May 25, 1992 - Swg Gynecol Obslet 1983; 156: 609-17. 11. Lequit P. Zip closure of the abdomen. Nech J Swg 1982; 34: 40-1. ZIPPER IN ABDOMINAL SEPSIS ...
INDIAN J GASTROENTEROL 1993 Vol 12 No 1: 1-4
ORIGINAL ARTICLES
Role of Zipper in the Management of Abdominal Sepsis KULDEEP SINGH, R S CHHINA
Depamnents of Emergency Surgety and Gastroenterology, Daymand Medical College and Hospital, Ludhiana 141 001 Abstract Background. Continuous peritoneal lavage, staged laparotomies and radical peritoneal debridement have been used to reduce mortality from severe abdominal sepsis. Recently, open abdomen technique using a 'zipper' with or without mesh for abdominal lavage has shown promising results. Aims: To evaluate open abdominal technique using a zipper in patients with advanced diffuse peritonitis with impending o r established multiple organ failure. Methodc Modified open abdomen technique using zipper with o r without mesh, was used for abdominal closure in eight patients with severe generalized peritonitis (APACHE-I1 score range 27-30). Results: Zipper was inserted a t first laparotomy in three patients, a t second e ~ ~ l o r a t i o n ' ifour n and a t the time of third laparotomy in one case. Two patients required strips of mesh in addition to zipper. Six of eight patients survived and were discharged afkr an average period of 27 days. Two deaths were due to multisystem organ failure, In four patients additional surgical procedures like closure of perforation, temporary ileostomy and resection anastomosis of small bowel was carried out through the zipper. Zipper-mesh were removed an average of 10.5 days h e r ,insertion. Three patients developed incisional hernia a t 6 months follow-up. Conclusion: This technique merits further controlled trials to ascertain its indications and benefits. (In4iu.n J Gastroenferol 1993; 12: 1-4). Key words: Peritonitis; peritoneal lavage Introduction Despite many t'echnical advances in surgery, mortality from severe abdominal sepsis remains unacceptably Comspondtnce (o: Dr Singh, donsultant Surgeon & In-charge, Emerg c n v Suwv Received May 25, 1992 Received in final revised form August 27, 1992 Accepted September 20, 1992 8 1993 Indian Society ofGastmenterology
high? This may result from (i) unsatisfactory drainage of the peritoneal cavity, (ii) kecurrent or residual sepsis which goes undetected, or (ii) multiple organ failure and wound complications. In an effort to reduce the mortality, various surgical procedures like continuous peritoneal lavage: staged laparotomies3 and radical peritoneal debridement4 have been employed without much success. In recent years several authors have used an open abdomen technique using a 'zipper', with or without a mesh, with promising Since experience from India in the zipper technique is limited, we present ou; preliminary experience with the zipper in the management of abdominal sepsis. Methods
From January to November 1991, 176 patients were operated on for intraabdominal sepsis. Eight patients (4.5%) who had advanced diffuse peritonitis with impending or established multiple system organ failure were subjected to open abdomen technique using 'zipper' for abdominal closure. These included six men and two women with a mean age of 37 years. Patients selected had a septic focus which could not be eliminated by conventional surgical procedures, or the bowel viability was in doubt or a compromised anastomosis was to be observed. Their pre-operative data were scored according to the Acute Physiology add Chronic Health Evaluation (APACHE 11) system.8 A written consent was taken from all the patients. Three patients had leukopenia and five had leukocytosis at the time of admission. Thrombocytopenia was present in two patients with septicemia following typhoid perforation. The initial serum creatinine and blood urea levels ranged from 2.1 to 6.3 g/dL and 54 to 240 mg/dL respectively. Hyperkalemia was present in two cases (cases 5 and 7) who underwent hemodialysis. Total proteins and serum albumin were decreased in patients but were normal in three patients who hid the zipper inserted at the first laparotomy. Liver enzymes were raised marginally in four patients and -two patients had serum bilirubin ranging from 2 to 3 mg/dL.
'ThisJournal is indexed and abstracted by EXCERPTA MEDICA, Amsterdam, Netherlands, and indexed by INDEX MEDICUS and MEDLINE, Philadelphia, USA
Fig Zipper ~ ~ a i r tm' dsh,n rnargru m,iihp;n!eit
i0
Tcckniq:[e At the end of iaparotomy, ap. aatoclaved cnmmercial plyioir zipper witk largt ~ c e ~wab h sutured eo chs sEn margins sf the wound (Fig). The Icngrh of ?he zipper was adjusted tb c-mirg one end. Mesh strips, u;heneeer needed, were saiured on either side of the z$per. The zipper and the mesh \+ere ccvered with saiiae and povidone iodine soaked gauze tnd su-gcal padn. DrriL~s were not used.
