STAR, Staged abdominal Repair (1991)
or
Damage Control and Repair - DC&R (2015)
or
Etappenlavage (1985), the original name.

Synopsis of Operative Technique

Staged abdominal repair (STAR) is one operation consisting of multiple abdominal entries planned either before or during the first (index) STAR 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;
• 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.

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EXAMPLE CASE: Seven days from severe pritonitis with massive abdominal compartment syndrome to final skin closure and hosptal discharge

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 seven weeks after a missed appendix perforation. The surgeon was seeking help because she could not close the abdomen after reoxploratin for persistent infection and sutured a Vicryl© mesh to temporarely close the midline wound. She also closed the appendectomy wound with a Vicryl© mesh.
At STAR entry #1 the bowel looked very inflammatory and edematous because a missed huge sub hepatic abscess within the lesser sack was maintaiung inflammation. During STAR # 1 we evacuated the lesser sack abscess. After copious irrigation with R/L we inspected the entire abdominal cavity (the appendix stump had healed well) and we closed temporaraly using the artificial bur fascia prosthesis and hypopack (not shown here).
Subsequent pictures below 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 because after many re-openings local defense is well established in within the wound an form of healthy granuation tissue as a reponse of inflasmmation. The healty inflammatory granulation tissue with its established local defense contrasts to a normal to the wound after a 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.

Missed appendix perforation and severe abdominal compartment syndrome (pictures shown abve)

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. (More detailed information is displayed under CASES from MCW case#111).

To see details of this case, please click the following link:

Case 111: STAR for diffuse peritonitis with abdominal compartment syndrome

Treated by Dietmar Wittmann, MD, PhD, FACS