“Complex abdominal wall” management: Guidelines of the Italian Consensus Conference
Italian Consensus Conference has released guidelines for “Complex abdominal wall” management. The guidelines have appeared in Updates in Surgery.
The purpose of the Conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives:
- To develop evidence-based recommendations to define “complex abdominal wall”;
- Indications for open abdomen in emergency and in elective cases;
- Management of “complex abdominal wall”;
- Surgical details and indication for use techniques for temporary abdominal closure;
- Use of biological and synthetic meshes and follow-up.
Although in elective surgery the term “complex abdomen” is often used as a synonym for “complex abdominal wall hernia”, where the main problem is to face a technically challenging and time-consuming hernias, in emergency situations to close and how the abdominal wall might represent, in particular and demanding situations, a surgical nightmare to solve by surgeons.
Indications to open abdomen in emergency and trauma.
- In conditions of Damage Control Surgery, the preventive Open Abdomen is indicated in the presence of packing that should be removed, massive hemorrhage, severe peritonitis, major abdominal and retroperitoneal tissue edema, loss or altered tropism of fascia or when it is necessary a second look (STRONG RECOMMENDATION).
- The therapeutic Open Abdomen both in emergency surgery and in trauma is indicated in cases of compartment syndrome in which medical treatment failed (STRONG RECOMMENDATION).
Although the therapeutic Open Abdomen is also recommended the cases of intracranial hypertension not responsive to medical therapy: cause the paucity of cases, it is not possible to give a greater level of evidence (WEAK RECOMMENDATION).
Temporary Abdominal Closure (TAC) technique
- In the absence of sepsis, the Wittmann patch and Negative Pressure Wound Therapy (NPWT) abdominal dressing offered the best outcomes. In the presence of sepsis, NPWT had the highest delayed primary closure rate and lowest mortality, especially when associated with continuous fascial retraction to achieve delayed fascial closure and a reduction of the risk of enteroatmospheric fistula (WEAK RECOMMENDATION).
- Protected non-absorbable and absorbable meshes can be used for temporary abdominal closure. Absorbable meshes may be left in place at the closure of abdomen, whereas non-absorbable materials usually need to be removed (WEAK RECOMMENDATION).
- All TAC systems that do not prevent retraction of the fascia should be used if a definitive closure is possible in a short time. They are simple, inexpensive and prevent bowel desiccation allowing the conservation of electrolytes and thermal effects (STRONG RECOMMENDATION).
The main indications of temporary abdominal closure (TAC) technique are prophylactic abdominal decompression, planned repeated explorations of the peritoneal cavity and the treatment of the abdominal compartment syndrome.
Decision-making in the management of open abdomen
- It’s recommended to close the abdomen as quickly as possible. It is suggested within 9 days (STRONG RECOMMENDATION).
- It’s recommended to revise TAC system every 24–72 h and to explore the abdomen only if it’s necessary. A restrictive fluid resuscitation and a strict control of the infections is suggested (WEAK RECOMMENDATION).
When a biologic graft may or must be used in a complex abdominal wall repair?
- The biological prosthesis should be implanted only in clinical cases where is present a contaminated or potentially contaminated surgical field (STRONG RECOMMENDATION).
- The use of not cross-linked material should be associated with abdominal wall midline restoration, with or without component separation, due to a higher recurrence rate in the bridge repair without midline restoration (WEAK RECOMMENDATION).
- The cross-linked material could be used in case of midline restoration. It should be used in case of bridging thanks to a higher tensile strength (WEAK RECOMMENDATION).
When a synthetic mesh may or must be used in a complex abdominal wall repair?
- All complex ventral hernia repairs (VHR) should be reinforced with prosthetic repair materials, but there is a significant increase in the risk of postoperative occurrences using mesh in clean-contaminated and contaminated cases compared to clean cases (WEAK RECOMMENDATION).
- The use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination seems a cost effective approach (WEAK RECOMMENDATION).
Biological prosthesis implant in pediatric and neonatal surgery.
- The use of biological prosthesis is safe and feasible in pediatric abdominal wall closure. The use of the biological prosthesis in a contaminated surgical field improves the surgical outcome without the need of prosthesis removal in case of infection. The use of biological prosthesis allows the abdominal wall closure after pediatric abdominal transplantation. The use of biological prosthesis allows the abdominal wall closure in patients with congenital abdominal wall defects (WEAK RECOMMENDATION).
The use of negative pressure wound therapy (NPWT) in complex abdominal wall repair’s SSO (Surgical Site Occurrence) with synthetic meshes and biological implants
- NPWT can be safely used both with synthetic and biologic infected meshes (WEAK RECOMMENDATION).
- NPWT is useful because promotes granulation tissue formation and tissue ingrowth over the synthetic mesh (STRONG RECOMMENDATION).
- NPWT could reduce hospital-stay with a decreased rate of complications (WEAK RECOMMENDATION).
The recurrence after biological mesh implant
- Hernia recurrence after abdominal wall repair with biological mesh is comparable to repair with non-biologic mesh. No significative differences in recurrence rate are found among several types of biological meshes (WEAK RECOMMENDATION).
- There is an evident correlation between hernia recurrence and postoperative infection as well as repair performed in contaminated field and in high-risk patients. The use of biological mesh in bridge technique results in a high recurrence rate, thus the fascial closure with or without component separation technique should be achieved when possible (STRONG RECOMMENDATION).
- The prosthetic mesh can be used safely in recurrent hernias, without biological mesh removal (WEAK RECOMMENDATION).
Nutritional and antimicrobial support treatment
- Early enteral nutrition in the open abdomen should be considered in all patients with a viable gastrointestinal tract (STRONG RECOMMENDATION).
- An antibiotic perioperative prophylaxis is essential in all cases. In the case of gross contamination, a therapy of broad-spectrum antibiotics should be continued for 4–7 days or more according to clinical conditions (WEAK RECOMMENDATION).
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Updates in Surgery