and abdominal

olid organs, bleeding is a significant risk, particularly whennflamed and traumatized bowel wall are exposed. Traumaatients with significant intra-abdominal injuries who re-uire damage control procedures often have the “deadlyriad” of acidosis, hypothermia, and coagulopathy on leavinghe operating room and arriving in the ICU. This can exacer-ate hemorrhage and very often the only options are directressure and packing in this environment. Angioemboliza-

igure 8 Bogotá bag closure. (Color version of figure is available
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ion may be an option for certain arterial bleeding in theetting of the open abdomen.

oss of Bowel Functionpen abdominal wounds with exposed bowel often result inoor nutrition from the increased metabolic demands on theatient, the loss of bowel motility, and the patient’s inabilityo tolerate oral feedings. Enteral feeding has been shown toecrease the incidence of infection in critically ill patients,resumably by enhancing the immune response.39,40

ypothermiahe open abdomen patient is at risk of developing a de-reased core temperature because of evaporative losses. Hy-othermia, as part of the “deadly triad” puts these patients atery high risk for additional complications and death. Post-perative management must include aggressive rewarmingith the use of passive and, if necessary, active rewarming

echniques. Fluid loss from the abdomen also contributes toeat loss by convection. In addition, if third space fluid lossesre uncontrolled, and the patient is allowed to remain in aet bed, heat loss from the patient will accelerate. One of theoals of a temporary abdominal closure is to maintain theatient in a dry environment with minimal heat loss.

oss of Domain Formationatients left with an open abdomen are at risk of losingignificant domain of their abdominal contents (Fig 5).he oblique muscles are not opposed and tend to pull thebdominal wall in a lateral direction. Additionally, the softissue shrinks, making re-approximation more and moreifficult over time, that is, loss of domain. This will lead to

Figure 9 Bogotá bag closure. (Col

hernia, unless measures to gradually re-approximate the s

ascia are not employed. That is why most acute care sur-eons now utilize a method to begin fascial re-approxima-ion while the patient is still in the ICU. As the edemaessens, fascial closure may be achieved over several days.

erniabviously, patients left with an open abdomen have a veryigh risk of developing a hernia. There is very little data on

ong-term hernia rates in these patients since the practice ofamage control laparotomy is relatively new. Although weave become enthusiastic about closing the open abdomenarlier and earlier, there is not yet any long-term follow-upvailable to assess the rate at which hernias develop after thisype of “definitive” closure. With the emergence of new prod-cts and techniques (discussed later), fewer patients are noweing left with a “planned” hernia. These are typically pa-ients unable to undergo definitive closure before going on toorm a frozen abdomen (Fig 6) resulting in the inability tosolate and develop fascial edges safely to achieve closure.hese patients undergo a skin graft over the granulatedowel. On healing, the patient is typically discharged to aehabilitation facility, and the abdominal wall is recon-tructed in a year or so (Fig 7).

echniques for Temporarybdominal Closure (TAC)

n open abdomen is maintained with a TAC that will facili-ate re-access to the abdominal cavity either in the operatingoom or at the ICU bedside. Qualities of the ideal TAC areutlined in Table 4.In a retrospective study, Ivatury and co-workers demon-

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trated the effectiveness of a TAC in preventing IAH.3 Patients

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efined as high risk for ACS included those with hemody-amic instability, multiple injuries, strong suspicion for theevelopment of ACS, or a need for intra-abdominal packing.hese patients were divided into two groups: one group hadTAC using a loosely applied prosthetic mesh; the other

roup had their abdomens closed at the time of surgery afterleeding was controlled and organs repaired. The incidencef IAH (defined as �25 mm Hg) was 22.2% in the meshlosure group versus 52% in the fascial closure group. Sur-ival was higher and organ dysfunction was less severe in theatients who did not develop IAH. There was an overallurvival of 90.1% in the mesh-closure group compared with8% in the fascial closure group.Bladder pressure may need to be monitored in patients

ho have a TAC depending on the clinical situation. Weecommend measuring bladder pressure in patients whoave evidence of poor perfusion despite adequate intravas-ular volume. The most common scenario is in the patientith a fascial closure or a TAC with an increasing abdominalirth and diminishing urine output. After adequate fluid re-uscitation, if urine output remains low, bladder pressure iseasured. If the pressure is greater than 25 mm Hg, the fascia

s reopened if it has been closed, or the TAC device is loos-ned.

