EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen.

M López-Cano, J M García-Alamino, S A Antoniou, D Bennet, U A Dietz, F Ferreira, R H Fortelny, P Hernandez-Granados, M Miserez, A Montgomery, S Morales-Conde, F Muysoms, J A Pereira, R Schwab, N Slater, A Vanlander, G H Van Ramshorst, F Berrevoet

Journal: Hernia : the journal of hernias and abdominal wall surgery 2019;22(6):921-939

PMID: 30178226

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Abstract

PURPOSE

To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used.

METHODS

The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument.

RESULTS

For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE.

RECOMMENDATIONS

When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

Address: Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain. [email protected].; DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK.; Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.; Royal Bournemouth and Christchurch Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK.; Department of General and Visceral Surgery, Cantonal Hospital of Olten,, Olten, Switzerland.; Department of Surgery: Upper Gastrointestinal and Abdominal Wall Surgery, Pedro Hispano Hospital, Matosinhos, Porto, Portugal.; Department of General Surgery, CUF, Porto Hospital, Porto, Portugal.; Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria.; Medical Faculty of Sigmund Freud University Vienna, Vienna, Austria.; Unidad de Cirugía General, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain.; Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.; Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden.; Unit of Innovation in Minimally Invasive Surgery, General and Digestive Surgery Unit, University Hospital Virgen del Rocío, Seville, Spain.; Department of Surgery, Maria Middelares Hospital, Ghent, Belgium.; Servei de Cirurgia General, Hospital del Mar, Parc de Salut Mar, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain.; General and Thoracic Surgery, Federal Armed Forces Central Hospital, Koblenz, Germany.; Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.; Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospita, Ghent, Belgium.; The Netherlands Cancer Institute, Amsterdam, The Netherlands.

DOI: 10.1007/s10029-018-1818-9

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MeSH Terms: Abdominal Wall, Abdominal Wound Closure Techniques, Europe, Fasciotomy, Humans, Negative-Pressure Wound Therapy, Postoperative Complications, Skin Transplantation, Societies, Medical, Surgical Mesh