|Year : 2022 | Volume
| Issue : 3 | Page : 670-675
Role of open laparostomy in severe abdominal sepsis and other acute abdominal conditions
Kishan Danvath1, Praveen Kumar Pokala2
1 Department of Surgery, Government Medical College, Nalgonda; Department of Surgery, Osmania Medical College, Hyderabad, Telangana, India
2 Department of Surgery, Osmania Medical College, Hyderabad, Telangana, India
|Date of Submission||17-Apr-2020|
|Date of Decision||18-Nov-2020|
|Date of Acceptance||14-Nov-2021|
|Date of Web Publication||2-Nov-2022|
Dr. Praveen Kumar Pokala
Department of Surgery, Osmania Medical College, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Laparostomy or open abdomen is defined as intentionally leaving the abdomen open following laparotomy and closed once condition of the patient becomes stable. The exposed abdominal contents are protected with a temporary cover. This is performed in severely where repeat access to the peritoneal cavity is needed in the postoperative period. This allows free drainage from the peritoneal cavity and prevents the development of complications due to immediate closure of abdomen, such as abdominal compartment syndrome. However, this is a morbid procedure and is associated with many complications. Materials and Methods: In this retrospective study, a total of 25 patients were included. Data were obtained from case records from the emergency and elective surgical departments of patients who had laparostomy in the last 3 years. Analysis of data was done with regard to indications, surgical procedure, timing of return to theatre, fascial closure, and complications including death. Results: In all cases, temporary abdominal closure (TAC) done using a plastic cover or silo bag. Out of 25 patients, 10 patients had gross peritoneal contamination due to gastrointestinal perforation, pancreatic necrosis in 2 cases, bowel gangrene in 2 cases, and abdominal trauma with intraperitoneal bleeding in 3 cases. Two patients died within 48 h of initial surgery. Fascial closure was achieved between 3 and 7 days, with an average of 3.8 days. Only skin closure without fascial closure was performed in 3 cases. Conclusions: Laparostomy is a very useful procedure in severely ill and unstable patients with multiple intra-abdominal injuries, gross peritoneal contamination, and severe bowel edema, where repeat access to the peritoneal cavity is required in the postoperative period. Fascial closure rates are similar to other TAC closure techniques. Wound infections and inability to close fascia are important complications.
Keywords: Abdominal compartment syndrome, Bogota bag, enteroatmospheric fistula, open abdomen
|How to cite this article:|
Danvath K, Pokala PK. Role of open laparostomy in severe abdominal sepsis and other acute abdominal conditions. J Datta Meghe Inst Med Sci Univ 2022;17:670-5
|How to cite this URL:|
Danvath K, Pokala PK. Role of open laparostomy in severe abdominal sepsis and other acute abdominal conditions. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 4];17:670-5. Available from: http://www.journaldmims.com/text.asp?2022/17/3/670/360176
| Introduction|| |
Laparostomy is a surgical procedure in which the abdomen is left open intentionally without closure after initial laparotomy. The concept of leaving the abdomen has emerged from failures in the past where the abdomen could not be or should not be closed. This technique was first used by Ogilvie in 1940 during the World War II in patients with exsanguinating hemorrhage. However, much attention was not paid to this procedure until Stone et al. in 1980 reported the advantages of staged laparotomy with abdominal packing in improving survival rates in patients with severe abdominal injuries. The term damage control surgery was coined by Rotondo et al. in 1993. In a retrospective study, they reviewed records of 46 patients with combined visceral and vascular injury due to penetrating trauma who required >10 units of blood transfusion. Twenty-two patients underwent damage control laparotomy and had improved survival rates. In all cases, abdominal contents were covered with a temporary cover to isolate viscera from the environment and facilitate subsequent closure. Recently, laparostomy is being increasingly used not only in trauma patients but also in the management of severe abdominal sepsis, pancreatitis, abdominal compartment syndrome, and bowel gangrene caused by mesenteric vascular occlusion.
