Modern Management of Complex Open Abdominal Wounds of War: A 5-Year Experience
Abstract presented at the American College of Surgeons 93rd Annual Clinical Congress, New Orleans, LA, October 2007.
Received 30 May 2008; received in revised form 12 August 2008; accepted 13 August 2008.
Background
Optimal management of the open abdomen remains controversial.
Study Design
Retrospective review of patients injured during Operations Enduring Freedom and Iraqi Freedom returning to Walter Reed Army Medical Center (WRAMC) from January 2003 to October 2007 for treatment of open abdomen.
Results
Three hundred fifty-four patients were evacuated to WRAMC after laparotomy, including 86 patients (24%) with open abdomen. Three transferred patients were excluded. Eighty-three patients, mean age 26 years (range 18 to 54 years), sustaining injury from secondary blast (n = 47), gunshot (n = 29), and blunt trauma (n = 7) were studied. Surgical management included early definitive abdominal closure (EDAC, n = 56; 67%), primary fascial closure (n = 15; 18%), planned ventral hernia (PVH, n = 9; 11%) and vacuum-assisted closure with AlloDerm (n = 3; 4%). EDAC closure involves serial closure with Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh (62%) or AlloDerm (31%). There was no substantial difference in injury mechanism, age, length of evacuation to WRAMC, or Injury Severity Score (average 30) according to closure type. Complications included removal of infected prosthetic mesh in 4 EDAC closure patients (5%). Overall morbidity was lowest (60%) in primary repair patients (p = 0.01). Rates of deep venous thrombosis, pulmonary embolism, abdominal wall hematoma, and infection did not differ between groups. Fistula rate was increased with PVH (20%). Two patients with PVH died. PVH and EDAC mesh complications have been minimized in the last 2 years of the study.
Conclusions
Primary closure of fascia is ideal but not always possible. Early definitive closure has avoided PVH. Mesh-related complications have decreased with time.
Correspondence address: Amy Vertrees, MD, Walter Reed Army Medical Center, General Surgery, Bldg 2, 5th Floor, 6900 Georgia Ave, NW, Washington, DC 20307
Disclosure Information: Nothing to disclose.
This article represents the personal viewpoint of the authors and cannot be construed as a statement of official US Marine Corps policy.
ABSTRACT