There are several methods to provide temporary abdomi-al closure. Mayberry and co-workers surveyed surgeonssking their “preferred” method of TAC.41 Results of this999 survey were as follows: Bogotá Bag 25%, absorbableesh 17%, polypropylene mesh 14%, PTFE mesh 14%, Si-

astic mesh 7%, miscellaneous techniques 28%, and towellip 1%. Three percent (3%) answered that they never leave aatient with an open abdomen.With techniques that involve progressive fascial ad-

ancement, vacuum-assisted wound therapy, and use ofiologic mesh, we have improved our ability to care for thepen abdomen with less complications and earlier defini-

Figure 10 Colonization of ePTFE mesh.

ive closure. s

kin Onlyowel clip closure of the skin is perhaps the most rapid of theAC techniques. The towel clips are applied to the skin ap-roximately 1 cm apart. The towel clips are then coveredith a towel and iodophor impregnated adhesive plasticrape (Ioban, 3 mol/L, St. Paul, MN). Advantages of towellip closure is its speed, low cost, minimization of heat anduid losses, and ability to maintain the abdominal contentselow the level of the fascia. Disadvantages include possiblevisceration between towel clips, injury, and loss of skin andhigh incidence of ACS. Alternatively, a running nylon su-

ure can be used in place of towel clips; however, this takesonger to apply.

ogotá Baghe Bogotá Bag was named by Mattox while observing this

echnique in Bogotá, Columbia. It uses a large IV bag toover the abdominal contents and is sutured to thekin.42-45 A cutting needle facilitates skin suturing but canause tearing of the plastic. Other nonadherent plasticrapes such as Steri-Drape, a bowel bag, a sterile X-rayassette sleeve, urology irrigation bags, and Silastic drapesubstitute for the IV bag (Fig 8 and 9). Advantages to thisechnique are its low cost, nonadherence, prevention ofvisceration, and ease of application and availability. Dis-dvantages are skin loss, difficult re-entry, need to sterilizehe material, minimal control of third space fluid, andost importantly, minimal control of leakage of third

pace fluid.

ynthetic Meshbsorbable meshes include polyglactin 910 (Vicryl; Ethicon,omerville, NJ) and polyglycolic acid (Dexon; Davis andeck, Danbury, CT). Either can be secured to the skin or

ascia. Suturing to the skin preserves the fascia for later clo-

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orbable, resistant to infection, and have a high early burstingtrength. However, because they are absorbable, there will ben expected late hernia if no other more permanent closure isrovided. Most surgeons will cover the granulated mesh withskin graft with a plan to reconstruct the abdominal wallonths to years later. Dexon has larger interstices that allow

asier needle passage and egress of fluid. Both absorbable o

eshes have been associated with the development of entero-utaneous fistula especially if allowed to desiccate. Beforeranulation, the mesh should be covered with an adhesiverape. As granulation begins and concern for intra-abdomi-al pathology subsides, other dressings to prevent desicca-ion may be used. This is important because the Ioban, and

re 11 (A-E) Application of Wittmann Patch. (Color version of fig-is available online.)

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xcoriation and damage to the skin that will be important forventual coverage. Once the absorbable mesh is in place, nourther procedures may be necessary acutely, an advantage incritically ill patient. After the mesh is allowed to granulate,

t can be covered with a skin graft before discharge with alan to reconstruct the abdominal wall later.A nonabsorbable mesh may also be used as a TAC. The twoost common are polypropylene (Marlex, Bard, Billerica,A; ProLite, Atrium, Hudson, NH; Prolene, Ethicon, Som-

rville, NJ), and expanded polytetrafluoroethylene (ePTFE)DualMesh, Gore, Flagstaff, AZ; Dulex or Reconix, Davol,ranston, RI). Because these meshes do not absorb, they arerone to colonization and infection and generally need to beemoved and cannot transition into being a permanent clo-ure (Fig 10). Surgeons have used these meshes in a siloashion, that is, securing them to the fascia with progressiveascial advancement and resuturing the mesh in the midlines the fascia is advanced. ePTFE is an attractive choice sinceowel generally does not adhere to its undersurface. In fact,ippers and Velcro have been added to nonabsorbable meshith the goal to advance the fascia to a point that it can be

losed primarily with removal of the nonabsorbable mesh.his technique is described in the next section.Miller and co-workers reported a significant wound com-

