Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure.

OBJECTIVE: The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC.

METHODS: Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible.

RESULTS: Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21% but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh.

CONCLUSIONS: MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.