Many different techniques are in use for temporary closure of the abdomen. These include Bogota bag, vacuum pack technique and vacuum-assisted closure, and dynamic retention sutures. An ideal temporary abdominal closure (TAC) technique should be inexpensive, easily available, prevent loss of domain of abdomen. At present, no ideal method is available. The simplest and most easily available technique is the usage of Bogota bag. This involves suturing of urologic irrigation bag to the fascia or skin. In our study, all patients had laparostomy using Bogota bag and achieved similar results as reported by other studies.
Open abdomen is associated with many complications such as enteroatmospheric fistulae, intra-adominal infections, multiorgan failure, and death. Another important aspect of laparostomy is to achieve fascial closure as early as possible. Many techniques are available to close the abdomen, of which direct closure of fascia is the best choice. If fascia cannot be approximated due to loss of fascia or retraction, various other techniques can be adapted. These include usage of prosthetic materials, component separation, skin only closure, and allowing granulation tissue to develop over viscera followed by a split skin graft. Latter two are associated with large ventral hernia formation, which can be repaired electively at a later period.
| Materials and Methods|| |
In our study, a total of 25 patients with laparostomies were included. Data were obtained from case records and computer data of patients who had laparostomy for various surgical conditions. Analysis of data was done with regard to indications, surgical procedure, timing of initial return to theater, fascial closure, and complications. Cases included were polytrauma with hemorrhage, mesenteric vascular occlusion with gangrene of intestine, severe sepsis due to intestinal perforation, and severe pancreatitis. In all cases, laparostomy was done by suturing a spread out sheet of urinary drainage to the skin 4–5 cm beyond margins of the wound, taking care not to injure underlying bowel. Multiple saline-soaked pads were placed over the sheet to absorb any exudate and secured with bandages [Figure 1]. Change of bandages was done in the intensive care unit (ICU) after 24–48 h depending on the need. Inspection of viscera was also done at the same time of the change of dressings [Figure 2]. Broad-spectrum antibiotics were administered to all patients and changed depending on sensitivity results. Any discharge from the peritoneal cavity was also noted. Re-exploration of the abdomen was performed after 2–5 days after stabilization of the patient.
|Figure 1: Open laparostomy in a patient with severe necrotizing pancreatitis. Note exposed abdominal viscera are covered with Bogota bag|
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|Figure 2: Bedside change of dressings in intensive care unit in a patient with laparostomy|
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| Ethical clearance|| |
The Institutional Ethics Committee of Govt Medical College, Nalgonda has approved the Research work proposed to be carried out at Govt Medical Collage, Nalgonda, Date : 8th July 2018 with Reference no GMC/GEC/2018-19/378.
| Results|| |
A total of 25 patients were included in our study of which 21 were male and 5 were female patients between the age group of 25–65 years. Eleven (44%) patients had gross contamination of the peritoneal cavity due to bowel perforation and delayed presentation. Two (8%) patients had massive gangrene of small and large bowel involving variable lengths, due to mesenteric thrombosis [Figure 3]. Damage control surgery was performed in 3 (12%) cases due to blunt and penetrating trauma abdomen with massive hemorrhage and contamination. Pancreatic necreosis with bowel edema was found in 2 (8%) cases. Only fascial closure leaving the skin open could be achieved in 14 (56%) cases, skin and fascia were closed in 5 (20%) patients, and only skin closure was performed in 3 (12%) patients. Two (8%) patients died in the postoperative period before, and closure was attempted. In our study, the average fascial closure time was 3.80 days and ranged from 2 to 7 days. Overall, 4 (16%) patients died of various complications in a period of 1 month postoperatively.