Peritonea: Iavages were performed in the post~perativeg1er:nd either dady or on alternate days. Using intravenous scdatloa and after abdor.ind preparation, the zipper-mesh :vas ivrsiled 'vith d i n e and opensd -4th g v i ~ ~finger. ~ ! A11 adhes.cns *ere broken gcxtly and perirorrea: ravdge perfarmed uslng saline and povidone iadine. Special care .iss taken to h a s a c iatraabdominal orgaris and bo$+zl to ?revent tnaunaric intraperitoneal b;eedlng, After :axcye, the ziF2e; was closed and covered 6 t h saline soaka gaze, leiria! lavages were done in the operdriag room apld Id:-; on at the bzdside in the intens;\e c;re \ , a d . 9rzss:rags a,e:r ci;a~:ged tivice daily. '.%'hen h e patierit's condition was stable and ail signs of contir~i:ing 3eus;s kacr abated as juZged by rapidity OF formation of adhesion., d e ~ c pofhedthy . granulation and general appzaran-e of the aodorninal cavity, the cxpioral;ox were disccnih~edand Firm adhesions were ailowed to form fcr se~era:jays. 3n3 then were the mesh and zipper removed and the asdorneri was dosed in a single Ihycr or ihe aousri was al!ow-,d to granulate. WesnPts Abdominal expiorallon and lavages were well toieratcd by a!i :h2 patiexis under rntravenous sedation. :o:J of ten zippers were inserted in eight patients. Two ~:atientsrequircd reinsertion of lipper due to slough-
Table: Clinical data Sr
ii'o I. 2.
3.
4.
5.
6.
.
Sei
Dtupzcsu and ,findznp
i70*n~h;r~dicq ficiors
>i;.~irrp:tdeal perf-rz! 01'. ( fever) ~ ! l hfecal Pri~I:a R4Perfortttd sp;.enl.u w!t",~-'ptic mulri,scc,arec! anccrsszs mi?f ~ z ! Esi,,a F h b d s r n i d d i t~hercdias.a, ,,&a peiforaiicn: rapdrotumy Cone, an6stomoi.c deh~scence M E n t e r ? = perfornL.on. m~:tip:e i~ltraabdomaa! akssesses =,*h anhealthy gut M Traumai~crnese.iieric, small gb? ana large gut ' n j ~ r y*iLh henatorria: Reseft~or,arnstomocis F Sepilc abor:~on w a r p ~ b : t i p ' e inIraabdominal restdual dSscc*be* M Enreric pe:fara:icn wtn fcca: fistula
4 score
4
Laa~ar~lonqy Zippc? m=mSer fdees;z
O:trcoine
M
GI b'eea
shocki;, rei?;,! ! n s u E s ~ e n ~ >
B:onciic~.~zurncn,a
25
Ti..rrd
Z+M
Aive
icwer GI meed, sepc:cem,a
28
F.ist
Z
.A:i\e
Sepi ieelri, ran' falure
30
nisi
2-I\I
9iea
Sept,c shock
28
Second
7,
&we
Septicemia,
?G
Second
Z
tUr-e
23
F~rst
Z
Alne
resslratory f a i i ~ rrenal ~, fii~l~ire 8.
M
IntesVnai obstr-ction (srra~plat~on) St.piic snock, GI SJ 1 n .I-!re-~'cdom~nal abscess bieedrng wtn renal la!i,rz
2 iWDIA\ J GA>TROEhTER3i J q V 1713 t'9l 12
\\.o
1
ZIPPER IN 4QIDO'd;UA:
';FPFIF
- SlhGV a rH?ll\j.
ing of the skin edges. In three patients zipper was inserted at the first surgery, in four at second exploration and in one case at the third laparotomy. In two patients strips of mesh were used in addition to the zipper due to difficulty in closure of the abdomen (Table). Nitrous oxide-oxygen mixture inhalation, local anesthesia and general anesthesia were used in 4,3 and 1patient respectively. Additional surgical procedrtres tltrwcglz the zbper Four patients underwent surgical procedures through the zipper. These consisted of perforation closure in two patients (including serosal patch repair with pelvic abscess drainage in one), fecal fistula exclusion as a temporary ileostomy in one patient and resection anastomosis in one patient. The patient with resection anastomosis (Case 5; Table) had received traumatic injury of the bowel and the mesentery and the small bowel viability was in doubt; this necessitated a close clinical observation. A total of 28 peritoneal explorations were done in six patients with maximum of 7 in one patient with multiple stab injuries with septicemia (Case 5). Morbidity soiling from fecal Three patients had repeated fistula and developed interloop and pelvic abscesses. In two of these cases, the fistulous site could be defined and was repaired through the zipper; in one case fistula could not be visualized and was treated as such. No fistula developed over the exposed bowel just underneath the zipper. All abdominal wounds and meshes developed polymicrobial infection. pseudomonas and E coli were present in six cases, whereas enterococcus, klebsiella and Staph altrezts were present in four cases. Two developed severe wound sepsis and were managed by dressings and debridement of necrotic tissue. The presence of ileostomy close to the zipper-mesh did not pose any problem. Five patients were treated with parenteral hyperalimentation. Serum electrolytes and renal function tests were monitored daily. Despite the daily bowel manipulation, paralytic ileus was not a problem except in two cases, where it was managed conservatively. The zipper and mesh strips were removed within a mean of 10.5 days (range 7-11) in six patients who survived. In four patients abdominal closure was done in single layer and of these, one got dehiscence of abdominal wound and this was allowed to granulate. This patient later developed incisional hernia. In three patients the wound was allowed to heal by secondary intention. In one case split thickness skin graft was put after partial
