World J Surg (2007) 31:2133–2137

DOI 10.1007/s00268-007-9222-0

Vacuum-assisted Wound Closure and Mesh-mediated Fascial

Traction—A Novel Technique for Late Closure of the Open
Abdomen
Ulf Petersson Æ Stefan Acosta Æ Martin Björck

Published online: 19 September 2007

Ó Société Internationale de Chirurgie 2007

Abstract after 32 (12–52) days with OA. No recurrent ACS was seen.
Background Open abdomen (OA) treatment often results No technique-specific complication was observed. Two
in difficulties in closing the abdomen. Highest closure rates small incisional hernias, one intra-abdominal abscess and
are seen with the vacuum-assisted wound closure (VAWC) one wound infection occurred in three patients.
technique. However, we have experienced occasional Conclusions Delayed primary closure in cases with
failures with this technique in cases with severe visceral severe visceral swelling and long periods of OA seems
swelling needing longer treatment periods with open feasible with this technique.
abdomen. Feasibility and short-term outcome of a novel
combination of techniques for managing the open abdomen
are presented.
Methods The VAWC technique was combined with
Several clinical conditions and situations are favourably
medial traction of the fasciae through a temporary mesh in
treated with open abdomen. Bowel edema following mas-
seven consecutive patients. The VAWC-system was
sive shock resuscitation and/or retroperitoneal bleeding, in
changed and the mesh tightened every 2–3 days.
trauma victims [1] and in patients with ruptured abdominal
Results Median (range) age in the 7 men was 65 (17–78)
aortic aneurysms (AAA) [2], sometimes precludes closure
years. The diagnoses were ruptured abdominal aortic aneu-
of the abdominal wall after surgery or leads to abdominal
rysm (AAA) (3), operation for juxtarenal AAA (1),
compartment syndrome (ACS) with its profound and life-
iatrogenic aortic lesion (1), trauma (1) and abdominal
threatening effects on cardiovascular, respiratory and renal
abscesses (1). Four patients were decompressed due to
functions [3]. Open abdomen (OA) treatment may also be
abdominal compartment syndrome (ACS) or intra-abdomi-
necessary in patients with intra abdominal infections,
nal hypertension, and 3 could not be closed after laparotomy.
abscesses or severe pancreatitis [1].
Intra-abdominal pressure prior to OA treatment was 24 (17–
Temporary closure of the abdominal cavity with plastic
36) mmHg. Maximal separation of the fasciae was 16 (7 –30)
bags, silicone sheets, absorbable and non-absorbable
cm. Delayed primary closure was achieved in all patients
meshes sutured to the fascial or skin edges [4, 5] do not
facilitate definitive closure of the abdominal wall. Skin-
U. Petersson (&) only closure or split-thickness skin grafting may be used
Department of Surgery, University Hospital Malmö, 205 02
Malmö, Sweden for covering the bowels and omentum. The major draw-
e-mail: [email protected] back with these techniques is the formation of extensive
ventral hernias that have to be dealt with later. The use of
S. Acosta airtight dressings and vacuum for handling the open
Department of Vascular Diseases, University Hospital Malmö,
205 02 Malmö, Sweden abdomen has improved the care and increased the possi-
bility for closure of the open abdomen, but in patients with
M. Björck longstanding visceral swelling it has failed in our hands. In
Department of Surgery, University Hospital Uppsala, SE-751 85 an attempt to achieve primary closure even in cases where
Uppsala, Sweden

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treatment with open abdomen has to be carried on for an Abdominal wall hernia development was evaluated clini-
extended period, a vacuum pack technique [6] was com- cally (n = 7) and with computed tomography (CT) (n = 4)
bined with continuous medial fascial traction through a during the follow-up period.
polypropylene mesh sutured to the edges of the fascia in
patients undergoing operations for ruptured aortic aneu-
rysms in Malmö. A similar technique, using the Wittmann Vacuum-assisted wound closure and mesh-mediated
patch [7] instead of a mesh, was recently reported to be fascial traction
successful in trauma patients [8]. Although the results in
our patients with long treatment periods were encouraging, At each operation where the abdomen was left open, either
we hypothesized that the mesh-mediated traction would be primarily or at a later decompression laparotomy, a vac-
even more effective if the vacuum treatment were opti- uum-assisted closure system (V.A.C.1 TherapyTM, KCI ,
mized by use of the vacuum-assisted wound closure San Antonio, TX, USA) was applied and activated at 125–
(VAWC) technique [9]. The aims of this feasibility study 150 mmHg of continuous negative pressure.
were to describe this combined technique and to report After 2 days the vacuum system and dressings were
preliminary results. changed in the operating room. After another 2 days the
possibility to close the abdomen was evaluated. If possible
the abdominal wall was closed; otherwise, a polypropylene
Materials and methods mesh (Prolene1, Ethicon Inc, Johnson & Johnson, Somer-
ville, NJ, USA) was applied in combination with the vacuum
Consecutive patients treated with OA in Malmö and system as follows (Fig. 1A–D): A thin perforated polyeth-
Uppsala were included. Case records were analyzed. Cir- ylene sheet with a central thin polyurethane sponge was
culatory failure, renal failure, and respiratory failure were tucked under the abdominal wall far out laterally on both
defined as needing support of inotropic drugs, renal sides to keep the abdominal wall clear of the bowel and
replacement therapy, and assisted ventilation, respectively. omentum. A polypropylene mesh of appropriate size to fit the
Intra-abdominal hypertension and ACS were defined wound was then divided into two halves and fashioned to fit
according to the World Society of the Abdominal Com- the fascial edges on both sides of the wound. The meshes
partment Syndrome (WSACS) consensus definitions [10]. were sutured to the fascial edges with a running 0

