Neue Anwendung der V.A.C.®-Therapie in der Bauchhöhle bei offenem Abdomen

Zusammenfassung

Ziel der Untersuchung: Das Problem der Vakuumversiegelung (Vacuum Assisted Closure, V.A.C.® ) beim offenen Abdomen liegt darin, dass die zu drainierenden Flüssigkeiten aufgrund des Unterdruckes der V.A.C.®-Therapie zentripetal durch die Peritonealhöhle fließen und im Fall einer lokalen intraabdominalen Infektion, diese sich entlang des Druckgradienten in der ganzen Bauchhöhle ausbreitet.
Methodik: Die bisher angewandte Technik der V.A.C.®-Therapie bei offenem Abdomen wurde durch die Einlage eines zusätzlichen intraabdominalen V.A.C.®-Systems modifiziert, das mittels eines separaten Schlauches durch die Bauchwand drainiert wurde. Diese Anordnung mit unterschiedlichen Unterdruckgradienten verhinderte die Ausbreitung einer intraabdominalen Infektion bei nekrotisierender Pankreatitis nach Pankreasruptur.
Resultate: Die Drainagevolumina des intraabdominalen V.A.C.®- Systems und der Vakuumversiegelung für das offene Abdomen waren gleich. Vor dem Faszienverschluss nach 72 Tagen der Behandlung mittels offenem Abdomen waren 30 Reoperationen nötig. Es wurden weder Darmfisteln noch intraabdominale Abszesse beobachtet. In der Nachbeobachtungszeit traten bisher keine Narbenhernien der Bauchwand auf.
Schlussfolgerungen: Ein zusätzliches intraabdominales V.A.C.®- System mit separater Drainage kombiniert mit der üblichen Vakuumversiegelung bei der Behandlung des offenen Abdomens mit unterschiedlichen Unterdruckgradienten führt zu einer Kompartimentierung einer intraabdominalen Infektsituation und verhindert die Ausbreitung in der Abdominalhöhle.

Abstract

Objective: The problem of the temporary vacuum assisted closure (V.A.C.®) of open abdomen situation is that the fluids, following the negative pressure, pass the abdominal cavity and in case of a local infection disseminate over the whole abdominal cavity.
Methods: The usual open abdominal wound V.A.C.® technique was modified by using an auxiliary, independently operating V.A.C.® system positioned intra-abdominally and connected with a separate drainage tube introduced into the lateral abdominal wall. This arrangement prevents further spreading of a local intra-abdominal infection in case of a necrotising pancreatitis after traumatic pancreas rupture.
Results: The drainage volumes were comparable from superficial and intra-abdominal V.A.C.® system. A total of 30 reoperations were necessary due to a leasion of the pancreas before a primary closure of the open abdominal wound could be applied after 72 days. No bowel fistulas or intra-abdominal abscess formations were observed. The follow-up have not shown any hernia of the abdominal wall up to the present.
Conclusion: Additional intra-abdominally positioned V.A.C.® system with an own drainage system supports open abdomen therapy with the standard abdominal V.A.C.® system and prevents dissemination of intra-abdominal infection.

