Application of vacuum-assisted therapy in postoperative ascitic fluid leaks: an integral part of multimodality wound management in cirrhotic patients

Abstract

Surgery in patients with hepatic cirrhosis and ascites is associated with significant morbidity, including poor wound healing. Postoperative management of abdominal and perineal wounds in these patients poses a unique challenge owing to increased intra-abdominal pressure, risk for peritonitis, and ascitic fluid leakage. Vacuum-assisted closure (VAC) therapy reportedly improves angiogenesis and epithelialization, controls bacterial contamination, and removes excess tissue fluid. We present 4 cases of successful management of intractable postoperative ascitic fluid leaks utilizing VAC-based techniques. In one case, closure of a profusely draining perineal wound following an abdominoperineal resection was accomplished within 5 days of specialized VAC dressing application. In the other 3 cases, refractory drainage from midline laparotomy incision was successfully managed with the use of VAC therapy. In all 4 cases, the VAC-based system was effective in controlling drainage of ascites and subsequently sealing the wounds. Postoperative use of VAC in conjunction with optimization of medical therapy and judicious tapping of ascites provides a safe and effective method to control ascitic fluid leaks and promote definitive tissue sealing in patients with hepatic cirrhosis.

Figure 1

Depiction of VAC dressing used in Case 1. (A) Bottom layer of biocclusive was placed over patient's skin overlying the incision, and a slit was created over the incision site to allow for drainage. A sponge was placed over the biocclusive and incision. Finally, a top layer of biocclusive was placed over the sponge and adhering to the bottom biocclusive layer. A small cruciate incision was made in the top biocclusive, to which the VAC was attached. (B) Cross-section schematic view of the abdominal wall and VAC dressing. Proposed vectors of subatmospheric pressure forces are indicated by arrows.

Figure 2

Depiction of VAC dressing used in Case 2. (A) Small sponge was placed over the anterior portion of the incision. This was covered with biocclusive, with a cruciate incision in the region overlaying the sponge. The VAC was attached with adhesive over this incision in the biocclusive. (B) Schematic cross section view of the VAC dressing. Proposed vectors of force are indicated by arrows.

Figure 3

Stepwise depiction of VAC dressing placement in Case 3. (A) Wound manager overlying the midline wound prior to removal. (B) Midline wound following removal of wound manager and prior to VAC placement. (C) The bottom layer of biocclusive placed on the skin around the incision, with the incision itself left uncovered by biocclusive. (D) VAC sponge placed over the midline incision, along with the second biocclusive (indicated by green diagonal lines). (E) VAC suction device placed over biocclusive prior to application of subatmospheric pressure therapy. (F) The VAC dressing after institution of subatmospheric pressure therapy.