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Laparostomy with temporary abdominal closure remains a controversial technique and may be under-utilised in emergency surgery in the UK. The main indications are in the prevention and treatment of abdominal compartment syndrome (ACS) and to facilitate second-look laparotomy in trauma and complex sepsis. The historical unpopularity of laparostomy is multifactorial. Reasons include: (i) under recognition of the potential or actual development of ACS; (ii) a lack of surgical familiarity with the techniques of temporary abdominal closure (TAC); (iii) visceral complications including fistulation; and (iv) the perceived difficulty of obtaining eventual fascial closure.
Most studies on ACS and TAC have focused on trauma patients who have undergone damage control laparotomy for multiple system injury.1-4 These principles can be usefully applied in patients with intra-abdominal sepsis,5,6 severe pancreatitis7,8 and ruptured abdominal aortic aneurysms9,10 in whom similar pathophysiological mechanisms may be operating.11 Regardless of the underlying aetiology, the development of ACS is a common ‘second hit’ in the pathogenesis of multiple organ failure in surgical patients. Established ACS is associated with a grim prognosis.
Many techniques for TAC are described in the literature. These include the ‘Bogota Bag’, towel-clip skin only closure,12 synthetic mesh, both absorbable2,8,13 and non-absorbable,10 the ‘sandwich’ dressing,14 various ‘vacuum pack’ derivatives15-17 and silicone elastomer sheeting.18 The variety of techniques described suggests that each may have limitations in use.
We describe our modification of the Opsite® (Smith & Nephew, Hull, UK) sandwich ‘vacuum pack’ dressing for laparostomy wound management and our experience with it in a small series.
Patients and Methods
Method of construction
1. Three personnel including the theatre nurse are required.
2. A medium-sized Opsite® dressing (45 × 55 cm) with the backing removed is placed with the adhesive surface upward on an empty, draped theatre trolley and gently tensioned.
3. A large abdominal gauze pack (45 × 45 cm) with the sides folded inwards to create a rectangular configuration in the longitudinal axis, is laid onto the Opsite® dressing (Fig. 1).
4. The Opsite® dressing is then folded over the pack on all four sides leaving some exposed gauze uppermost (Fig. 2). This manoeuvre creates a dressing with both a non-adherent (under) and upper side for laying onto the intestinal surface and insertion beneath the posterior abdominal wall, respectively, while permitting fluid...