Abdominal and thoracic wall closure: damage control surgery's cinderella

Abstract

Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Keywords: Damage Control Surgery; Delayed Cavity Closure; Hemodynamically Unstable; Negative Pressure Dressing; Open Abdomen; Temporary Closure; Thoracic Packing.

Figure 1. Temporary abdominal wall closure techniques. (A) Temporal Closure with Towel Clips, (B) Wittmann’s Patch, (C) Bogotá Bag, (D) Vacuum Pack Barker.

Figura 2. Kaplan-Meier analysis of time to definitive closure regarding the use of commercial or artisanal negative pressure system. Time to definitive closure is not statistically different between pressure negative systems (Log-Rank Test 0.439).

Figure 3. Hemostatic effect over the thoracic wall using a Foley catheter. To control persisting surgical bleeding from thoracic wall bone structures (vertebral bodies, ribs, or sternum), a Foley catheter should be inserted directly into the bone wound, then inflated and gently retracted until hemorrhage control is achieved.

Figure 4. Negative pressure dressing with a fenestrated plastic interface. A plastic with linear perforations not longer than 5 mm should be extended over the entire cavity covering the recesses completely and separating intra-abdominal organs from the abdominal wall.

Figure 5. ABThera™ VAC System. This negative pressure dressing contains an open-pore polyurethane ether foam sponge that separates intra-abdominal organs, 2 additional foam sponges transmitting the negative pressure, various adhesive sheets for system sealing and a suction tube which extends into a disposable collection canister.

Figure 6. Negative pressure dressing system placement. A fenestrated plastic separates intra-abdominal organs, while foam sponges or dressings are placed over it and secured beneath a double layer of adhesive sheets. The suction device is installed over the adhesive film by cutting out a 3 to 3.5 cm diameter circle.

Figure 7. Negative Pressure Dressing Placement Following Sternotomy Approach. A fenestrated plastic sheet is placed over the heart, followed by a first foam that covers the entire mediastinum and a second foam covering the two edges of the sternotomy and the space between them. The system is sealed with an adhesive sheet, which is connected to the suction tube by a hole cut in the adhesive film.

Figure 8. Thoracic Packing Following Thoracotomy. The source of bleeding (usually ribs, intercostals, serratus and latissimus dorsi muscles) is first packed, followed by the upper and lower ribs. The cavity is then closed with a continuous suture starting at the medial edge and a fifth compress is introduced into the wound as the skin suture progresses.

Figure 9. Thoracic Packing Following Medium Sternotomy. Surgical compresses are placed directly on the heart and mediastinum until it is completely occupied, always monitoring for hemodynamic changes. Then, a drain is placed and the edges of the sternotomy and the space between them are also packed before skin closure is performed.

Figura 1. Técnicas de cierre diferido de pared abdominal. (A) Cierre con pinzas, (B) Parche de Whitman, (C) Bolsa de Bogotá, (D) Vacuum Pack Barker

Figura 2. Análisis de Kaplan Meier de tiempo de cierre de la herida respecto al uso de sistemas de presión negativa artesanal y comercial. No hubo diferencia significativa en el tiempo de cierre de la herida entre los sistemas de presión negativa (Log-Rank Test 0.439).

Figura 3. Efecto hemostático sobre la pared torácica con el uso de Sonda Foley. El sangrado persistente que proviene de las estructuras óseas del tórax (cuerpos vertebrales, costillas o esternón) se puede controlar al introducir un catéter con balón (Sonda Foley) directamente por el orificio de la herida ósea, inflar el balón y retraer la sonda suavemente.

Figura 4. Sistema VAC con interfaz de plástico fenestrado. Un plástico con perforaciones lineales menores de 5 mm debe extenderse por toda la cavidad cubriendo completamente los recesos y separando los órganos intraabdominales de la pared abdominal.

Figura 5. Sistema Comercial ABThera™ VAC. Este sistema contiene una espuma de poliuretano de célula abierta que separa los órganos intraabdominales, 2 espumas que transmiten la presión negativa, varias láminas adhesivas que sellan del sistema y un tubo de succión que se extiende hasta un contenedor de recolección desechable.

Figura 6. Instalación del sistema de presión negativa. Una interfaz de plástico fenestrado separa los órganos intraabdominales, mientras que las espumas o apósitos se ubican encima y se fijan con una capa doble de plástico adhesivo. El dispositivo de succión se instala sobre el plástico adhesivo recortando un círculo de 3 a 3,5 cm de diámetro.

Figura 7. Instalación del sistema de presión negativa en el abordaje por esternotomía. Se extiende un plástico perforado directamente sobre el corazón, seguido de una primera espuma que abarque todo el mediastino y una segunda espuma que cubra los dos bordes de la esternotomía y el espacio entre ellos. Se sella el sistema con un plástico adhesivo, que se conecta al tubo de succión mediante un orificio cortado en el adhesivo.

Figura 8. Empaquetamiento torácico en el abordaje por toracotomía. Primero se empaqueta la fuente del sangrado (usualmente costillas o músculos intercostales, serrato o dorsal ancho), seguido de las costillas superior e inferior. Luego se cierra la cavidad con una sutura continúa comenzando en el borde medial e introduciendo una quinta compresa en la herida a medida que avanza la sutura de la piel.

Figura 9. Empaquetamiento torácico en el abordaje por esternotomía mediana. Se sitúan las compresas quirúrgicas directamente sobre el corazón hasta ocupar el mediastino completamente, siempre monitorizando los cambios hemodinámicos. Luego, se ubica un dren, se empaquetan los bordes de la esternotomía y el espacio entre ellos y se cierra la piel.