Open abdomen treatment (OAT) is increasingly used, most often to prevent intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) after emergency abdominal surgery. The goal of temporary abdominal closure (TAC) techniques no longer is abdominal coverage alone, but fluid control and facilitation of early fascial closure are now important aspects. Various methods are available, but negative pressure therapy seems to be best suited to achieve these goals. Fascial approximation techniques prevent lateral retraction of the abdominal muscles and can be combined with TAC techniques. Mesh-mediated vacuum-assisted wound closure is emerging as one of the most promising approaches for OAT. In the intensive care unit, continued attention to IAH/ACS and measures to prevent or treat these conditions is imperative.
We have categorized the different TAC techniques into three generations reflecting the historical evolution of both devices and insights in the pathophysiology (Table 2); first-generation TAC was mainly aimed at bridging the defect and covering the abdomen; second-generation TAC aimed at fluid control and improved barrier function; third-generation TAC applies negative pressure to actively remove fluid from the abdomen.For this and other VAT products visit
www.vatvalve.com, email
US@vatvalve.com or contact VAT at 800-935-1446.The FlapVAT is designed for vacuum production tools with slit heights smaller than 80mm. The valve technology is based on the common flapper valve that enables a swift exchange of the gate O-Ring and the integrated actuator allows for differential pressure opening wherever this is required. Depending on temperatures and outer conditions, the actuator can be placed on top or at the sides of the valve. Stainless steel or aluminum body and gate and horizontal or vertical orientation are other standard options that are available.The midline laparotomy incision that is left open exposes the peritoneal cavity with the liver, stomach, omentum, and small bowel most often in direct contact with the wound. Initially, the main goal of TAC techniques was to prevent injury to these organs and contamination of the sterile abdominal cavity. As experience increased, control of fluid loss, prevention of loss of abdominal domain, and avoidance of damage to the fascia that could affect subsequent abdominal closure were also found to be important goals. With the advent of negative pressure therapy (NPT), active fluid removal from the abdominal cavity could be the next therapeutic target.Natural filament brushes will comb through the densest carpet, brushing out the pet hair. The great benefit of the natural fiber roller brush is that the hair will not get trapped around the roller brush. hair wrapping around a bush causes many problems. It slows down the roller brush, stretching the vacuum cleaner cleaner belt. Dog and cat dander and hair clogs up the brushes itself, making the brushes powerless to comb through the carpet fibers. Puppy and cat hair will get trapped in the roller brush's bearing, causing the bearings to burn out. Normal replacement of the roller brush is the outcome. All in all, it's better to use natural bristle brushes when possible.The FlapVAT is available from slit openings 30 x 500mm up to 80 x 3000mm with a flange to flange dimension of 160mm. It can be used in door, valve or insert configurations and will be displayed at Intersolar North America 2011. Visit VAT at Intersolar North America Booth #9026 from July 12 - 14, 2011, in West Hall at the Moscone Center in San Francisco, California.Problems with Temporary Abdominal ClosureUsing a strong vacuum cleaner motor will undoubtedly help. Motors are rated by the number of amps of electricity they utilize.SOURCE VATThere are many higher end vacuum cleaners that utilize natural fiber brushes, have motors with double fans, and even have turbine driven brushes for your upholstery cleaning. Most models of vacuum cleaners that have the benefits we talked about are just available from independent vacuum cleaner retailers.The more principal feature, when picking up pet hair, is what number of fans the motor uses. A motor with two fans, will pull the air, and also the pet hair, just about fifty percent harder than a motor with one fan.Second-Generation Temporary Abdominal Closure: Fluid ControlSynthetic CoverA list of the characteristics of the ideal TAC is long (Table 1) and so far none of the currently available methods possesses all of them. There have been considerable improvements in the TAC techniques, especially with improved fluid control and barrier function in the more recent techniques. This has greatly improved the care for the patient with an open abdomen in the ICU and reduced the workload for the nurses. Negative pressure is the latest improvement in TAC; active fluid removal from the abdomen appears to be the next step in open abdomen management.Skin ClosureThe abdominal wound can also be covered by a synthetic prosthesis. This was first introduced by Colombian surgeons, who used a simple sheet cut out of a 3-L saline irrigation bag (the so-called "Bogot� bag" or "Bolsa de Borraez") that is sutured to the fascia or the skin (Fig. 2). Silicone sheets can be used as well. Various meshes of different material fall into this category; these can be absorbable or nonabsorbable meshes that are sutured to the fascia; polypropylene (Marlex, Prolene, Surgipro), polyglycolic acid (Dexon), polyglactic acid (Vicryl), and PTFE (Gore-Tex) have been used (Fig. 3). Biological meshes such as those manufactured from human or porcine dermis have been used mostly for reconstruction of the abdominal wall at a later stage, but these can also be used for temporary cover; no large-scale experience has been reported so far. Each mesh has specific characteristics and disadvantages that fall beyond the scope of this review. A prosthesis can also be used to progressively approximate the fascia by reducing the size. Other prostheses have been developed specifically with this purpose, e.g., the Wittman patch(TM) (NovoMedicus, Nokomis, FL) (or "artificial burr") that consists of two sheets of Velcro.Indications for Open Abdomen Treatment and Temporary Abdominal ClosureTemporary Abdominal Closure Techniques
NPT has been used for some time in the management of various types of wounds. The use of this approach was introduced in the Abdominal VAC Abdominal Dressing (Kinetic Concepts, Inc., San Antonio, TX), which consists of a perforated plastic sheet containing a foam, on top of which a sponge is inserted that covers the abdominal defect (Fig. 5). This is covered by an airtight seal and connected to a pump. Apart from covering the abdomen, it allows evacuation of excess abdominal fluid and keeps constant tension on the fascia. Clinical experience confirms that NPT in this setting is safe and despite concerns for the development of intestinal fistulas, the reported incidence in a recent review is the lowest of all TAC techniques.5 The latest version of this dressing, the ABThera(TM) (Kinetic Concepts, Inc., San Antonio, TX), has "arms" that make it easier to insert and also improve the application of the negative pressure across the surface of the abdomen. Increasingly, NPT is combined with a first-generation TAC system to progressively approximate the fascia (see subsequently).
Author: De Waele, Jan J, Lepp�niemi, Ari K
