Shock/Sepsis/Trauma/Critical CareA Novel Abdominal Decompression Technique to Treat Compartment Syndrome After Burn Injury
Introduction
Abdominal compartment syndrome (ACS) remains a dreaded complication of the inflammatory response often seen after burns, trauma, or emergency surgery. Defined by the World Society of the Abdominal Compartment Syndrome as a sustained intraabdominal pressure >20 mm Hg associated with new organ dysfunction or failure, the overall incidence of ACS in the critical care setting ranges from 0.5% to 8% and occurs more frequently in patients necessitating extensive fluid resuscitation.1,2 Increased intraabdominal pressure resulting in ACS can be catastrophic, as decreased end perfusion can lead to organ failure and ultimately death.
Burn injuries have long been noted to carry an increased risk of intraabdominal hypertension and are an independent risk factor for ACS, according to the World Society of Emergency Surgery.1,3 In severely burned patients (total body surface area >20%), the prevalence of ACS is estimated to be 4.1%-17%, with 65%-75% at further risk of developing intraabdominal hypertension without end-organ dysfunction.4 The increased susceptibility to ACS is multifactorial. Large volumes of fluid are often necessary to resuscitate patients with severe burn injuries. When combined with the systemic inflammatory response, this can lead to significant capillary leakage and “third-spacing” of fluid into the abdomen in the form of tissue edema and ascites. Furthermore, there is a reduction in tissue and abdominal wall compliance associated with burn injuries to the abdomen or thorax because of the rigidity of burnt tissues. Collectively, these factors create an increase in intraabdominal pressure.4
If left to its natural course, ACS results in intestinal ischemia, necrosis, sepsis, and even death.5 Even when treated, ACS can carry a mortality rate of up to 100% in severely injured patients.6 Current treatment consists of decompressive laparotomy with subsequent temporary abdominal closure (TAC) methods, including the Bogota bag, skin closure over open fascia, Wittmann Patch, and vacuum-assisted technologies.7 These methods have been studied and established as reliable temporizing methods for patients necessitating extended open abdomen after laparotomy.8 Although decompressive laparotomy can be lifesaving for many patients with ACS, the procedure is associated with significant morbidity. One of the most dreaded complications is the development of an enterocutaneous or enteroatmospheric fistula, occurring in 2%-45% of patients after laparotomy and open abdomen. These fistulae are notoriously difficult to repair and can result in electrolyte abnormalities, malnutrition, and death in approximately 40% of cases.9, 10, 11
We present an alternative technique of relieving intraabdominal pressure using extracavitary fascial-releasing incisions, obviating the need for decompressive laparotomy. We hypothesize that by releasing fascial tension, an adequate decrease in the intraabdominal pressure can be achieved without violating the peritoneum. Maintaining an intact peritoneum could reduce the risk of complications from an open abdomen. Our technique also uses subcutaneous tunneling, leaving the overlying skin largely intact with preserved blood supply for cases where large areas of skin grafting are required.
Section snippets
Methods
Institutional review board exemption was obtained from the University of Southern California. A total of 10 cadavers were included, none of which had prior abdominal surgery. Escharotomy incisions were marked with ink, and the fascial incision locations were identified at the subcostal, inguinal, and anterior component separation locations. The abdomen was entered with a Veress needle in the subxiphoid region and confirmed to be in position using aspiration and the saline drop test. The needle
Results
Using the pooled data of both the modified anterior component separation and the tunneled fascial release techniques, overall reduction in abdominal pressure was 29.7 ± 1.8 mm Hg to 6.9 ± 5.0 mm Hg (n = 10; Fig. 3), which occurred immediately after the incisions were made. Next, we analyzed the data by comparing the modified anterior component separation technique against the minimally invasive tunneled technique. The modified anterior component separation technique demonstrated an overall
Discussion
An early prospective study evaluating in vivo abdominal decompression using laparotomy and TAC demonstrated reduced intraabdominal pressures from 24.2 ± 9.3 mm Hg to 14.1 ± 5.5 mm Hg.12 A more recent analysis in 2016 using the same operative technique showed similar findings with a decrease in median intraabdominal pressure from 23 to 12 mm Hg within 2 h13 Our study, using cadaveric subjects, explores a less invasive method of decompression using component separation without raising extensive
Conclusions
A variation of anterior component separation using a minimally invasive tunneling technique adequately reduces intraabdominal pressure in cadaver models with simulated ACS. In select cases, this technique could prevent the need for laparotomy with the extended open abdomen and its associated morbidity. It also spares the overlying skin of the abdomen, which could be used for skin grafting in patients with severe burn injuries. Larger studies involving living patients are warranted to further
Acknowledgment
Authors’ contributions: R.H., C.G., A.G., D.G., J.C., and A.S. contributed to literature review. R.H., C.G., A.G., E.B., D.G., K.M., D.C., K.I., J.C., and A.S. contributed to study design. R.H., C.G., A.G., E.B., D.G., J.C., and A.S. contributed to data collection. R.H., C.G., A.G., E.B., D.G., K.M., J.C., and A.S. contributed to data analysis/interpretation. R.H., C.G.,. A.G., E.B., D.G., K.M., D.C., K.I., J.C., and A.S. contributed to writing/critical revision.
Neither internal nor external
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Cited by (1)
This paper was presented at the 78th Annual Meeting of the American Association for the Surgery of Trauma Dallas, TX, September 2019.