lication rate when using synthetic mesh in the managementf the open abdomen.46 In 344 consecutive trauma patientsreated with an open abdomen, 276 survived to wound clo-ure. A delayed primary closure was achieved in 180 (65%)atients. A temporizing method was used in 81 (29%)hereas 15 (6%) were managed with a final closure pros-

hetic. Sixty-nine (25%) of the patients who survived to clo-ure suffered a total of 94 complications, which includedstula formation in 32 patients. The primary closure groupeveloped fewer fistula (6 of 180, 3%) when compared withhe temporizing group (24 of 81, 30%, P � 0.001). Thirty-our patients (12%) died after wound closure, importantly, 6f 17 patients who developed a wound complication in therimary closure group died and 5 of these 6 deaths werettributed directly to an abdominal-related complication.hey reported universal failure with attempts at primary clo-ure under too much tension. The complication rate in-reased significantly after 8 days of an open abdomen. In thistudy, the best result was obtained in patients undergoing aelayed primary fascial closure before 8 days; however, at-empts at fascial closure under undue tension was fraughtith significant morbidity and mortality.

ittmann Patcheveral techniques have been designed to maintain abdomi-al integrity and allow for fascial advancement and frequente-exploration of the abdomen. These include zippers,47,48

lide fasteners, and Velcro. All of these devices are designedo be removed eventually. The Wittmann Patch (Star Surgicalnc., Burlington, WI) was developed by Drs Wittmann andprahamian at the Medical College of Wisconsin.49-51 It is aurr-like device made of two adherent sheets of polyamidend polypropylene with a Velcro-type closure. The sheets areutured to the fascial edges and stick to each other whenompressed. At re-exploration, they are separated and can be
rimmed as the fascial edges are approximated (Fig 11). The i
atch is removed at the final operation and some form ofefinitive closure can be performed (Fig 12). Advantages in-lude ease of re-exploration and prevention of loss of abdom-nal domain. Disadvantages include expense, multiple ma-ipulations of fascia with possible fascial necrosis, and aecreased ability to control third space fluid. We have had aood experience utilizing the Wittmann Patch as our primaryode to TAC. In 78 consecutive trauma patients with an

pen abdomen, 48 had a Wittmann Patch placed. The pa-ients who did not receive a Wittmann Patch were generallyble to have a delayed primary closure at their first or secondaparotomy. Despite a mean ISS of 21.5, 79% of the Witt-

ann Patch patients achieved fascial closure, on average, byay 12; however, although only nine patients in this groupent on to require skin grafting and a delayed abdominalall reconstruction, only one patient developed an enterocu-

aneous fistula.38 Hadeed and co-workers recently reported aery similar result using the staged abdominal reconstructionechnique.52 They were able to achieve a delayed primaryascial closure in 20 of 26 patients at a mean of 13 days inpen abdomen trauma patients treated with a Wittmannatch.

acuum-Assisted Wound Therapyhe vacuum-assisted closure has been used by acute careurgeons for several years, first as a homemade system, andore recently as a more sophisticated commercially availableroduct (V.A.C., KCI, San Antonio, TX). The vacuum-as-isted TAC utilizes a nonadherent dressing placed over theowel. This is first fenestrated by the surgeon cutting holes inhe drape. Laparotomy pads are placed over this with twoarge drains sandwiched between laparotomy pad layers.his is covered with an Ioban drape and suction is applied to

he drains to assure an airtight closure so that negative pres-ure can be applied to the wound (Fig 13). In the ICU, therains are maintained on wall suction and the third spaceuid is removed and can be quantified. Re-exploration, either

igure 12 Closure of abdomen after removal of Wittmann Patch.Color version of figure is available online.)

n the operating room or in the ICU, and re-application of the

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acuum closure is quite simple. Although the V.A.C. is veryimilar, the polyurethane sponge is more effective in distrib-ting the negative pressure throughout the wound and main-aining the fascial edges in closer approximation (Fig 14). Ineneral, these dressings are changed every 48 to 72 hours

Figure 13 (A) Ioban being placed over open abdomen. (B)

ith re-approximation of the fascial edges as much as possi- t

le at each dressing change. Advantages to vacuum-assistedound therapy include a decreased incidence of ACS, pre-ention of loss of domain, removal, and quantification ofhird space fluid, and achievement of an early fascial closure.nother advantage of the Wittmann Patch and the V.A.C. is

ac” dressing. (Color version of figure is available online.)

he ability to extend the time that a TAC can be applied with

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onstant tension on the fascial edges to prevent loss of do-ain. Disadvantages include the requirement for special

quipment, expense, and the fact that, to date, there is min-mal long-term follow-up data.

