Immediate closure of abdominal incisions after exploration and treatment of
gunshot wounds is not always feasible or advisable. Significant bowel
edema after massive fluid
resuscitation might preclude primary closure, whereas any attempt to close under tension might result in complications ranging from
wound dehiscence,
infection, and
necrosis to the
abdominal compartment syndrome with abdominal, cardiopulmonary, and renal complications. For these difficult cases, the open technique has been recommended. The abdomen is left open and is closed when the patient's condition permits. When immediate
wound approximation is not possible, temporary coverage can be achieved with a mesh, patch, or a split-thickness skin graft and the definitive reconstruction is deferred for a more optimal time. The purpose of this retrospective study is to report the authors' experience with staged abdominal wall reconstruction after
gunshot wounds. From 1989 to 1998, 1933 patients underwent exploratory
laparotomy for
penetrating wounds to the abdomen. Twenty-nine patients in grave condition and with multiple medical problems were comanaged by the
Trauma and Plastic Surgery Services at Cook County Hospital with the following protocol: The abdomen was initially left open and exposed viscera were covered with a variety of methods, including a Gore-Tex patch (W. L. Gore and Associates, Inc., Flagstaff, Ariz.). A split-thickness graft was subsequently placed on the granulation tissue over viscera at an average of 14 days after the last
laparotomy. These planned
ventral hernias were definitively treated at an average of 7 months after the
skin grafting procedure, primarily using the components separation technique. In 24 patients, the fascia was closed primarily without tension, while five patients required the use of synthetic mesh to restore fascial continuity. Nine patients underwent closure of a
colostomy or repair of
fistulas simultaneously with abdominal wall reconstruction. One patient developed a
postoperative hernia, two developed superficial
wound dehiscence that healed without further surgery, and one required re-exploration for a failed anastomosis after
colostomy closure. All but one patient maintained a stable abdominal wall after the reconstruction. The authors concluded that staged abdominal wall reconstruction should be primarily recommended for patients with complex abdominal
wounds and a compromised general condition that precludes primary closure. With this treatment protocol, patients can recover faster from their trauma surgery and the risk of perioperative complications can be reduced. After final reconstruction, the continuity, stability, and strength of the abdominal wall are maintained in the vast majority of cases with the use of autogenous tissue and without the need for alloplastic material. With close cooperation between the
trauma team and the
plastic surgeon and appropriate timing and planning of each stage, the success rate of the technique is high and the incidence of complications limited.