This right column displays thumbnails of the pictures addressed in the text of the publication. To see a larger version of the picture, please click the thumbnail.
Figure 1:
Excessive peritoneal edema covered with the artificial bur in a trauma case similar to the
one described
Figure 2
Hypopack: In 1992/93 the HYPOPACK has been used on top of the BUR t0 prevent exogenous infection and to collect peritoneal fluid for measuring protein losses (for meaningful replacement), to measure antibiotic concentrations (to make sure that the MIC in the peritoneum is above the MIC required to kill infecting bacteria) and to measure cytokines (published data). The Hypopack system has also been used without bur which, of course, is associated with much higher hernia rates.
Figure 3:
Bur in place with loop sheet attached to one fascia and lifted up:
Figure 4:
Bur in place with hook sheet attached to the other fascia and lifted up
Figure 5:
Hook sheet of bur with the hooks side pressed into a gauze sponge that we commonly call “lap”
Figure 6:
Reducing the size of the hook sheet becomes necessary or better possible as peritoneal edema decreases
Figure 7: REPLACE PIC
The size of the artificial burr is now narrower. The abdomen is about ready for final closure
Figure 8:
Closing the fascia with interrupted sutures. The Klöppel Technique is obvious from the illustrations. There is sufficient host defense localized in granulation tissue of the wound edges (never remove granulation tissue!!), that closing tolerates a bit more tension that what we normally teach and do. I never had to leave an abdomen open after STAR (Staged abdominal Repair) using the Wittmann Patch following midline incision.
This text has been edited and published in Advanced Trauma Operative Management
by L.M. Jacobs, R. Gross, and S. Luk (eds.) 2006/2007
Surgical Strategies for Penetrating Trauma. Cine-Med, Inc, Woodburry, CT 06789, ISBN: 0-9749358-8-0.
The Acronym of this EAST (Eastern association for Surgery of Trauma) publication became known as "ATOM"
TECHNICAL OPERATIVE PROCEDURES:
Staged Abdominal Repair (STAR)
for Penetrating Abdominal Trauma
SCENARIO
A 27-year-old man presented 45 minutes after a gunshot injury with a wound penetrating the abdominal wall 5 cm below the umbilicus. In spite of vigorous resuscitation with crystalloids during transport he remained hypotensive. He is immediately taken to the operating room. The abdomen is distended suggesting abdominal hypertension from hemoorhage.
Operative management: Staged Abdominal Repair
Index STAR
A full length midline incision from xyphoid to the symphysis provides sufficient access to the injuries. As the incision is opened further edematous bowel protrudes. There are multiple ileal perforations. Blood comes from a source within the pelvis which is packed. Clotted blood is scooped out of the abdomen and the extend of the injury inspected by applying pressure to the packs and lifting them up little by little. The projectile has also injured the internal iliac vein, the pre-sacral venous plexus, and has perforated the sigmoid colon twice.
A clean pack is broughtinto the presacral space and the internal iliac vein is freed, clamped and ligated. There is still considerable bleeding from the sacral venous plexus. The patient temperature is 35.8°C. New packs are inserted into the pre-sacral space which controls bleeding. After hemodynamics stabilized a second dose of 2 grams of cefotaxime and 500 mg metronidazole is given intravenously.
The sigmoid perforations are debrided, connected and closed with single layer 4xO PDS. To avoid time consuming repairs of the 6 irregular small bowel perforations the entire 20 cm segment is resected and both ends are stapled deferring anastomosis to the next abdominal entry (STAR#2) when the patient has been rewarmed and his hemodynamics and coagulation have stabilized and peritoneal edema is decreasing.
The abdomen is now washed with 8 liters of R/L and then quickly closed temporarily using the artificial bur with hypobaric wound shield (HBS) to provide closure over edematous intestines, to prevent complications of compartment syndrome, to avoid exogenous contamination, and to measure protein losses for meaningful replacement.
Closure with the Artificial bur (Wittmann Patch):
The softer loop sheet is sutured to the right fascia using a running looped #1 Nylon suture. The stitches are 2 cm apart and 2 cm into the fascia and 1-2 cm into the bur. The sheet with loops facing outwards is then pushed between parietal and visceral peritoneum of the other side of the incision covering abdominal content.
Then the harder hook sheet is similarly sutured to the left fascia, and hooks are gently pressed into the loops of the loop sheet. Because of the massive peritoneal hypertension in this case the hook sheet does not need trimming to fit the wound opening.
The space above the bur sheets is now packed with Kerlex wrapped around tubing that was used during the operation for suctioning. It stays connected to the intraoperative suction pump, which must continue suctioning until the wound is hermetically sealed and the tubing is connected to a transportable suction pump.