Barker and co-workers reported on their experienceith the vacuum pack technique.53 Of 112 patients, 22

19.6%) died before closure and 62 (70.5%) were able tochieve a delayed primary closure at a mean of 3.1 days.wenty-seven (30%) patients required a skin graft overranulated bowel at a mean of 32.5 days. Five patientseveloped an enterocutaneous fistula, five developed an

ntra-abdominal abscess, and one developed ACS. Simi-arly, Miller and co-workers reported on their experienceith vacuum-assisted fascial closure of the open abdo-en.54 In 53 patients with a mean ISS of 34, 45 (64.1%) sur-

ived to closure. Forty-three patients underwent vacuum-as-isted fascial closure and 38 (88%) were successfully closed. In aean follow-up of 6 months, only one patient had developed

entral hernia.

efinitive Closure Techniquess techniques improve, and acute care surgeons, operating

oom personnel, and ICU nurses become more facile at car-ng for the open abdomen patient, it is not unusual for defin-tive abdominal closure to occur while the patient is still inhe ICU. Vacuum-assisted wound therapy and the develop-ent of biologic mesh products has greatly enhanced our

igure 14 (A) Application of nonadherent layer with fenestrations from.A.C. (B) V.A.C. with retention sutures in place as negative pressure iseing initiated. (Color version of figure is available online.)

bility to care for the open abdomen patient. Achieving 70% g

o 80% fascial closure rates, either primarily, or with thessistance of a biologic mesh, often in less than 2 weeks withstula rates less than 5%, was unheard of 10 years ago. Thebility to place biologic mesh in a contaminated or franklynfected field has revolutionized the care of these patients.

rimary Closureelayed primary closure, without significant tension, isrobably the most preferable way to close the open abdomen.lthough difficult to quantify, the risks of infection, entero-utaneous fistula, and recurrent wound problems appear toe lower if primary closure is utilized. In their large experi-nce, Miller and co-workers reported significantly less mor-idity and mortality in the primary closure group despiteimilar injury severity scores as the TAC group.46 Further-ore, they attributed the majority of the morbidity and mor-

ality in the primary closure group to undue tension on theascia. As the patients overall status improves and edemaessens, primary closure can be achieved days to weeks afterhe original celiotomy. If the abdomen cannot be closed pri-arily after the second or third laparotomy, many surgeonsould utilize a TAC that would either maintain or advance

he fascia so that the delayed primary closure will be possiblehile the patient is still in the ICU.If primary closure is not possible, the options include clo-

ure with a permanent prosthetic, either synthetic or bio-ogic, closure with an autologous tissue flap or closure with akin graft over a bed of granulated absorbable mesh or bowel.n the latter case, a large ventral hernia will develop that cane repaired months to years later (Fig 7).

ynthetic Meshynthetic, nonabsorbable mesh, such as polypropylene orPTFE, are excellent choices to repair ventral hernias electively;owever, their use in reconstruction of the open abdomen, par-icularly in a contaminated field, are limited. Risk factors foromplications are multiple and the complications can occurears after the original procedure. Causes of enterocutaneousstula include prior bowel desiccation, adherence of bowel toesh, and adherence of bowel to exposed fascial edges. With

ny increase in abdominal pressure, the open fascia and theesultant tension on the adherent bowel wall over time cause ito tear.55 This adherence of the bowel to the fascial edge, not justo the mesh itself, helps explain why enterocutaneous fistulasccur with all the mesh products.

olypropylenearlex mesh was first utilized nearly 50 years ago and there are

ow three products available: Marlex (Bard, Billerica, MA), Pro-ite (Atrium, Hudson, NH), and Prolene (Ethicon, Somerville,J). Polypropylene induces a vigorous fibroblastic reaction and

s well incorporated after 2 weeks. The peritoneal surface wrin-les with the dense fibroblastic reaction that may predispose todhesion formation. Seroma and infection are the most com-on complications.56 In a review of all series using polypro-ylene for closure after trauma, the overall rate of enterocutane-us fistula was 3%.57 Not surprisingly, fistula rates are highesthen closure is by secondary intention using local wound carer when skin grafting over granulating mesh is used.57 It is
enerally accepted that polypropylene should not be placed in

