“How to Close a Laparostomy”

Nigel Suggett

Queen Elizabeth Hospital, Birmingham

3 Questions

• How do you make a laparostomy

• When do you close a laparostomy?

• How do you close a laparostomy?

Aims of a laparostomy

• Reduce intra-abdominal pressure• Facilitate further access• Manage exudate• Reduce oedema• Maintain abdominal domain• Protect bowel• Reduce adhesions from bowel to abdominal wall

Options

• Skin Closure• Pack / Op-site• Bogota Bag• Topical Negative Pressure

Proprietary

D.I.Y

bowel

interface

muscle

skin

Skin approximation

D.I.Y

bowel

interface

muscle

skin

suctionAdhesive dressing

Skin approximation

TNP and open abdomen

• Know what you are doing!

• Protect and separate the bowel

• Check 48-72h

• Risk of fistulas?

When to Close?

When to close

• Ideally <5 days• Before granulation/ adhesion• Try to avoid fascial retraction

Primary Fascial Closure?

How to Close?

• 2o intention• Skin graft

• Bridging

• Gradual / Staged Closure

• Direct Suture +/- Mesh

• Component Separation +/- Mesh

Component Separation (Ramirez 1990)

Bleichrodt et al.

Case

• 51y M - LUQ Stabbing• Left renal vein, stomach and splenic hilum damaged• 24U Blood, 20U FFP , 4U plt• Pack + TNP

• Re-look d1 - Colonic ischaemia – stapled off – TNP

• Re-look d4 – Re-anastomosis – TNP – unable to close

• Relook d9 – Unable to close

Component Separation

1-2cm

Component Separation

Component Separation

3-5cm upper abdo7-10cm waist1-3cm lower abdo

Component Separation

Component Separation

2-4cm

Component Separation

Mesh

• Biologic (in this setting)

• Intra-peritoneal• (Extra-peritoneal)• On-lay

Caution!

• Returned to ward 5/7 later• Witnessed VF arrest ? cause• Aspirin, clopidogrel, therapeutic enoxaparin• Bleeding!!!!

So……

• Evacuation of haematoma and re-application of TNP– Tracheostomy– Fascia intact

• Skin re-closed 4 days later• Discharged (after ICD)

Component Separation

Pros

• A useful technique

• Allows primary fascial closure

• Gets you out of trouble

Cons

• Time consuming

• Potential morbidity

• Can only be done once!

3 Questions

• How do you make a laparostomy– Depends on your knowledge and skills– Carefully and thoughtfully

• When do you close a laparostomy?– As soon as it is safe to do so– Or not at all

• How do you close a laparostomy?– Primary suture– Component Separation + Mesh– Or not at all