Abdominal Wall: Temporary Abdominal Closure (TAC) & The Difficult Abdomen

Open Abdomen (OA) & Temporary Abdominal Closure (TAC)

Indications

  • Damage Control in an Unstable/Crashing Patient
  • Excessive Edema/Tension & Unable to Close Fascia
    • “The Difficult Abdomen”
  • Abdominal Compartment Syndrome
  • “Second-Look” to Reevaluate Questioned Bowel Viability or Hemostasis

Techniques

  • Negative Pressure Wound Therapy (NPWT) – Use of a Negative Pressure System to Assist in Closure
    • Commercial Systems Include AbThera & VAC Therapy
    • Suctioned at 100-150 mmHg
    • More Expensive but Provides Excellent Fluid Control
  • Vacuum-Pack (Barker’s Technique) – The “Home-Made” NPWT System (“Ghetto-VAC”)
    • Technique:
      • A Nonadherent Sheet is Placed Over the Abdominal Viscera Beneath the Anterior & Lateral Abdominal Walls
        • Necessary to Protect the Bowel
        • Add Intermittent Perforations Through the Sheet to Promote Fluid Absorption
        • Options: Polyethylene Sheet, “10/10” Steri-Drape, X-Ray Cassette Cover
      • A Surgical Dressing (Towels/Sponges) is Placed Over the Sheet
      • Two Silicone Suction Drains are Placed Along the Dressing to Allow Negative Pressure
      • An Adhesive Sheet (Ioban) is Covered Over the Wound & Skin Edges
    • Suctioned at 100-150 mmHg
    • Uses Cheap Material Already Found in the OR if Other NPWT Systems are Unavailable
  • Patch Closure – Use of a Synthetic Mesh Bridge Between the Fascia (PTFE Mesh or a Wittmann Patch)
    • Can Additionally Use a WVAC Over the Patch
  • Bogota Bag – A Sterile IV Fluid Bag is Sutured to Each Side of the Abdominal Wall
  • Zipper Closure – Zipper Device Sutured to Wound Edges to Permit Multiple Repeated Examinations
  • Skin-Only Closure – Uses Staples or Towel Clamps Every 1-2 cm, Covered with a Plastic Drape

ABTHERA WVAC 1

Barker Vacuum-Pack 2

Closure of the Difficult Abdomen (When Primary Closure is Not Possible)

Adjuncts

  • Appropriate Diuresis
  • WVAC to Drain Exudate & Decrease Edema

Options

  • Velcro (Hook & Loop) – Two Velcro Sheets Allow Progressive Tightening to Close Over a Period of Time
    • Wittmann Patch – Attached to the Fascial Edges
    • Transabdominal Wall Traction (TAWT) Method – Uses a Whittmann Patch Attached to the Underside of the Abdominal Wall, Lateral to the Rectus Muscle with Sutures Brought Through the Skin to a Bolster
  • Bogota Bag – A Sterile IV Fluid Bag is Sutured to Each Side of the Abdominal Wall & Progressively Tightended (Similar to a Whittmann Patch)
  • Canica ABRA System – Elastic Bands Trough Each Side Allow Progressive Tightening to Close Over a Period of Time
  • Delayed Skin Grafting – Can Either Place a Temporary/Absorbable Mesh or Use WVAC to Form Granulation Tissue Prior to Grafting
  • Skin-Only Closure – Allows Recovery of the Acute Period with Plan for Abdominal Wall Reconstruction Later Under More Favorable Terms

Wittmann Patch 2

Bogota Bag 2

Canica ABRA System 3

Delayed Skin Grafting 2

References

  1. Alvarez PS, Betancourt AS, Fernández LG. Negative Pressure Wound Therapy with Instillation in the Septic Open Abdomen Utilizing a Modified Negative Pressure Therapy System. Ann Med Surg (Lond). 2018 Oct 10;36:246-251. (License: CC BY-4.0)
  2. Huang Q, Li J, Lau WY. Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review. Gastroenterol Res Pract. 2016;2016:2073260. (License: CC BY-4.0)
  3. Iype S, Butler A, Jamieson N, Middleton S, Jah A. Delayed dynamic abdominal wall closure following multi-visceral transplantation. Int J Surg Case Rep. 2014;5(12):988-91. doi: 10.1016/j.ijscr.2014.08.006. (License: CC BY-NC-ND-3.0)