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pposition to bowel. However, fistulas may develop despite in-erposition of omentum, peritoneum, or other tissue because ofhe fibroblastic reaction. Once polypropylene becomes contam-nated or infected, it is generally necessary to remove the mesh tochieve clearance of infection and healing.

xpanded Polytetrafluorethylenexpanded polytetrafluorethylene (ePTFE) is a microporous,exible, woven material available from several companies

ncluding DualMesh or MycroMesh (Gore, Flagstaff, AZ) andulex or Reconix (Davol Inc., Cranston, RI). The fibroblastic

eaction to ePTFE is significantly less than with polypro-ylene. The mesh is surrounded by macrophages and fibro-ollagenous tissue with minimal in growth of fibers. At leastnitially, adhesion formation of ePTFE is less than witholypropylene. Infection appears to increase the risk of ad-esion formation. As with polypropylene, infection and se-oma are the most common clinical complications associatedith ePTFE and occur at similar rates. A single enterocuta-eous fistula was reported in 191 incisional hernia repairsxclusive of trauma. Being a synthetic, ePTFE has a limitedse in the face of contamination and infection, therefore,here are not enough data with its use in trauma patients toomment on fistula rates.57 With decreased fibroblastic reac-ion and apparent lack of enterocutaneous fistula formation,n intraperitoneal position adjacent to bowel seems accept-ble. A disadvantage of ePTFE is its expense.

omposite Synthetic Meshor years, general surgeons have sandwiched polypropylenend ePTFE to repair ventral and incisional hernias withPTFE placed over the peritoneal contents and the polypro-ylene on top in the subcutaneous space. Theoretically, thisill take advantage of the lack of fibroblastic reaction of

PTFE over the bowel and the abundance of fibroblastic re-ction in the subcutaneous space to “scar” in the mesh repair.his composite is available in several forms (Composix andulex, CR Bard, Murray Hill, NJ; Proceed, Ethicon, Piscat-way, NJ; Surgipro, Covidien, Mansfield, MA). These com-osite meshes are very popular, and an excellent choice inepair of elective ventral and incisional hernia; however, asynthetic meshes they have limited applicability in transi-ioning from a TAC to a definitive closure in the open abdo-en. Although theoretically attractive, long-term follow-up

s sparse, and there are reports describing dense adhesions tohe fascial/mesh interface in some of these products. Thisnterface may be more prone to buckling and wrinkling thanPTFE alone and this may contribute to adhesion forma-ion.56 We have seen this buckling and wrinkling in severalatients who have had reoperation of recurrent herniationfter repair with a composite material.

iologic Meshhe use of any of the synthetic mesh product is associatedith a small, but real, increased incidence of infection and

nterocutaneous fistula formation. The resulting abdominalall catastrophes can be disastrous. The use of an extracellu-

ar matrix from animal or human tissue, cadaveric fascia, orutologous tissue in the form of flaps is attractive because it
voids or reduces the frequency of these potential complica- t
ions. In the setting of contaminated wounds, the use of suchissue is required, because the biologically inactive syntheticeshes do not have the ability to resist infection.

orcine Small Intestine Submucosamall intestinal submucosa (SIS) is an acellular, extracellularatrix from porcine small intestine and is composed primar-

ly of type I collagen. This SIS technology has been developedy Cook Biotech Inc. (Surgisis, West Lafayette, IN). Surgisis

s available in several sizes and has been used for abdominaleconstruction. Because of the vascularized in-growth andubsequent resistance to infection, Surgisis has been useduccessfully in contaminated or potentially contaminatedernia repairs.58 The newer eight-ply product is available

n larger sheets making it a reasonable choice for transi-ioning from a TAC to a definitive closure in the openbdomen. Disadvantages of this product include seromaormation, separation of the layers, and uncertain long-erm outcome.59 Some patients will develop a febrile reac-ion and/or a noncellulitic erythema over the mesh thatasts for 48 to 72 hours.

uman Acellular Dermal Matrix (HADM)n general, synthetic prosthetic materials should not be im-lanted into sites with known contamination or infectionecause they lack an endogenous vascular network and arehus unable to clear bacteria. This is of particular importancen closure of the open abdomen or repair of recurrent hernias.hese hernias are often refractory to repair because of indo-

ent bacterial colonization that weakens the site and retardsealing. Although fascia lata grafts and muscle flaps are viableptions in these situations, they carry the potential for donorite morbidity. Recently, a growing number of surgeons haveeen using HADM (AlloDerm, LifeCell, Branchburg, NJ) as araft material for the repair of complex ventral hernias. Thisaterial has been shown to become revascularized in both

nimal and human subjects.60,61 Once populated with a vas-ular network this graft material is theoretically capable oflearing bacteria.

