Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control laparotomy

Abstract

Background: The ability to massively transfuse and resuscitate critically ill surgical patients has resulted in unprecedented survival and a new set of complications including abdominal compartment syndrome (ACS) and the "unclosable" abdomen. Traditional methods of temporary abdominal closure have met with several limitations, not the least of which is a marked delay in achieving definitive fascial closure. Since 1991, we have consistently used reinforced silicone elastomer (Silastic) sheeting as a form of temporary abdominal closure in these settings. We report our results using this technique in a large cohort of critically ill surgical patients.

Methods: All patients undergoing silicone elastomer temporary abdominal closure since 1991 were identified and their charts abstracted for principal diagnosis and indication for temporary abdominal closure, fluid requirements, number of operations, and time to fascial closure. Time to definitive closure in the respective groups was analyzed using Kaplan-Meir survival curves and the Wilcoxon rank-sum test. Odds ratios for death were analyzed using logistic regression.

Results: One hundred thirty-four patients underwent temporary abdominal closure with silicone elastomer over this period and only 62% (83) survived their hospital admission. Trauma and ruptured abdominal aortic aneurysm were the most frequent diagnoses. The most frequent indication was edema precluding abdominal closure. The mean crystalloid and blood requirements in the 24 hours preceding temporary abdominal closure were 21 +/- 16 L and 15 +/- 11 U, respectively. Of survivors, 75% (63 of 83) achieved fascial closure during their index admission. The median time to fascial closure in patients ultimately closed was 5 days. The median time to closure and the proportion of patients ultimately closed varied with the indication for closure with an earlier and greater chance of success in patients who could not tolerate closure (ACS) or could not be closed primarily (edema). Age-adjusted mortality was 5 times (95% confidence interval: 2 to 13) higher in patients developing ACS.

Conclusions: Nylon reinforced silicone elastomer is a safe, reliable material for temporary abdominal closure in severely ill patients. Primary fascial closure can be obtained in a timely fashion in the majority of patients. The success of obtaining definitive fascial closure depends on the indication for temporary abdominal closure, with visceral edema and ACS having the highest likeliest of early success.