The wound including Kerlex and at least 15 cm of skin surrounding the wound is now covered with a self-adhesive sterile plastic drape. A mesentery is formed between the tubing and the skin to avoid any fluid leak around the tubing. It is important to keep suction running continuously (even during transport) to avoid fluid leaks between the skin and the drape that would open a path for exogenous contamination.
Also planned subsequent abdominal entries, STAR#2 through STAR#5 are scheduled immediately with the charge nurse in the operating room to make sure that all subsequent abdominal entries are happening at 24 hours interval.
28 hours later
Hemodynamics have stabilized, coagulation is normal and there is no evidence of further hemorrhage. 3580 ml of slightly hemorrhagic fluid has been collected via hypobaric tubing and peritoneal fluid protein content is 30% of serum levels. These protein losses have been replaced by intravenous fresh frozen plasma. Antibiotic were continued every 12 hours because of the potentially contaminated pack within the pelvis. Antibiotic concentrations within peritoneal fluid were 4 to 10 times above the MIC of intraperitoneal pathogens isolated. There was no fluid leak underneath HBS.
STAR # 2
The hypobaric and Kerlex are removed and the bur hook sheet pulled off the loop sheet and folded sideway using a lap to cover the hooks. Then the loop sheet is pulled to open the abdomen. Peritoneal fluid is reddish clear, and bowel is edematous. Before removing the presacral pack the stapled end of the ileum is reconnected using a 4xO running PDS suture to form a single layer anastomosis.(Alternatively stapling of the anastomosis has the advantage that the bowel edema is gently squeezed out while hand sown sutures may loosen as edema decreases).
The presacral packs are now gently removed. There is only some minor oozing from the pre-sacral space. Inspection of the sutured sigmoid reveals no leak and no necrotic tissue around the sutures.
All four quadrants of the abdomen are irrigated with R/L. A new pack is brought into the pelvis and the abdomen is closed by pulling the bur sheets together with some tension to reapproximate the fascias. The hook sheet is now too large and cut to fit opening. HBS is done as described for the INDEX STAR
24 hours later
The patient has been stable, no fever, slight leucocytosis. Peritoneal fluid collected was yellowish clear with a protein content of 50% of serum protein. Patient continues to be on TPN. Diuresis has been forced to reduce peritoneal edema and permit fascial reapproximation.
STAR # 3
The bur is opened as described above. There is still some bowel edema. Neither the small bowel anastomosis nor the sigmoid colon suture is leaking and peritoneal fluid is clear and peritoneal inflammation is much improved. The pack from the pelvis is removed. No further hemorrhage. The peritoneal cavity is then washed with 6 L R/L and closing the burr permits reapproximating the fascia up to a 7 cm gap. The hook sheet is further trimmed. Hypobaric is then applied.
After reopening the bur the abdomen looks ready for final closure and an abdominal x-ray is done to exclude any left lap sponges. Meanwhile all suture lines appear to be healing well, no leak no necrosis no new pathology. The bur sheets are pulled approximating fascia edges which show that final fascial suture is possible. Both sheets are then removed and multiple fascial #1 PDS sutures are placed, secured with clamps, and lifted by the assistant while the surgeon ties each single fascial suture. There were no complications postoperatively.
Critical Details
From lessons learned over 15 years experience with STAR
- Handle tissue and fascia gently
- Exert some tension to the fascia pulling both sheets medially while closing
- Replace packs often
- Exert some tension to the fascia via bur
- Do deferred anastomoses early, avoid colostomies
- Stick to 24 hrs interval. Avoid transmural feeding tubes
- Final fascial closure at the end of STAR tolerates more tension than closure after a single laparotomy
- Do abdominal x-ray at last STAR to account for packs
- Prevent contamination of wound in the ICU
- Time antibiotic, like prophylaxis 1/2h prior to STAR entry
- Knowantibiotic tissue concentration in peritoneal fluid
- Abdominal Hypertension & Mediators
- Measurementof intra-abdominal pressure
- Purging of bad cytokines(TNF)is possible on a more rational basis
- Replacing lost proteins with FFP
- Obtain initial informed consent for multiple abdominal entries
Bibliography
Wittmann, DH: Newer methods of operative therapy for peritonitis: In Nyhus LM, Baker RJ, Fischer JE, (eds.) Mastery of Surgery, Third edition Little Brown and Company, Publishers, Boston, pp 146-152,
Wittmann, DH. Chapter 160: Compartment Syndrome of the Abdominal Cavity. In RS Irwin, FB Cerra, JM Rippe (eds.) Intensive Care Medicine, 5th Edition, Lippincott-Raven Publishers, pp. 1694-1709, 2002
Wittmann, DH. Chapter 37: Status of the open abdomen in patients with uncontrolled intra-abdominal infection with sepsis. In Deitch, Vincent; Windsor (Editors. Sepsis and Multiple Organ Dysfunction. WB Saunders. London, NewYork,2002, pp 308-316,