HADM is processed from human cadaver skin. Donors areigorously screened by social, medical, and serologic history.fter harvesting with a dermatome, a patented three-step pro-ess results in a biomaterial containing a structurally intact base-ent membrane with an overlying matrix. This matrix contains

lycosaminoglycans, intact human dermal collagen fibers andundles of types I, III, IV, and VII, and intact elastin and laminin.he normal dermal architecture supports angiogenesis and hostellular migration while the collagen and elastin provide biome-hanical strength.62 Until recently, HADM use for large abdom-nal wall reconstructions was limited because of the sizes avail-ble. This would require quilting several pieces together to coverlarge fascial defect (Fig 15A). However, there is now a 20 � 24m sheet of AlloDerm available for this use (Fig 15B).

HADM shares many favorable characteristics with otherllograft materials. Like fascial grafts, HADM develops a vas-ular supply allowing it to resist infection. In addition, stud-es have shown HADM to actually be stronger than fasciacutely.63,64 Although HADM becomes incorporated and in-ested by native tissue, it has been shown to persist aftermplantation. Constantino and co-workers, using HADM as aoft tissue filler, found it persisted after 22 months of implan-
ation in humans.65


Figure 15 (A) Suturing of HADM for definitive closure. (B)20 � 24 cm HADM to cover a large area. (Color version offigure is available online.)

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Several groups have reported initial success in the use ofADM for abdominal wall reconstruction. Many of these re-orts involve reconstruction of very complicated patients espe-ially after therapy with an open abdomen as well as in the facef infection and/or fistula. Our group routinely uses HADM as aascial bridge or as an overlay reinforcement of a componenteparation in these types of complex abdominal wall reconstruc-ions (Fig 16). Table 5 summarizes the published data availableo date for the use of HADM for complicated abdominal recon-truction.59,62,66-74 Although there is a wide range of recurrenceates reported (0-50%), the vast majority of these reconstruc-ions were performed in “high-risk” patients frequently in theace of contamination and infection. Remarkably, it is rarelyequired to remove the HADM despite infection and wound

able 5 Review of Literature on Use of HADM for Reconstruc

Author(reference) N Patient Type(s)

iaz (66) 77 Contaminated or infected 11 m14 s

atton (67) 67 Complex and/orcontaminated

olton (62) 49 Various, 39 infecteduinewicz (68) 44 Various, 8 infectedcott (69) 37 Acute trauma open

abdomenupta (59) 33 Contaminated or infected NR

im (70) 29 “High risk,” infected or poorskin coverage

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utler (73) 13 “High risk” canceruy (74) 9 Acute trauma open

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Figure 17 Porcine dermal collagen (PDC) use for fascial cl

omplications. With meticulous wound care, and the applica-ion of antibacterial dressings, the HADM can usually be left initu and salvaged. This is presumably because of its vascularitynd ability to clear infection. Importantly, long-term follow-ups not yet available with HADM. In fact, no study in Table 5 hadfollow-up greater than 1 year with most being 6 months or less.Gupta and co-workers compared porcine intestinal sub-ucosa (Gold 8-ply Surgisis) to HADM (AlloDerm) in the

epair of ventral hernias in contaminated or potentiallyontaminated fields.59 The first 41 patients were repairedith Surgisis and the next 33 with Alloderm. At follow-up

he first 10 of 11 Surgisis patients developed a seroma.his complication was reduced by perforating the Surgisis3 of 30 patients with seroma). Explanted material re-

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Figure 18 (A-D) Component separation to achieve fascial advance-ment in repair of large ventral hernia. (A) Cross-sectional view ofnormal anatomy above arcuate line. RM � rectus muscle, EO �external oblique, IO � internal oblique, TA � transverse abdomi-nus; (B) Cross-sectional view of ventral hernia; (C) Cross-sectionalview after dissection. Curved arrows demonstrate plane of dissec-tion between the EO and the overlying subcutaneous tissue and theincision in the EO lateral to the rectus sheath. Straight arrows dem-onstrate optional incision into posterior sheath; (D) Cross-sectionalview of the completed component separation. (E) Anterior view ofthe ventral hernia. (F) Completed component separation. Often anunderlay and/or onlay mesh is applied for reinforcement. (Re-printed with permission from Rutherford et al.56)

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ealed separated layers of un-incorporated middle layersf the 8-ply Surgisis. However, of the 33 patients, thereere eight hernia recurrences in the AlloDerm group and5 developed a diastasis. However, only two AlloDermatients developed a seroma. Again, the mean follow-upime was well under 1 year.

