Army Physicians Present New Research on Best Practices in Open Abdomen Surgery

SAN FRANCISCO, Oct. 26, 2011 /PRNewswire/ -- U.S. Army surgeons today presented two posters at the American College of Surgeons' Clinical Congress on laparotomy, or open abdomen surgery.

The first poster showed that new techniques and protocols in definitively closing the abdomens of wounded Soldiers have reduced follow-up procedures and complications. The second poster cautioned that a temporary abdomen closure procedure, which many Soldiers undergo before definitive surgery, is associated with an elevated risk of potentially fatal blood clots that may require a change in screening guidelines.

The two poster presentations are described below:

Evolving trends in mesh utilization for serial closure of open abdomens

In an update to previously published research on a surgical technique known as early definitive abdomen closure (EDAC), Maj. Amy Vertrees, M.D., Walter Reed National Military Medical Center, presented a poster on "Decreased Mandatory Use of Supplemental Interposition Mesh Using Serial Abdominal Closure Technique of the Open Abdomen." The poster discussed the evolution in the use of mesh to regain abdominal domain and definitively close large abdominal wounds.

Damage control laparotomy (DCL), conducted at combat support hospitals, is a phased treatment strategy that controls hemorrhage and contamination through aggressive resuscitation and temporary abdominal closure. This allows wounded Soldiers to be stabilized and evacuated to the United States where physicians reopen the abdominal wound for definitive closure. Sometimes, the wound is difficult to close because of visceral blockage and retraction of the fascia. EDAC was developed by the Army in the early 2000s to more effectively pull together retracted fascia in the open abdomen following DCL. The technique uses a Gore-tex Dualmesh® prosthetic that is serially adjusted to pull together retracted fascia over time. The prosthetic is removed before closure, but sometimes a gap in the fascia remains and supplemental material is required for final closure – either polypropylene or a biologic mesh.

The poster was based on a retrospective review of 112 consecutive war-injured trauma patients who arrived at Walter Reed with open abdomens from 2003 to 2009, and showed that several changes in practices and outcomes have taken place in that time frame.

"Our surgical techniques and the way we resuscitate Soldiers in theater have led to an evolution in how we close abdomens. We've been able to reduce the number of patients who receive supplemental mesh in abdomen closure, which decreases complications," said Vertees. "While we don't know with certainty, this is probably due to changes in trauma resuscitation for war injuries and the experience base of Army surgeons in developing and perfecting the EDAC technique."

Other innovations captured in the study included a modification of the serial abdominal closure technique to change the angle of closure, and cessation of the planned ventral hernia (PVT) technique, which has not been used since 2005.

Lauren Greer, M.D., Jeffery Nelson, M.D., Sue Gillern, M.D., Jayson Aydelotte, M.D., and Craig Shriver, M.D., also participated in the study.

Risk factors for blood clots following damage control surgery

Also presented today at Clinical Congress, the poster "Higher Risk of Thromboembolic Complication After Damage Control Laparotomy with Occurrence Often Weeks After Injury," contained new insights on the risk factors for venous thromboembolism (VTE) — a potentially fatal set of complications that includes blood clots in the veins — for combat-wounded Soldiers who undergo DCL for severe abdominal injury.

Capt. Mary T. O'Donnell, M.D., also based at Walter Reed National Military Medical Center, presented a retrospective review of medical records of injured Soldiers who underwent laparotomy between January 2003 and November 2009. The research showed that while DCL remains an important life-saving approach, the occurrence of VTE doubles in DCL patients compared to those receiving non-DCL procedures. Further analysis indicated that in addition to abdominal injuries, head and pelvic injuries also were associated with higher rates of VTE.

"Despite new protocols and guidelines, there has been no change in VTE incidence over time," said O'Donnell. "Moreover, because the timing of the diagnosis is often weeks after the initial injury, we anticipate our findings will implicate future VTE screening guidance for war-injured patients."

Amy Vertrees, M.D., Margaret Clark, Lauren Greer, M.D., Darrell Carpenter, M.D., Jayson Aydelotte, M.D., Stephen Flaherty, M.D., and Craig Shriver, M.D., also participated in the study.

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SOURCE U.S. Army Medical Department