Overview of Traumatic Open Abdomen
An open abdomen procedure is a common method used by doctors to treat injuries from traumas like falls or stabbings. In this type of procedure, the surgeon doesn’t immediately close the stomach-layer after operating. Instead, they plan to go back in and close it up after some time. This technique is helpful because it allows the doctor to go back in for further surgeries if needed, or to wait until the patient is more stable before completing the operation.
A specific type of open abdomen procedure is the damage control laparotomy (DCL). In this method, the surgeon first focuses on stopping any bleeding and fixing contamination issues to help preserve the patient’s strength and overall being. This is particularly useful if the patient is too weak for a long surgery. Afterwards, the abdomen is left open and can be closed later once the internal injuries are completely treated, which is a main advantage of this method.
After this procedure, the patient will be closely monitored in the intensive care unit (ICU). Doctors typically evaluate the patient every 24 to 48 hours to decide if they’re ready to go back into surgery for closure. In the meantime, if needed, the doctor will ‘washout’ or clean the open abdomen. Some signs that a patient is ready to head back into surgery include stable vital signs (like their heart rate and blood pressure), appropriate urine output, and no signs of an infection in the abdomen.
Patients who have their abdomen closed during their initial hospital visit typically spend less time in the ICU, have shorter hospital stays, and enjoy a better quality of life. Some studies suggest that patients are more likely to successfully have their abdomen closed if they’ve had fewer than four operations prior, or if the closure happens within eight days after the initial operation.
Also, feeding these patients through a tube in their stomach or small intestine (enteral nutrition) can increase the chances of successful first attempt abdomen closure. Studies showed that this also reduced the death rates in these patients compared to those who weren’t allowed to eat or drink anything (NPO). Therefore, doctors consider giving enteral nutrition to all patients with an open abdomen once they are no longer in shock.
Anatomy and Physiology of Traumatic Open Abdomen
An open abdomen from trauma refers to a surgical cut made along the middle of the stomach area. When we look from the outer layer to the innermost layer, the structure of this part of the stomach area includes:
- Skin,
- Fat tissue beneath the skin (known as Camper’s fascia),
- A layer of fibrous tissue just below the fat (Scarpa’s fascia).
- The linea alba or the middle line of the sheath that surrounds the stomach muscles (made up of the tissue coverings of the external oblique, internal oblique, and transversus abdominis muscles),
- Transversalis fascia, which is another layer of fibrous tissue.
Just under this final fibrous layer, you find the preperitoneal space (an area just before the abdominal cavity) and the parietal peritoneum (the layer lining the abdominal wall). When surgery is done, all these layers are cut through so that the surgeon can reach the organs within the abdomen.
Why do People Need Traumatic Open Abdomen
After an abdominal surgery due to an injury, doctors might decide to keep the belly open for various reasons. These include a build-up of pressure inside the abdomen, need for further control over an injury, impossibility to stitch the belly closed, or because they plan to do another surgery.
Conditions like Abdominal Compartment Syndrome (where a serious increase in pressure in the abdomen can harm your organs), swollen or blockage of intestines, severe infections inside the belly, heavy bleeding after an injury, inflammation of the peritoneum (the lining of your abdomen), or dangerous conditions like hypothermia (extremely low body temperature) and acidosis (too much acid in your body fluids) may also lead doctors to leave an abdomen open.
Additionally, if the doctors see the chance of sepsis (a life-threatening infection that spreads in your body) or think that the patient might need more than two hours in an operation that can’t be delayed, they may similarly choose to keep the belly open for a while after the surgery.
When a Person Should Avoid Traumatic Open Abdomen
There are situations where damage control surgery with an open abdomen isn’t suitable. This includes cases where the patient is stable in terms of their blood circulation and can withstand an operation that won’t last more than 2 hours. Damage control surgery refers to a type of surgery aimed at stopping bleeding and controlling contamination when a patient is facing a life-threatening injury. The term “hemodynamically stable” means the patient’s blood pressure and heart rate are in a stable range, allowing their body to function effectively.
How is Traumatic Open Abdomen performed
After certain types of surgeries, doctors use specific techniques to keep the belly (or abdomen) open for a short while. Such techniques are collectively known as “temporary abdominal closure” (TAC). They include negative pressure therapy (NPT), mesh-mediated fascial closure (MMFC), and several others.
Negative pressure therapy and mesh-mediated fascial closure are two common forms of TAC. For negative pressure therapy, the doctor uses affordable materials found in most operating rooms, like certain kinds of plastic and surgical towels. They can also use special systems made for this purpose. Similarly, mesh-mediated fascial closure involves using mesh materials, which are also readily available and inexpensive.
Negative pressure dressings help in multiple ways. They keep the abdominal wall steady, safeguard the internal organs in the abdomen, allow doctors to measure fluid loss from the wound, and help keep the tissue layer beneath the skin (fascia) ready for curing up the wound later on. But research indicates that there is no significant difference in the successful final curing of the belly between using negative pressure therapy or mesh-mediated fascial closure. The most important factor for healing is believed to be a procedure that keeps a constant pull on the wound’s edges, preventing further complications.
After temporary abdominal closure, the final treatment involves fully closing up the belly. This can be done early or in stages. If this fails, doctors may resort to creating a planned hernia (a bulge caused by organ pushing through a weak spot) with a thin layer of skin grafted (moved from one place to another on the body) to cover and protect internal organs in the belly. After about 9 to 12 months, the patient might need to go back to the operating room to remove the skin graft and mend the hernia.
Possible Complications of Traumatic Open Abdomen
Sometimes, after a certain type of surgery called an “open abdomen” surgery, patients may experience complications. These complications can be quite serious, affecting as many as 25% of patients. The chance of complications increases if the abdomen remains open for more than eight days. These complications can include the following:
1. A hole forming between your intestines and the outside air (entero-atmospheric fistula formation).
2. Excessive bleeding.
3. Infections.
4. Failure of multiple organs.
5. An abscess or pocket of pus inside your abdomen.
6. A severe, body-wide infection called sepsis.
7. Loss of bowel function.
8. Loss of fluids and proteins required by your body.
9. Loss of abdominal domain, which means you lose the natural shape of your abdomen.
10. Ventral hernias, which occur when tissue bulges through a hole in your abdominal muscles.
In emergency cases that required a laparotomy, which is a type of surgery involving a large cut in the abdomen, up to 40% are left open. However, due to the risk of complications, many hospitals are trying to find ways to minimize the use of these open abdomen procedures in trauma patients. For example, one hospital reduced its use of open abdomen procedures from 36.6% to 8.8% by prioritizing stopping bleeding, using blood products (like plasma) early, and reducing saltwater injections. This approach also decreased the death rate from 21.9% down to 12.9% among trauma patients who needed a laparotomy.
What Else Should I Know About Traumatic Open Abdomen?
A traumatic open abdomen is a procedure a trauma surgeon can utilize when a patient’s life is in danger during surgery. Basically, it’s a way of temporarily managing a critical situation until the patient can undergo final surgery under safer conditions.
Recently, the use of this approach, also known as damage control laparotomy (DCL), has decreased due to the introduction of new methods of controlling blood loss. These include allowing a slightly lower blood pressure than normal, reducing the use of certain fluids in treatment, and using blood components in a way that mirrors the composition of whole blood, a technique known as hemostatic resuscitation. This shift has led to fewer cases of open abdominal surgery and a significant drop in death rates.
There’s currently ongoing research to better understand specific cases where open abdomen treatments may still be necessary. From the information so far, DCL and related techniques should be used selectively, for patients who would continue to benefit from them even after the newer blood management strategies have been implemented.
