CASE REPORT

Closure of Massive Abdominal Wall DefectsA Case Report Using the Abdominal Reapproximation Anchor (ABRA)

System

Roderick M. Urbaniak, MD,* Dana K. Khuthaila, MD, FRCSC,† Abdullah J. Khalil, MD,†and Dennis C. Hammond, MD†

Abstract: Closure of massive abdominal wounds can be a challeng-ing surgical problem. Presented here is a novel technique forreconstitution of the abdominal wall after severe internal injuriescomplicated by sepsis required a prolonged period of open abdom-inal dressing changes. By using an innovative and effective progres-sive tension band system, the fascial edges could be reapproximatedover time allowing primary wound closure. This system is recom-mended as an effective instrument to accomplish closure of thesedifficult wounds.

Key Words: abdominal wound, hernia

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Multiple approaches for repair of massive abdominal wallhernias have been described. Some involve tissue ex-

pansion1,2; others, separation of native abdominal wall mus-culature3,4; and still others involve mesh,5 pedicled flaps,6

and even free-tissue transfers.7,8 This article describes aninnovative approach designed to restore lost abdominal do-main and achieve closure of large wounds using a continuousdynamic tension device called the abdominal reapproxima-tion anchor (ABRA) system (Canica Design, Almonte, On-tario, Canada). This system consists of a variable number ofanchor-pulley-elastomer units designed to apply closing ten-sion to the wound (Fig. 1). The surgical approach includesinitial application of the device, followed by incrementalbedside reapproximation of wound edges using continuoustension elastic bands, which are adjusted daily. Once thewound edges are nearly approximated, complete surgicalrepair of all layers of the abdominal wall is performed. In thisfashion, restoration of abdominal domain and complete repair

of the musculofascial support of the abdominal wall with aprimarily closed wound are achieved.

CASE REPORTA healthy 33-year-old male civilian contractor was

involved in an incendiary explosive device detonation andensuing vehicle rollover while working in Baghdad, Iraq. Asa result, he suffered multiple rib fractures; bilateral pneumo-thoraces and pulmonary contusions; splenic, pancreatic, andliver lacerations; clavicle and scapular fractures; and bilateraladrenal hematomas. He underwent an initial exploratorylaparotomy with splenectomy and distal pancreatectomy, andthe abdominal wound was left open to facilitate easy accessneeded for multiple explorations and debridements. Afterstabilization of the abdominal injuries, a regimen of openabdominal dressing changes was instituted, which includedthe placement of a vacuum-assisted closure (VAC) device.This VAC dressing was changed every 2 days until the bedwas well granulated. During this time, recurrent intra-abdom-inal abscesses were drained percutaneously using computedtomography (CT) guidance. After 3 weeks of conservativewound management, considerable edema was present in theintestinal viscera, which protruded markedly through theopen midline abdominal wound (Fig. 2A, B). With contractionof the surrounding musculature, herniation of the abdominalcontents through the wound was exacerbated, leading to earlyloss of abdominal domain. The wound measured 35 by 25 cmand involved all layers of the abdominal wall. The large andsmall bowel protruded through the midline abdominal defectand presented as a matted and granulated mass. At this point,plastic surgery was consulted for definitive wound management.

Operative TechniqueStage 1

To restore abdominal domain and decrease the swellingpresent in the viscera, the ABRA system was applied to theedges of the midline abdominal wound. Under general anes-thesia, a series of transversely oriented sturdy elastic bandswas placed percutaneously across the wound. In all, 9 elasticswere inserted through the full thickness of the abdominalwall, including skin, fascia, muscle, and peritoneum, suchthat they entered the skin and pierced the peritoneum 5 cmdistant from the wound edge (Fig. 3A–C). This necessitated

Received March 2, 2006 and accepted for publication April 6, 2006.From the *Plastic Surgery Program and the †Center for Breast and Body

Contouring, Grand Rapids, MI.Reprints: Dennis C. Hammond, MD, Center for Breast and Body Contour-

ing, 4070 Lake Dr. SE, Suite 202, Grand Rapids, MI 49546. E-mail:cbbcmain@iserv.net.

Copyright © 2006 by Lippincott Williams & WilkinsISSN: 0148-7043/06/5705-0573DOI: 10.1097/01.sap.0000237052.11796.63

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the freeing up of the granulated bowel away from the under-side of the wound edges to prevent inadvertent injury to thebowel. In the central portion of the wound, where it wasanticipated there would be maximal tension, the elastics weredoubled to provide additional support. Each elastic band wasthen secured into position with the aid of a specificallydesigned button-pulley unit attached to each end, which

FIGURE 2. A, B, AP and lateral view of the massive abdomi-nal wound measuring 35 � 25 cm. The bowel has granu-lated and protrudes significantly through the midline fascialopening.

FIGURE 1. Display of the ABRA system including the elas-tomers and buttons.

FIGURE 3. A, AP view of the abdomen after 9 elastic bandshave been placed across the defect. The middle 6 bandshave been doubled to provide extra support to the woundedges in the area of maximal tension. B, C, AP and lateralview of the abdomen after complete insertion of the 9 elas-tomers and their respective buttons, side supporting adhe-sive tapes, and the silicone gel sheeting to protect thebowel. Note on the lateral view that the abdominal visceraare already largely reduced back into the peritoneal cavity.

