Recent advances in temporary abdominal closure techniques have allowed safe management
of the open abdomen after damage control laparotomies. The eventual goal of managing
such patients is closure of the fascial defect as soon as clinically feasible. When
fascial closure is not possible, skin-only coverage over healthy granulation and planned
delayed ventral hernia repair is the only option. If adequate skin is available, it
can be primarily closed over the fascial defect. Otherwise, split-thickness skin grafting
can be performed once adequate granulation tissue forms over the bowel [1]. A planned delayed ventral hernia repair is subsequently performed once the skin
graft matures over the bowel. In most instances, a pseudomesentery develops between
bowel and graft, which becomes evident with a “pinch test.” This provides a safe plane
from which the skin graft is elevated off the bowel before definitive hernia repair
is performed.
Nonetheless, the interface between bowel and skin graft may not be very well-defined
in some cases, and the margin of error may become dangerously narrow during dissecting
a plane between the skin graft and bowel.
We describe the use of tumescence for hydro-dissection and improving the safety margin
when elevating skin grafts from the underlying bowel. This case is a 70-year-old male
with a background history of diabetes mellitus and ischemic heart disease. He sustained
polytraumatic injuries following a road traffic accident in 2018. His list of injuries
included multiple rib fractures and a severe splenic injury complicated by abdominal
compartment syndrome. An emergency laparotomy and splenectomy were performed followed
by temporary abdominal closure. This was followed by several subsequent relook laparotomies
and negative pressure wound therapy dressings. After sufficient granulation had formed,
split-thickness skin grafting was performed to the central abdominal wound a month
after the index surgery.
A large ventral hernia subsequently developed with an abdominal wall defect size of
35 × 32 cm ([Fig. 1]). He returned for definitive repair of the abdominal wall defect approximately 2
years later. The mature skin graft was excised safely and with ease after hydro-dissection
with tumescent infiltration.
Fig. 1. An abdominal wall defect size of 35×32 cm.
Normal saline solution was used for tumescent infiltration in the subcutaneous plane
with a blunt liposuction cannula and a 50 mL syringe. Stab incisions of 2–3 mm were
made with a 15-blade at entry points around the borders of the skin graft. To avoid
penetrating into deeper tissues, the tip of the cannula is angled at a slight upward
angle during insertion, and always visualized just under the skin ([Fig. 2]). The skin is also tented up prior to infiltration, during which superficial spreading
of tumescent solution confirms the correct tissue plane. Elevation of the skin graft
is performed easily and safely with sharp dissection using scissors ([Fig. 3]). Anterior component separation was performed, and a biological mesh was used to
bridge the remnant abdominal wall defect.
Fig. 2. Insertion of a cannula with its tip angled upwards and always visualized during infiltration
to avoid inadvertent bowel injury.
Fig. 3. Safe elevation of skin graft from underlying abdominal viscera, with a clearly visualized
plane of dissection (A, B).
The concept of “damage-control” surgery was born from the recognition that critically
ill patients are more likely to die from the vicious triad of coagulopathy, acidosis,
and hypothermia, than from the completion of surgical repairs [2]. This led to the emphasis on abbreviated surgery and prompt return to intensive
care and aggressive resuscitation. Hence, patients are often left with an open abdomen,
with a plan to return to the operating room for definitive repair of injuries. Various
temporary abdominal closure techniques exist, and allow maintenance of sterility in-between
operations without compromising intra-abdominal pressures [3].
Definitive fascial closure during the initial hospitalization may not be possible
in patients who have undergone multiple reoperations, have ongoing intra-abdominal
infection, visceral edema, or loss of fascial substance. In such circumstances, planned
ventral hernia is the only option. Skin coverage options in such cases include skin-only
closure, or a split-thickness skin graft once adequate granulation tissue forms over
the bowel. The latter option can be further supplemented by an absorbable mesh (e.g.,
Polyglactin 910 mesh) to prevent evisceration [1]. A ventral hernia ensues and often times, the patient is planned for elective repair.
The skin graft matures over 6 to 12 months, forming a stable connective tissue interface
between the bowel and skin. Once this occurs, the adhesions mature to a filmy stage,
allowing the skin graft to separate from the underlying tissue [4]
[5]. This is determined clinically by a positive pinch test, when the skin graft can
be pinched without grabbing the underlying viscera. Nonetheless, a clear and safe
plane may not always be evident between the skin graft and underlying bowel, resulting
in a very narrow margin of error during graft elevation. Furthermore, despite allowing
adequate time for skin graft maturation, a positive pinch test may not be uniformly
apparent throughout the grafted field, resulting in unpredictable areas of closely
adherent bowel. Notwithstanding meticulous surgical techniques, inadvertent bowel
injury is a possibility during skin graft dissection [5]. This may lead to infectious complications and prolong the healing process.
Tumescence involves local subcutaneous infiltration of a solution to produce a swelling
under the surgical site. Solutions may include various combinations of adrenaline
for its hemostatic properties, normal saline, and a local anesthetic agent. It is
commonly used in a number of plastic surgery procedures including liposuction, hair
transplantation, cervicofacial rhytidectomy, mammoplasty, abdominoplasty and flap
surgery. Apart from its content-dependent advantages in reducing intraoperative bleeding
and providing anesthesia, tumescence facilitates surgical dissection by hydro-dissection.
This is especially important in cases such as ours, where tumescent infiltration helps
create a clear plane of separation between skin graft and the underlying bowel through
hydro-dissection. Hydro-dissection also loosens scar tissue and adhesions in that
plane and increases the thickness of tissue through which separation occurs, further
facilitating dissection while reducing the risk of shearing and bowel wall injury
during skin traction. This improves the margin for error during dissection through
adhesions, reduces the amount of sharp dissection required, accelerates large areas
of skin elevation, and improves the overall safety of such a procedure. Furthermore,
using a blunt liposuction cannula carries a low risk of bowel injury, especially when
used in the above-mentioned manner.
To date, there are no fail-safe methods to reduce bowel injury during skin graft elevation
in delayed ventral hernia repairs. Tumescence is a well-established technique used
in a variety of plastic surgery procedures. Its novel application as described above
will allow the surgeon to elevate the skin graft safely and expediently, and ultimately
alleviate the risk of bowel injury.
NOTES
Ethical approval
The study was performed in accordance with the principles of the Declaration of Helsinki.
Written informed consent was obtained.
Patient consent
The patient provided written informed consent for the publication and the use of his
images.
Author contribution
Conceptualization: HW Ng. Formal analysis: K Koh. Methodology: HW Ng. Project administration:
HW Ng. Writing - original draft: K Koh. Writing - review & editing: K Koh.