|Figure 3: Massive bowel gangrene caused by superior mesenteric artery thrombosis|
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| Discussion|| |
The concept of open abdomen has emerged out of failures in the past to manage abdomens that could not be or should not be closed due to severe sepsis and trauma requiring intra-abdominal packing. A correct and timely decision to undertake laparostomy is crucial to reduce many complications associated open abdomen., Laparostomy has the advantages of reducing sepsis and decreasing operative time in a moribund patient at primary surgery and allows planned relook after a few days, by that time patient's general condition will have improved and abdominal wall wound infection also significantly reduced as abdomen is left open for free drainage. Primary anastomosis of bowel may be carried in most patients as bowel wall edema decreases significantly after 3–5 days, which eliminates the need for stomas and related complications.One of the important indications for laparostomy is severe intra-abdominal sepsis. Whether abdomen should be left open or closed is a big controversy. Many conflicting studies have been published, claiming advantages and disadvantages. Decision to perform on-demand laparotomy in patients with abdomen closed remains one of the biggest challenges. This requires a dedicated team to recognize complications early. Moreover, repeat laparotomies may damage the fascia, which precludes future definitive closure. Mortality and morbidity resulting from severe peritonitis are very high. This is because continuing intraperitoneal sepsis results in multiorgan failure. Keeping this in view, Steinberg et al. left the peritoneal cavity completely open following laparotomy in severely decompensated patients due to peritonitis resulting from disruption of gastrointestinal anastomosis. Abdomen was closed after 48–72 h and found dramatic improvements in clinical course with markedly reduced mortality. Once the patient was stable after 48–72 h, abdomen was closed leaving skin open or closed primarily depending on wound infection.
In our study, majority of laparostomies were performed in patients with severe abdominal sepsis due to gastrointestinal perforations, and majority are caused by perforation of gastric and duodenal ulcers and trauma [Table 1]. Many of these cases were often delayed with organ failure bowel edema and severe sepsis.
|Table 1: Indications for laparostomy, closure of fascia/skin, and final outcome (n=25)|
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In severe pancreatitis, the most common cause of death after hypovolemia and organ failure is severe sepsis. This may be due to continued production of pus and formation of necrosis postoperatively with resulting severe sepsis. In a study by Bradley et al., necrosectomy and debridement of lesser sac with packing of lesser sac were done, and abdomen left open, dressings were changed at 2–3 days intervals. Out of 28 patients, 25 survived of the surgical procedure. It was also observed that none of the patients died of septic complications. Despite decreased mortality, morbidity due to pancreatic pathology remained high. Pancreatic fistula was found in 10 cases, incisional hernia in 8 cases, retroperitoneal hemorrhage in 2 cases, and fistula in 1 case. They opined that increased mortality after conventional laparotomy was due to limited drainage by abdominal drains placed after laparotomy where the abdomen was closed. Open abdomen allowed free drainage of exudate and purulent material and improved survival. In our study of the two patients with severe pancreatic necrosis, one patient presented with severe shock. Extensive debridement was done during initial surgery and pancreatic bed was packed with gauzes due to diffuse ooze from pancreatic bed. Serosanguineous discharge continued for 5 days postoperatively.
Since the introduction of damage control surgery in 1993 for trauma, open abdomen is now routinely used in patients with unstable physiology due to massive hemorrhage caused by trauma in patients at risk of developing acidosis, coagulopathy, and hypothermia. In this situation, abdomen is opened and hemorrhage is rapidly arrested by packing or any other means and abdomen is temporarily closed. This is also done to prevent intra-abdominal compartment syndrome, which results from massive bowel edema or intraperitoneal hemorrhage. Other indications for open abdomen in trauma cases include the need for second-look laparotomy in the immediate postoperative period, the need to remove visceral packing. It is estimated that damage control surgeries account for 10%–15% of all trauma laparotomies. If the damage control surgery has been done for bleeding in a severely injured patient, early return to theater and vessel repair should be considered, as long interval may lead to organ damage due to tissue ischemia supplied by that vessel. If damage control surgery (DCS) was done for liver or other solid organ injuries, it may be appropriate to remove packs after 48 h. Delay in the removal of packs more than 72 h is associated with more septic complications. In our study, damage control surgery was performed in three patients with penetrating and blunt abdominal trauma with exsanguinating bleeding from liver and pancreas and abdominal trauma. Perihepatic packing was done as the bleeding points were not amenable to primary suturing and severe hypotension during surgery. Re-exploraton was done at 48 h after stabilization, packs removed, and abdomen closed [Figure 4]. Similarly, in other two patients with pancreaticoduodenal injuries with retroperitoneal hematoma, packing was done to control bleeding.