contraction of the wound. Of six patients, two developed sinus formation at one month follow up and were explored under general anesthesia and chronic granulation tissue was excised. Three patients developed incisional hernia at six month follow up and have been advised surgery. MoHality Six of the eight patients survived and were discharged from the hospital after an average stay of 27 days (16-37 days). One patient with severesepsis died of disseminated intravascular coagulopathy and renal failure on the 8th post-operative day; the second patient had severe pulmonary infection and died of multiple organ failure after 12 days (Table). Discussion The principles of prevention or treatment of persistent or recurrent intraabdominal sepsis include debridement of dead tissue, drainage of septic foci, and prevention of their reaccumulation. Newer treatment regimens to accomplish the latter have included intraoperative peritoneal irrigation2 with various antibiotics or antiseptics, use of multiple drains with and without irrigation, and radical debridement4 of all visceral and parietal peritoneal surfaces. While initial reports of radical debridement were encouraging, this has not been reproduced in a randomized, controlled trials? The concept of leaving the abdomen 'open' gained some popularity but was associated with the need for mechanical ventilatory support to prevent e v i s ~ e r a t i o n ~ ' ~ this facility is not readily available in our hospitals. Suturing of the mesh alone to the abdominal incision eliminates the problem of evisceration and lowers the mortality rates.'' However, residual deep seated abscesses are liable to be missed or diagnosed late. The 'zipper' modification of the classical laparostomy technique was popularized by ~ e ~ u i who t " used it to gain easy re-entry into the abdominal cavity in two cases of bowel necrosis. Recently, other authors have described its use successfully in diffuse severe peritonitis.5J The only Indian experience7 in zipper technique has also been encouraging, with successful control of abdominal sepsis in 4 of 5 patients, 'though three patients died ultimately. In our series, the expected mortality was 4550% according to the APACHE 11 scoring system, but we had a mortality of only 25%. The clinical presentation of our patients is similar to that of the other Indian study? The cause of high mortality in the study by Bose et a1 was due to multiple organ failure; our patients also had similar problems, possibly due to the fact that surgical treatment was initiated too late. Although our series included only eight patients, our
INDIAN J GASROENIEROL JAN 1993 Vol 12 No 1 3
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results have been-encouraging. We feel that this aggressive approach of open abdomen enables better surgical treatment of critically ill patients with diffuse peritonitis. The advantages of this technique with life-saving potential are numerous and include: effective drainage of abdominal sepsis, early diagnosis of recurrent sepsis and easy 'access for reoperation, observation of a compromised anastomosis and additional surgical procedures can be performed in these sick patients.
peritonitis. The results of a prospective randomized clinical trial. .
,
5.
6.
7. 8.
References 1. Hau TI Ahrenholz DH, Simmons R L Secondary bacterial peritonitis. The biological basis of treatment. Curr Prob Swg 1979; 16: 1-64. 2. Stephen M, Lmwenthal J. Continuing peritoneal lavage in high risk peritonitis. Swgsy 1979;85: 603-6. 3. Pennicks FW,Kerremans RP, Lauwers PM. Planned relaparotomies in surgical treatment of severe generalized peritonitis from intestinal origin. Wodd J Swg 1983; 7: 762-5. 4. Polk HC, Fry D E Radical peritoneal debridement for established
4 INDIAN J GASIROENIEROL JAN 1993 Vol 12 No 1
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Ann Suq 1980; 192:3504.
Hedderich S, Wexler MJ,McLean APH, Meakins J L The septic abdomen: open management with marlex mesh with a zipper. S w g q 1986;99: 399-407. Garcia, Sabrido JL, Tallado JM, Christou NV,Polo JR, Valdecantos E Treatment of severe intraabdominal sepsis andlor necrotic foci by an 'open abdomen' approach. Arch Surg 1988;123: 152-6. Bose SM,-Kalri M, Sandhu NPS. Open management of septic abdomen by marlex mesh zipper. AIM NZ J Surg 1991;61: 385-8. Knaus WA, Draper EA, Wagner DP, cf d. APACHE-11: A severity of disease classification system. Cd Care Med 1985;1 3 818-29. Duff JF, Moffat J. Abdominal sepsis managed by leaving the abdomen open. Surgny 1981;90: ?74-8. Wouters DB, Krom RAF, Sloof UIH, laotstra G,Kujjer J. The use of marlex mesh in patients with generalized peritonit-is and multiple organ system failure. Swg Gynecol Obslet 1983; 156: 609-17. Lequit P. Zip closure of the abdomen. Nech J Swg 1982;34: 40-1.
ZIPPER IN ABDOMINAL SEPSIS
- SINGH & CHHINA
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