Offenes Abdomen - Infektion - Vakuumversiegelung - V.A.C.®

Open abdomen - infection - Vacuum assisted closure - V.A.C.®

Literatur

• 1 Admire A A, Dolich M O, Sisley A C, Samimi K J. Massive ventral hernias: role of tissue expansion in abdominal wall restoration following abdominal compartment syndrome.  Am Surg. 2002;  68 491-496
• 2 Argenta L C, Morykwas M J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.  Ann Plast Surg. 1997;  38 563-577
• 3 Barker D E, Kaufman H J, Smith L A, Ciraulo D L, Richart C L, Burns R P. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients.  J Trauma. 2000;  48 201-206
• 4 Ciresi D L, Cali R F, Senagore A J. Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula.  Am Surg. 1999;  65 720-724
• 5 Collicott P E, Hughes I. Training in advanced trauma support.  JAMA. 1980;  293 1156-1159
• 6 Cullen D J, Coyle J P, Teplick R, Long M C. Cardiovascular, pulmonary, and renal effects of massively increased intra-abdominal pressure in critically ill patients.  Crit Care Med. 1989;  17 118-121
• 7 Ertel W, Oberholzer A, Platz A, Stocker R, Trentz O. Incidence and clinical pattern of the abdominal compartment syndrome after “damage-control” laparotomy in 311 patients with severe abdominal and/or pelvic trauma.  Crit Care Med. 2000;  28 1747-1753
• 8 Fietsam R, Villalba M, Glover J L, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair.  Am Surg. 1989;  55 396-402
• 9 Fleischmann W, Strecker W, Bombelli M, Kinzel L. Vacuum sealing as treatment of soft tissue damage in open fractures.  Unfallchirurg. 1993;  96 488-492
• 10 Fox V J, Miller J, Nix A M. Temporary abdominal closure using an i.v. bag silo for severe trauma.  AORN J. 1999;  69 530-535
• 11 Foy H M, Nathens A B, Maser B, Mathur S, Jurkovich G J. Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control laparotomy.  Am.J Surg. 2003;  185 498-501
• 12 Kafie F E, Tessier D J, Williams R A, Podnos Y D, Cinat M, Lekawa M. et al . Serial abdominal closure technique (the “SAC” procedure): a novel method for delayed closure of the abdominal wall.  Am Surg. 2003;  69 102-105
• 13 Kron I L, Harman P K, Nolan S P. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration.  Ann Surg. 1984;  199 28-30
• 14 Labler L, Oehy K. Vacuum sealing of problem wounds.  Swiss Surg. 2002;  8 266-272
• 15 Loftus I M, Thompson M M. The abdominal compartment syndrome following aortic surgery.  Eur J Vasc Endovasc Surg. 2003;  25 97-109
• 16 Loi P, De Backer D, Vincent J L. Abdominal compartment syndrome.  Acta Chir Belg.. 2001;  101 59-64
• 17 Losanoff J E, Richman B W, Jones J W. Temporary abdominal coverage and abdominal compartment syndrome.  Arch Surg. 2003;  138 565-566
• 18 McNelis J, Marini C P, Simms H H. Abdominal compartment syndrome: clinical manifestations and predictive factors.  Curr Opin Crit Care. 2003;  9 133-136
• 19 Mooney J F, Argenta L C, Marks M W, Morykwas M J, DeFranzo A J. Treatment of soft tissue defects in pediatric patients using the V.A.C.® System.  Clin Orthop. 2000;  376 26-31
• 20 Morken J, West M A. Abdominal compartment syndrome in the intensive care unit.  Curr Opin Crit Care. 2001;  7 268-274
• 21 Morykwas M J, Argenta L C. Nonsurgical modalities to enhance healing and care of soft tissue wounds.  J South Orthop Assoc. 1997;  6 279-288
• 22 Morykwas M J, Argenta L C, Shelton-Brown E I, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation.  Ann Plast Surg. 1997;  38 553-562
• 23 Morykwas M J, Faler B J, Pearce D J, Argenta L C. Effects of varying levels of subatmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine.  Ann Plast Surg. 2001;  47 547-551
• 24 Myers J A, Latenser B A. Nonoperative progressive “Bogota bag” closure after abdominal decompression.  Am Surg. 2002;  68 1029-1030
• 25 Nathens A B, Brenneman F D, Boulanger B R. The abdominal compartment syndrome.  Can J Surg. 1997;  40 254-258
• 26 Navsaria P H, Bunting M, Omoshoro-Jones J, Nicol A J, Kahn D. Temporary closure of open abdominal wounds by the modified sandwich- vacuum pack technique.  Br J Surg. 2003;  90 718-722
• 27 Oelschlager B K, Boyle E M, Johansen K, Meissner M H. Delayed abdominal closure in the management of ruptured abdominal aortic aneurysms.  Am J Surg. 1997;  173 411-415
• 28 Peralta R, Hojman H. Abdominal compartment syndrome.  Int Anesthesiol Clin. 2001;  39 75-94
• 29 Rasmussen T E, Hallett J W, Noel A A, Jenkins G, Bower T C, Cherry K J, Panneton J M, Gloviczki P. Early abdominal closure with mesh reduces multiple organ failure after ruptured abdominal aortic aneurysm repair: guidelines from a 10-year case-control study.  J Vasc Surg. 2002;  35 246-253
• 30 Saggi B H, Sugerman H J, Ivatury R R, Bloomfield G L. Abdominal compartment syndrome.  J Trauma. 1998;  45 597-609
• 31 Sherck J, Seiver A, Shatney C, Oakes D, Cobb L. Covering the “open abdomen”: a better technique.  Am Surg. 1998;  64 854-857
• 32 Sieh K M, Chu K M, Wong J. Intra-abdominal hypertension and abdominal compartment syndrome.  Langenbecks Arch Surg. 2001;  386 53-61
• 33 Tiwari A, Haq A I, Myint F, Hamilton G. Acute compartment syndromes.  Br J Surg. 2002;  89 397-412
• 34 Tobias A M, Low D W. The Use of a Subfascial Vicryl Mesh Buttress to Aid in the Closure of Massive Ventral Hernias following Damage-Control Laparotomy.  Plast Reconstr Surg. 2003;  112 766-776
• 35 Tons C, Schachtrupp A, Rau M, Mumme T, Schumpelick V. Abdominal compartment syndrome: prevention and treatment.  Chirurg. 2000;  71 918-926
• 36 Tremblay L N, Feliciano D V, Schmidt J, Cava R A, Tchorz K M, Ingram W L, Salomone J P, Nicholas J M, Rozycki G S. Skin only or silo closure in the critically ill patient with an open abdomen.  Am J Surg. 2001;  182 670-675
• 37 Wittmann D H, Iskander G A. The Compartment Syndrome of the Abdominal Cavity: A State of the Art Review.  J Int Care Med. 2000;  15 201-220