|Figure 4: Severe abdominal injury with evisceration caused by penetrating trauma|
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Several techniques are used for TAC with variable success and complication rates. An ideal technique should be easy to apply, cheap, easily available and prevent complications associated with open abdomen. One of the simplest TAC techniques is using Bogota bag which is sutured to fascia or skin; other methods of closure include vacuum pack technique and vacuum-assisted closure and dynamic retention sutures. In our study, all patients had laparostomy using Bogota bag due to free availability and nonfamiliarity with other techniques, and we achieved almost similar results as other different TAC techniques described. Disadvantages include that it easily tears during suturing and allows herniation of bowel and cannot prevent loss of domain of abdomen. To overcome evisceration, we wrapped sterile gauzes of 4 or 6 inch size around the abdomen from xiphisternum to symphysis pubis loose enough to allow abdominal wall movement during respiration. Despite this, evisceration was observed in the postoperative period in three patients, which was caused by massive bowel edema and severe cough due to pulmonary infection. In both the situations, bag was torn on the one side and bowel loops were lying just beneath bandages.
Patients with open abdomen may require frequent change of dressings. Ideally, dressings should be changed in the operation theater. However, patients with open abdomen are often unstable and may have multiple catheters and tubes attached. This makes shifting of patient difficult and hazardous. Hence, feasibility of changing of dressing in the ICU must be considered. Seterns et al. demonstrated that the change of dressings in the ICU neither influenced 30, 60, and 90 days survival rate nor bloodstream infection rate and also showed reduced cost and time spent on change of dressings. In our study group, all dressing changes were done in the ICU only due to poor general condition of patients and improper facilities to shift patients. Frequency of dressing changes depends on underlying pathology. If laparostomy was performed for peritonitis and pancreatitis, frequent change may require. In our study, patients with peritonitis and pancreatitis required frequent change of dressings due to soakage. None of our patients needed any form of analgesia or sedation for change of dressing and all patients were well tolerated.
Closure of the abdomen should be done as early as possible once the patient is stable. Closure may be attempted after 48 h as most of the pathology will have resolved. Many clinical and laboratory parameters may help decide timing of closure of the abdomen. These include general condition, subsidence of bowel edema, and decrease in acidosis. A delay in closure of abdominal wall may increase complications, such as enteroatmospheric fistulae, infections, and loss of domain. Ideally, the abdomen should be closed within 7–10 days of laparostomy and efforts must be made to close during the initial hospitalization. If fascia cannot be approximated due to loss of fascia or retraction, various techniques can be adapted. These include usage of prosthetic materials, component separation of techniques, and skin only closure. Only skin closure is associated with large ventral hernia formation, which can be repaired electively. If the abdomen is not closed within 10–14 days, significant retraction of the abdominal wall may take place, leading to loss of domain. Hence, early closure should be attempted in all cases whenever feasible. In a retrospective study by Seterns A, et al fascial closure rate by silo closure was 82%, with a mortality rate of 18% when compared with patients in whom dynamic retention sutures were applied in which 85% fascial closure rates with 23% mortality rates was achieved
., In our study, fascial closure was achieved in 19 (76%) patients with an average fascial closure time of 3.80 days and ranging from 2 to 7 days. Only skin closure was done due to fascial retraction and bowel edema in 3 (12%) cases, leaving a large defect in abdominal wall. In patients where only fascia was closed initially, skin was left open and closed later due to fear of wound infection [Figure 5]. Overall mortality was seen in 4 (16%) cases in our study within a 30-day period following initial surgery. Mortality and fascial closure rates are almost similar to techniques of TAC methods. Two patients died within 48 h of surgery due to severe sepsis and multiorgan failure, and other two patients died of pulmonary infections. Enteroatmospheric fistula is a peculiar complication related to open abdomen and is defined as fistulous communication between the intestine and the external environment without any intervening tissue. In our study, none of our patients developed enteroatmospheric fistula which is a most dreaded and important complication of open abdomen.
| Conclusions|| |
Laparostomy is a very useful emergency procedure where relook or exploration of abdomen is needed in the immediate postoperative period. Despite many TAC techniques are available, the simplest and cheapest technique is silo bag coverage. Fascial closure and mortality rates are similar to other advanced TAC methods. Most important complication is failure to close fascia due to loss of domain. Accurate and timely identification of patients who need a laparostomy is very important. At present, there are no clinical or other criteria to select patients for laparostomy.
Informed consent obtained from all patients before surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]