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provided a narrow channel into which the elastic band couldbe seated. By securing the 2 ends of the elastic band on eitherside of the wound to these buttons, tension was applied acrossthe wound in a continuous and controlled fashion. An additionaladhesive tape was secured to a small loop located on the lateralaspect of each button and applied under slight tension to thelateral aspect of the abdominal wall to help hold the buttonsin position and relieve some of the tension on the button-skininterface. To prevent the elastic bands from eroding into theunderlying bowel, Silastic sheeting was placed under theelastic bands and on top of the viscera. This more evenlyapplied the force of the elastics to a larger surface area andprotected the bowel from any potential direct and concen-trated pressure, which might lead to localized ischemic ne-crosis with bowel perforation. With initial placement of thedevice and modest tension on the elastic bands, the herniatedviscera were completely relocated back into the abdominalcavity. Three days after placement, gradual tightening of theelastic bands was begun at the bedside by reseating eachelastic band at a slightly higher tension within the channel ofeach button. Marks on the elastic bands themselves helpedguide the setting of correct tension based on how much thesemarks elongated as the elastic band was stretched. Tensionwas adjusted daily based on the response of the tissues to thepressure applied by the elastic bands and the buttons as theypressed against the skin edges (Fig. 4A, B). Wound approx-imation was actually achieved by day 17, but definitiveclosure was delayed secondary to concerns about continuedfevers with leukocytosis.

Stage 2Three weeks after application of the ABRA device, the

condition of the patient was dramatically improved. The patientwas returned to surgery where, under general anesthesia, theSilastic sheet was removed and the wound edges were debridedand primary reapproximation of the fascia and muscle in themidline was performed using numerous interrupted figure of 8#1 permanent monofilament sutures (Fig. 5A–C). The closurewas reinforced using a running suture technique through theanterior rectus sheath along the length of the wound. No meshwas used as the closure of the fascia was accomplished easilywithout the creation of undue tension. The skin was then simplydebrided and reapproximated in the midline. It should be notedthat no attempt to remove the granulation tissue adherent to thebowel was made other than gentle scraping of the surface.Drains were placed in the subfascial and subcutaneous spaces(Fig. 5D). Localized areas of pressure necrosis of the skin underseveral of the buttons were noted and treated conservatively withdressing changes. The remainder of the postoperative coursewas uncomplicated, and the patient was subsequently transferredto a rehabilitation facility 1 week after final closure. Woundhealing proceeded uneventfully and the drains were subse-quently removed. He presented 6 weeks later with a deepintra-abdominal abscess unrelated to the granulated surface ofthe previously exposed abdominal viscera that was drainedpercutaneously without the need for formal operative interven-tion. At follow-up 9 months after definitive wound closure, thepatient has a competent abdomen, with no evidence of hernia,

and excellent abdominal strength (Fig. 6A, B). He has sinceresumed his normal daily activities and is without disability.

DISCUSSIONLifesaving management of catastrophic intra-abdominal

trauma often involves a period of open abdominal wound man-agement. Using this strategy, prevention of abscess formationand exposure for additional debridement and abdominal irriga-tion are greatly facilitated. Once the life-threatening injurieshave been effectively managed, the full-thickness open woundof the abdomen then provides a significant reconstructive chal-lenge. As in this case, the abdominal viscera are often edematousand can protrude significantly through the wound in a mannerwhich precludes primary wound closure.9 As well, particularlyin patients who have undergone a lengthy recovery process, lossof intra-abdominal volume or abdominal domain due to contrac-tion of the abdominal cavity can severely hamper attempts toreplace the abdominal viscera back into the peritoneal cavity.

FIGURE 4. A, Appearance of the abdomen 9 days afterplacement of the ABRA system. B, Appearance of the abdo-men 21 days after placement of the ABRA system. All layersof the abdominal wall are approximated and ready forclosure.

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For these reasons, previous strategies for management of thesetypes of patients have included simply closing the skin over theexposed viscera or even skin grafting the granulated surface ofthe bowel. While these strategies can result in a healed cutane-ous wound, the significant abdominal hernia which results canbe a difficult reconstructive challenge at a later date as the degreeof contraction of the abdominal cavity can progress, resulting inan irreversible loss of abdominal domain. Repair of the herniamay then necessitate the use of alternative techniques of repairincluding the use of mesh5 or collagen frameworks such asAlloDerm (LifeCell, Branchburg, NJ),10,11 tissue expansion andrelaxing incisions,1,2 separation of abdominal wall compo-nents,3,4 pedicled flaps,6 or free-tissue transfer.7,8 An algorithmfor closure of difficult abdominal wounds has been previouslypresented by Rohrich et al.12

