Management and treatment options for patients with open abdomen

Module overview

Abdominal sepsis and trauma are the main indications for open abdomen. However, there is no robust evidence that open abdomen is better than closed in these cases. When using open abdomen, treatment goals are to control the source of infection, protect the bowel from damage, minimise adhesions between the bowel and abdominal wall, facilitate nursing care and allow permanent closure of the wound by bringing the fascial edges closer. Several temporary abdominal closure techniques exist, but are associated with high mortality and morbidity rates. There is no evidence that any specific temporary abdominal closure technique is better than others; however, negative pressure wound therapy appears to be a popular method of management of open abdomen.

Keywords

bacteria, bacterial infections, infection, infectious diseases, sepsis, wound care, wound closure

Aims

The aim of this module is to provide up-to-date information on managing patients with open abdomen and enable informed, effective nursing care.

Intended learning outcomes

After reading this module and completing the time out activities you should be able to:

• Define open abdomen and explain the difference between open abdomen and burst abdomen.
• Discuss the indications for open abdomen.
• Classify open abdomen according to its severity.
• Explain the main methods of managing patients with open abdomen.
• Compare the different temporary abdominal closure techniques.

Open abdomen

Definition

Open abdomen, or laparostomy, involves leaving the abdomen open deliberately and not closing the fascial and skin layers of the abdominal wall following surgery.

Open abdomen occurs most often after an emergency laparotomy, with the intention of closing the abdomen permanently at a later date (Carlson et al 2013, Kreis et al 2013, Lambertz et al 2014). Burst abdomen, or abdominal wound dehiscence, is an emergency complication of laparotomy. It involves the acute dehiscence of the skin, subcutaneous tissue and fascia of a previously closed laparotomy wound (López-Cano et al 2013).

Reasons for using open abdomen

The main conditions managed by open abdomen include abdominal infection and trauma (Howdieshell et al 2004, Kritayakirana et al 2010, Acosta et al 2011, Burlew et al 2011, Carlson et al 2013, Fortelny et al 2014). Abdominal infections may occur because of spontaneous perforation, inflammation of the structures of the gastrointestinal tract or as result of post-operative infection following abdominal surgery (Kritayakirana et al 2010, Carlson et al 2013, Fortelny et al 2014). Post-operative infections may occur as a result of an anastomotic leak. The abdomen may also be left open as part of the initial treatment of the condition, or as part of the treatment of post-operative complications (Howdieshell et al 2004, Kritayakirana et al 2010, Carlson et al 2013).

Other conditions that may be managed by open abdomen include: congenital abdominal wall defects, intra-abdominal haemorrhage, necrotising pancreatitis and necrotising enterocolitis(Kritayakirana et al 2010, Carlson et al 2013, Lambertz et al 2014). It is difficult to estimate how often patients are managed using open abdomen in the non-trauma setting. In the trauma setting, about 0.6% (88/15,000, Howdieshell et al 2004) to 1.5% (248/16,917, Bee et al 2008) of trauma patients admitted to specialist trauma centres in the United States required open abdomen to manage their injuries (Figure 1).

Figure 1. Main conditions managed by open abdomen

Complete time out activity 1

Make a list of possible indications for managing patients using open abdomen in your clinical area. What are the possible benefits and risks?

The major indications for open abdomen are listed in Box 1. In unstable patients with abdominal trauma, the initial surgery is performed to control any bleeding and to stabilise the patient. Definitive re-exploration of the abdomen is performed at a later date. Open abdomen is advocated in the case of bowel ischaemia since there may be uncertainty about the viability of the bowel anastomosis. An inability to close the abdomen may arise from increased intra-abdominal pressure resulting from sepsis or trauma, or an insufficient abdominal wall. The usual intra-abdominal pressure is 5-7mmHg in critically ill adults (Malbrain et al 2006). Abdominal compartment syndrome involves an increased intra-abdominal pressure >20mmHg, resulting in multi-organ failure in adults (Malbrain et al 2006).

Box 1. Indications for open abdomen

To allow drainage of infected material resulting from:

• Intra-abdominal sepsis because of perforated abdominal organs.
• Intra-abdominal sepsis secondary to anastomotic leak.

To allow planned re-inspection of the abdominal organs and further management in relation to:

• Unstable patients with abdominal trauma.
• Bowel ischaemia.
• Necrotising pancreatitis.
• Necrotising enterocolitis.

Inability to close the abdomen because of:

• Oedema of the abdominal organ secondary to inflammation or as a result of high fluid requirement to maintain blood pressure.
• A defect in the abdominal wall.
• A congenital defect (gastroschisis).
• Necrotising fasciitis.
• Increased intra-abdominal pressure or abdominal compartment syndrome (pressure >20mmHg, resulting in multi-organ failure).

(Howdieshell et al 2004, Malbrain et al 2006, Cheatham et al 2007, Bee et al 2008, Pliakos et al 2010, Kreis et al 2013, Bertelsen et al 2014, Fortelny et al 2014, Rencüzoğulları et al 2015)

Complete time out activity 2

Discuss with your colleagues the main reasons for management using open abdomen in your clinical area.

Learning Points

1. Open abdomen, or laparostomy, involves leaving the abdomen open deliberately; that is, not closing the fascial and skin layers of the abdominal wall following surgery which occurs most often after an emergency laparotomy, with the intention of closing the abdomen permanently at a later date.
2. The main conditions managed by open abdomen include abdominal infection and trauma. Abdominal infections may occur because of spontaneous perforation, inflammation of the structures of the gastrointestinal tract or as result of post-operative infection following abdominal surgery.
3. Other conditions that may be managed by open abdomen include: congenital abdominal wall defects, intra-abdominal haemorrhage, necrotising pancreatitis and necrotising enterocolitis.
4. The indications for open abdomen are oedema of the abdominal organ secondary to inflammation or as a result of high fluid requirement to maintain blood pressure, defect in the abdominal wall, a congenital defect (gastroschisis), necrotising fasciitis, increased intra-abdominal pressure or abdominal compartment syndrome.