Very recently another HADM has become available, FlexD (MTF, Edison, NJ). There are no clinical studies yet

eported with this product.

orcine Dermal Collagen (PDC)here are currently two porcine derived biologic mesh prod-cts available for use in abdominal wall reconstruction. Col-

amend (CR Bard Inc., Cranston, RI) and Permacol (Tissuecience Laboratories, Hampshire, UK). There is less datavailable compared with HADM. The main advantage ofhese xenografts over the HADM allograft has been theirvailability in larger sizes for use in covering large fascialefects (Fig 17). Other than a few case reports, there are only

Figure 19 (A) Exposed HADM. (B) V.A.C. device app

wo clinical studies reporting the results with PDC. In a pro- f

pective study, Catena and co-workers reported on sevenatients treated for complicated incisional hernia using PDCith no surgical complications.75 Parker and co-workers re-orted only one recurrence after intentional removal of theDC and no infectious complications in nine complicatedascial defects repaired with PDC.76

lastic Surgical Techniqueshe use of tissue expanders, free flaps, and rotational flapsill not be discussed in this review. Rohrich and co-workersrovide an excellent review, classification based on size,epth, and location, and an algorithm for the optimal recon-tructive technique of complicated abdominal wall hernias.77

e often involve our plastic surgery colleagues in the man-gement of our most complicated open abdomen patients,articularly when we feel coverage of the biologic mesh maye problematic or if there has been massive destruction of the

HADM. (Color version of figure is available online.)

ascia from trauma or infection.

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omponent Separationomponent separation, described by Ramirez and col-

eagues, reconstructs the midline defect with an innervateddvancement of muscle and fascia.78 This technique is beingsed more often by plastic and general surgeons for recon-truction of large ventral defects. The external oblique isransected approximately 2 cm lateral to its insertion into theectus sheath and separated from the internal oblique (Fig8). This separation extends 5 to 7 cm cephalad to the costalargin, and as far laterally as possible. The rectus muscles are

dvanced medially and sutured to close the defect in theidline. Additional mobility in each location can be gained

y separating the rectus muscles from the posterior sheath.ilateral advancement yields enough mobility to close defectsf up to 10 cm at the epigastrum, up to 20 cm at the umbi-icus, and 6 cm at the suprapubic level. A biologic mesh isften used as an underlay and/or overlay reinforcement inhese complicated post open abdomen patients (Fig 16). Skins closed over closed suction drains that should remain inlace for 1 to 2 weeks. Necrosis of the overlying skin is aommon complication because of the extensive mobilizationhat is required. Skin grafts or other local wound care may beecessary. In fact, vacuum-assisted wound therapy appliedver exposed HADM will form a bed of granulation tissue forkin graft application (Fig 19). However, there is data sug-esting that the biologic mesh, which was intended to be apermanent” repair, has a very hernia recurrence rate in thisetting.71 Component separation can be used in the acuteetting, or in a delayed fashion to repair a hernia occurringfter temporary mesh closure. Long-term follow-up of com-onent separation techniques, with and without mesh rein-

orcement, demonstrates recurrent hernia rates ranging from.4% to 32%.79-82

ummaryith the development of damage control laparotomy and a

etter understanding of the pathophysiology of resuscitation,he use of the open abdomen has become very common incute care surgery. Temporary and definitive closure tech-iques for the open abdomen have improved a great deal inhe last 10 years. Techniques of gradual fascial advancement,acuum-assisted wound therapy, and the development ofiologic mesh products that become revascularized and areble to clear infection have revolutionized the care and clo-ure of the open abdomen. It is not uncommon that we canow achieve a definitive closure of the open abdomen evenefore the patient leaves the ICU. This can be achieved eitherith a delayed primary closure or a biologic mesh being used

s a bridge or reinforcement for a component separationechnique. Although initial reports demonstrate acceptableecurrent hernia rates, good long-term follow-up is needed inhese patients to further refine and improve our closure tech-iques.

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