In designing the strategy used in this case report,several treatment goals were defined. The major obstacle to acomplication-free wound closure was deemed to be the defect

in the abdominal wall. Left unrepaired, it was feared that thisdefect would expand and a significant loss of abdominaldomain would result, making subsequent repair difficult. Itwas felt that the best way to prevent this from happening wasto reverse the effect of the initial clinical situation, where theprotrusion of the abdominal contents through the midlinewound was actually being worsened with each contraction ofthe surrounding musculature. As well, a strategy for edemaresolution in the viscera needed to be developed to allow theswollen bowel to fit back into the peritoneal cavity. Clearly,the clinical condition of the patient precluded a direct surgicalapproach. However, with gradual restoration of normal 3-di-mensional tissue relationships in the abdomen, it was felt thatthese obstacles to direct closure could be overcome using theconcept of progressive and continuous tension.9,13 This is theconcept behind the ABRA system. By developing a uniquemethod of fixation using the buttons and the tension-reducingadhesive strips, elastic bands can be used to span the defect

FIGURE 5. A, Appearance of the abdomen immediately after removal of the elastomer bands, buttons, and Silastic sheeting.B, Appearance of the wound after the skin edges have been debrided and the medial edges of the rectus muscles and fasciaseparated from the overlying skin and fat in preparation for primary closure. C, Appearance of the abdominal wall after full-thickness 2-layer closure of the muscles and fascia. A completely competent and secure closure has been accomplished with-out the need for mesh. D, Appearance after final skin closure and placement of drains.

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and gradually overcome the effects of injury and edema. Thismakes logical sense as no tissue was actually lost as a resultof the patient’s injuries. By overcoming the effects of edema,direct closure of the fascia in the midline should be possible.Certainly direct reconstitution of the abdominal wall is thebest option for long-term function and prevention of hernia.

In this case, there was no difficulty noted at all indirectly closing the midline muscle and fascia as the woundedges came together without undue tension. However, despitethe ease with which the fascia was closed, concerns remainwith regard to the intra-abdominal sequelae of closing thefascia over the granulated bowel as there exists the potentialfor the development of recurrent infection and intra-abdom-inal abscess formation.14 In this case, the intra-abdominaldrain placed directly under the fascia removed only serousfluid until it was discontinued. The late deeper intra-abdom-inal abscess which developed was related to previous injuriesand the unusual organisms which were present and assumedto be related to the unique flora of Iraq. When using thistechnique, it is highly recommended to place a drain betweenthe granulated surface of the bowel and the underside of theabdominal wall when closing a wound such as this.9 Not only

will the drain remove fluid which could become potentiallycontaminated, but the quality and consistency of the drainagefluid can help identify or rule out potential infectious sourcesshould postoperative fevers or septic symptoms develop.Also related to these infectious concerns is the concept ofmesh reinforcement of the wound. If at all possible, meshproducts or collagen framework sheeting such as AlloDermare probably best avoided in contaminated wounds such asthese, and they are best used only when necessary to achievea strong and stable fascial closure.

One complication related to the use of the buttons waspressure necrosis of the skin where the elastic band and thebutton were joined on the skin surface. This was likelysecondary to overzealous tightening of the elastic bands.Attention to skin hygiene and a more gradual stretching of theelastic bands can completely eliminate this problem.

SummaryMassive open abdominal wounds present a challenging

surgical problem, and many approaches and techniques forrepair have been reported. This article describes an innova-tive approach for restoration of lost abdominal domain withprimary wound closure using a dynamic tension device calledthe ABRA system. The ease of application and the effective-ness of the technique make it an attractive option for resto-ration of abdominal wall integrity.

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massive ventral hernias. J Am Coll Surg. 2004;196:484–488.2. Bashir AH. Wound closure by skin traction: an application of tissue

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6. Williams JK, Carlson GW, de Chalain T, et al. Role of tensor fasciaelatae in abdominal wall reconstruction. Plast Reconstr Surg. 1998;101:713–718.

7. Heitmann C, Pelzer M, Menke H, et al. The free musculocutaneoustensor fascia lata flap as a backup procedure in tumor surgery. Ann PlastSurg. 2000;45:399–404.

8. Ninkovic M, Kronberger P, Harpf C, et al. Free innervated latissimusdorsi muscle flap for reconstruction of full-thickness abdominal walldefects. Plast Reconstr Surg. 1998;101:971–978.

9. Koniaris LG, Hendrickson RJ, Drugas G, et al. Dynamic retention: atechnique for closure of the complex abdomen in critically ill patients.Arch Surg. 2001;136:1359–1363.

10. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chestwall reconstruction with AlloDerm in patients at increased risk formesh-related complications. Plast Reconstr Surg. 2005;116:1263–1275.

11. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm®): a newalternative for abdominal hernia repair. Ann Plast Surg. 2004;52:188–194.

12. Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for abdominalwall reconstruction. Plast Reconstr Surg. 2000;105:202–216.

13. Atweh NA, Lye KD, Kavic S, et al. Closure of large abdominal wounds withan adjustable suture-tension device. J Am Coll Surg. 2002;195:281–283.

14. Kendrick JH, Casali RE, Lang NP, et al. The complicated septicabdominal wound. Arch Surg. 1982;117:464–468.

FIGURE 6. A, B, AP and lateral views of the abdomen 9months after definitive primary closure reveal a competentabdomen with restoration of normal abdominal contours.

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