Fig. 1 Patient operated upon for ruptured abdominal aortic aneurysm innermost perforated polyethylene sheet underneath the mesh. The
(AAA). A. View of abdominal wound after 2 weeks of VAWC separation of the fascial edges was reduced to 22 cm. D. The wound
treatment. The separation of fascial edges was still 28 cm. B. A was dressed with the occlusive self-adhesive polyethylene sheets
polypropylene mesh was sutured to the fascial edges. C. The mesh covering the thick polyurethane sponges. The suction device was
was tightened with a running suture, applying some tension on the applied in the lower part of the wound and activated
fascia. Note the thin polyurethane sponge in the center of the

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attended the first outpatient visit 2 months after closure of

the abdomen. There was no 30-day mortality, but one
patient died in the hospital of an acute myocardial infarc-
tion 3 months after abdominal closure.

Abdominal wound–specific morbidity

One patient developed a small intra-abdominal abscess 1

month after closure of the abdominal wall. Following
percutaneous drainage, an iatrogenic procedure-related
small bowel fistula developed. This fistula healed within 2
weeks on bowel rest and somatostatin treatment, and a
Fig. 2 The same patient two dressing changes and mesh-tightening
procedures later. Fascial separation has been reduced to 15 cm. After residual abscess was treated with antibiotics for several
13 days the mesh was removed and the abdominal wall was closed weeks for complete recovery of the patient. This patient
and another extremely obese patient developed 4 and 5 cm
polypropylene suture (Prolene1, Ethicon Inc, Johnson & incisional hernias, respectively. One patient had a wound
Johnson) with narrow bites. The two meshes were then infection after delayed primary closure of the abdomen,
sutured to each other in the midline, on top of the polyeth- which was treated by incision and drainage. In all, 3/7
ylene sheet, keeping the viscera from protruding and putting patients had some complication related to the abdominal
some tension on the abdominal wall. The intra-abdominal incision.
pressure (IAP) was measured as bladder pressure through an
indwelling catheter according to the method of Kron et al.
[11]. The thick polyurethane sponge was then placed on top Discussion
of the polypropylene mesh, and the wound was covered with
occlusive self-adhesive polyethylene sheets as the skin edges A vacuum-assisted wound closure (VAWC) system com-
were pushed medially, aligning the sponges. bined with mesh-mediated fascial traction resulted in
Every second to third day the patient was taken to the delayed primary closure of the abdomen in seven consec-
OR, where the vacuum system was changed and the mesh utive patients with severe edema of the abdominal contents
tightened. The continuous mesh-mediated traction on the requiring prolonged treatment with open abdomen. The
abdominal wall pulled the fascial edges together (Fig. 2). combination of these methods worked in a synergistic way
Abdominal closure was considered when 3–7 cm of sepa- to facilitate closure of the open abdomen. Survival among
ration of the fascial edges remained. The mesh was then these patients with severe pathologies was also promising.
removed, and the fasciae were closed, followed by skin Although there were wound complications, we did not
closure. Signs of respiratory or circulatory failure or IAP relate them to the specific technique used.
above 20 mmHg perioperatively would have resulted in Closure rates after VAWC of the open abdomen in
redo abdominal wall decompression. trauma patients [9, 12–16] was reported to be 86%–92% [9,
15, 16], but a large proportion of these patients were young
and were treated with open abdomen liberally during short
Results time periods according to the ‘‘damage-control’’ concept.
In contrast, the majority of the study patients were older,
All seven patients were men with a median age of 65 had renal failure, and suffered from more diverse pathol-
(range: 17–78) years. Diagnoses, initial operation, and ogies. The extreme visceral swelling in these patients
indications for treatment with open abdomen are presented required treatment with OA for longer time periods. Thus,
in Table 1. Open abdomen treatment and body fluid bal- the majority of patients in this study represent a different
ance characteristics are shown in Table 2. The median population compared to the studies including merely
(range) hospital stay was 62 (37–106) days. trauma patients.
In most previous reports it was seldom possible to close
the fascia if treatment with OA exceeded 3 weeks [9, 12,
Follow-up and mortality 14, 15], even if successful closure was reported among
individual patients after prolonged treatment [13, 15]. That
The median (range) follow-up time was 9 (2–19) months the open abdomen could be closed in all patients in our
after closure of the abdomen. One expatriate patient only consecutive series after a median of 32 days indicates that

