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An experimental novel alternative for temporary abdominal closure of the open abdomen: Transfascial continuous tension

C losure of the open abdomen after damage-control laparotomy (DCL) presents a significant challenge. It is often not possible to use primary closure, resulting in patients requiring an absorbable mesh with subsequent skin grafting and the anticipated formation of a ventral hernia. The introduction of negative-pressure wound therapy has assisted in reducing this problem by decreasing tissue edema and intra-abdominal fluid and by minimizing intra-abdominal contamination; using such a strategy decreases ventral hernia rates. Tension is generated across the abdominal wall in equal and opposite directions, normally bridged by the rectus sheath at the midline and by the lateral abdominal musculature. Severing the midline portion of this tension with a laparotomy leads to an unopposed lateral preload on the abdominal wall. The normal equilibrium of the lateral musculature is disrupted, and the fascia tends to retract laterally on either side of the laparotomy. Attempted solutions to this problem have included various methods, such as medial traction on each of the incised fascial edges, with moderate success. Other methods that are less dynamic with respect to length have been used. Invariably, those methods create variable tension for extended periods, requiring tension adjustment through operative intervention. This leads to either cutting through fascia or allowing the fascia to gradually retract until the maximal tension is reached. The current approaches have focused on moderating the lateralization of fascia or on attempting to reverse lateralization, and while fascial closure rates have improved, significant progress still needs to be made. We report a method for generating dynamic tension across the midline in DCL with a technique that does not require proprietary equipment and uses material that is available at nearly all centers. We hypothesized that this technique distributes forces across the midline more effectively than current methods used for fascial closure, such as retention sutures and running continuous suture. We believe this technique may provide the basis for future studies to optimize the patient’s probability for successful fascial closure.