Openabdomen.org wants improve patient care by providing detailed information for surgeons and patients alike to help them understand, utilize and explain causes leading to the need for a PLANNED OPEN ABDOMEN and by offering information about surgical and non-surgical treatments in detail and state of the art information on the science of abdominal compartment syndrome and other underlying diseases which cause the difficult to treat abdomen. I also present a detailed description of the DC&R (damage control & repair) od STAR (staged abdominal repair) methodology from simple decompression to complex procedures with multiple (sometime more than 20)) abdominal re-entries to assure complete source control and final cure.
The case below demonstrates nicely the power of the method and strategy of Staged Abdominal Repair or Damage Control & Repair to solve desolate cases. The patient came together with his surgeon with a septic abdomen 7 weeks after a missed appendix operation. The surgeon was seeking help because she could not close the abdomen anymore and sutured a Vicryl© mesh into the midline wound and the appendectomy wound. At STAR # 1 entry the bowl looked very inflammatory and edematous cause by a missed huge sub hepatic abscess with the lesser sack which we evacuated. After copious irrigation with R/L we closed using the artificial bur fascia prosthesis and hypopack (not shown here). Subsequent pictures show the healing process during reduction of the inflammatory edema, the technique of opening and closing the bur fascia prosthesis, its trimming to adjust to the narrower opening and, final closure after seven abdominal entries. Note that at final fascial closure a little more tension goes unpunished in the inflammatory tissue with its established local defense as opposed to a normal one time laparotomy with its defenseless virgin tissue. On post STAR day # 1 I discontinued antibiotics, on post Star day #5 there was a bowl movement and on Post STAR day # 6 the patient was discharged. I saw him one year later without evidence of a hernia or other abdominal discomfort.
Damage Control $ Repair DC&R (also known as "staged abdominal repair (STAR)") is one operation consisting of multiple abdominal entries planned either before or during the first (index) DC&R which are performed every 24-48 hours until final fascial closure is accomplished. The operatice tactic includes:
Closing the abdomen with a dynamic fascial expander prosthesis (Fascia Prosthesis);
Preventing fascial retraction;
Controlling intra-abdominal pressure;
Reversing pulmonary, renal, CV, hepatic and intestinal dysfunction / pathology;
Fascial closure after the last abdominal entry.
Although a laparotomy or single abdominal entry is routine for the general surgeon, multiple sequential abdominal entries require more attention to detail with respect to timing, infrastructure & operative manipulations such resections & excisions as well as suturing leaks & anastomoses.
The Wittmann Patch as a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn: link to Burns 2008
Closing the Open Abdomen: Improved Success With Wittmann Patch Staged Abdominal Closure: link to J Trauma 2008
The use of the Wittmann Patch facilitates a high rate of fascial closure in severely injured trauma patients and critically ill emergency surgery patients: link to J Trauma 2008
Delayed Primary Closure in Damage Control Laparotomy: The Value of the Wittmann Patch: link to Am Surg 2007
Temporary Closure of the Opene Abdomen:A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen: Link to World J Surg (2009) 33:199-207
Diffuse peritonitis from anastomotic leaks. Treated by Dietmar Wittmann, MD, PhD, FACS; Patient Age: 69
The patient is a 69 year old man with a history of morbid obesity (107kg, 172cm), hypertension and ischemic heart disease who had previously undergone two operations for diverticulitis: read more (Link)
Missed appendix perforation and severe abdominal compartment syndrome. Treated by Dietmar Wittmann, MD, PhD, FACS;
This 13 year old boy had an appendectomy 9 days after onset of symptoms, because his condition was misdiagnosed as influenza. Ten days after resection of the perforated appendix, peritonitis persisted and abdominal re-explorations through a midline incision for multiple intra-abdominal abscesses became necessary. read miore (link)
Beitr Anaest Intensivmed 30(1989)199-221
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Theoretical Surgery 9(1994)201-207
Annual Meeting AAST; 2000 San Antonio
European Surgeon 32(2000)171-178
As designed and tested from 1987 to 2000 by Prof. D.H. Wittmann to treat the planned open abdomen, measure antibiotic levels to taylor therapy to measure protein losses for adequate replacements with e.g. FFP, and to prevent exogenous infection