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abscesses needing sequential laparotomies

edema secondary to massive resuscitation
Table 2 Open abdomen treatment and body fluid balance
Median (range)

Not possible to close at reoperation due

IAH, organ failure and intra-abdominal

Left open at initial operation. Visceral
Abdominal wound therapy characteristics

Left open at initial laparotomy due

ACS (decompression laparotomy)

ACS (decompression laparotomy)

ACS (decompression laparotomy)
Abdominal pressure at time of decompressive 24 (17–36)
Indications for open abdomen

laparotomy (mmHg) (n = 4 )
Maximum separation of fasciae (cm) 16 (7–30)

to visceral edema

to visceral edema
Treatment with open abdomen (days) 32 (12–52)
Duration of vacuum treatment (days) 30 (7–43)
Changes of VAWC dressings 10 (3–12)
Treatment with mesh (days) 26 (7–43)
Mesh tightening procedures 9 (3–12)
Fascial necrosis 0/7
Successful abdominal wall closure 7/7
Body fluid balance characteristics
Blood transfusions (l) 10 (1–18)
iliac artery and endovascular stentgrafting
Damage control procedure with splenectomy,
abdominal packing, coiling of the right

Maximum excess weight after resuscitation (kg) 17 (4–29)

Elective aorto-aorto interposition graft and

Emergency thoracotomy, laparotomy after

Organ failure: cardiac, pulmonary, renal 3 (2–3)

Redo endovascular stentgraft procedure

(No. failing systems/patient)

bypass to the right renal artery

VAWC vacuum assisted wound closure

Table 1 Diagnoses, initial operations, and indications for treatment with open abdomen in seven consecutive patients

accidental liver laceration

Aorto-aorto interposition graft

of the thoracic aorta

AAA abdominal aortic aneurysm; ACS abdominal compartment syndrome; IAH intra-abdominal hypertension

this combined technique may offer an advantage for late

Aorto-biiliacal bypass

closure of the abdomen.

An advantage with the technique described in this arti-
cle, compared to VAWC combined with partial suturing of
Colectomy
Operation

the fascia in a sequential manner [15, 16], is the possibility

of cleansing the entire abdominal cavity during the period
of treatment with open abdomen, where the total length of
the incision is accessible until the fascia is closed. This
superior drainage effect, facilitating the reduction of peri-
Acute pancreatitis, iatrogenic aortic injury, pericardial tamponade

toneal fluid and bacteria, may be a key factor for using this
Ruptured AAA (due to insufficient seal after previous EVAR)

technique, especially in OA following vascular graft

Myeloma (cytostatic treatment and stemcell transfusion)
Aortic dissection, hemo-pneumothorax, fractured pelvis,

implants within the abdomen. No graft infections were

(secondary to placing of a central venous catheter)

Ruptured iliac aneurysm (previous operation for AAA)

abdominal sepsis, ischemic necrosis of the colon,

observed among the four study patients with aortic grafts.

Furthermore, the study technique also allows the abdomi-
lacerated spleen, and liver (car accident)

nal wall to move freely toward the midline at every

dressing change without interference of adhesions between
the bowel and the abdominal wall.
Two patients in this series developed smal incisional
hernias after fascial closure. The closure was performed
intra-abdominal abscesses

according to the surgeon’s choice. A standardized suturing

technique using a running suture with a suture length to
wound length ratio of 4:1 [17] is of interest to evaluate in
an attempt to reduce the incidence of incisional hernias,
Juxtarenal AAA

Ruptured AAA

and such standardization has been included in the protocol

Diagnoses

of a prospective study now in progress.

We preferred to perform the dressing changes and the
mesh-tightening procedures in the operating room in these
patients. Several of the patients had vascular grafts that
needed to be protected against infection. It is perfectly
Patient

possible, however, to perform these procedures in the

Intensive Care Unit.
1

3
4
5

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