Innovative Management Of Open Abdomen: Ultrasound Doppler-Guided Gradual Abdominal Wall Closure After Pediatric Liver Transplantation.

Objective: Primary abdominal wall closure can be difficultafter liver transplantation (LT), mostly in cases involving anoversized liver graft with edema of the intestine. Conventionalclosure with extensive tension may compromise graft perfusion.An open abdomen significantly increases the risk of infectionand fluid loss. In one of our patients who recently underwenttransplantation, we applied an innovative method usingultrasound Doppler-guided gradual abdominal wall closure toensure adequate flow within the graft during manipulation. Methods: A 1.8-year-old child diagnosed with biliary atresiaunderwent elective living-donor LT; the donor was 46 yearsold. The patient’s body weight was 9.7 kg. The graftweight was 370 g, with a graft-to-recipient weight ratio of3.81. The operative course was complicated by portal veinthrombosis, and portal flow was reestablished by interpositionof a homologous iliac vein graft. A large-for-size graft anddistension of intestinal loops did not allow primary abdominalwall closure. Skin closure was also not possible. The muscularfasciallayer was closed with a Bogota bag. On postoperativeday (POD) 2, to facilitate abdominal closure, 3 TopClosure®Tension Relief System (TRS) sets were temporarily applied atthe bedside. Approximation of full thickness abdominal skinedges was performed by gradual approximation of woundedges using the TRS sets. The closure tension was determinedand adjusted with Doppler control of portal flow measurement.The targeted portal velocity was set to a pre-closure value of40 cm/s. On POD 4, the patient returned to the operatingroom for approximation of the muscular layer. The temporaryTRS sets were removed, and 5 new sets were installed alongthe abdominal wound margins to substantially reduce thewound edge gap. Results: Complete abdominal wall closure was limited by compromised portal blood flow. The TRS allowed animmediate release of over-tension. The wound was coveredwith a V-care® vacuum dressing above the Bogota. Duringsuccessive days, the TRS plates were gradually approximatedusing ultrasound Doppler measurement. On POD 8, thepatient underwent reoperation and primary fascial closurewas considered impossible despite marked improvementin intestinal edema. The fascial defect was repaired withPermacol® biologic mesh and a complete, staged skinapproximation was achieved without undermining with 8 TRS8-mm sets under intraoperative Doppler ultrasound control.Skin closure was performed with intradermal running sutures,with an excellent cosmetic result. After complete woundclosure, the pattern of portal, arterial, and venous flow wasnot changed from the values measured at the beginning ofthe procedure. For prevention of tension on skin edges, theTRS system and V-care vacuum system were left in place untilPOD 16. At the 4-month follow-up, no vascular or surgical siteinfectious complications were observed, and liver graft functionremained normal. The abdominal wall functional and scarappearance were not different from those of other childrenundergoing primary closure. Conclusions: Ultrasound Doppler-guided gradual abdominalwall closure using the TopClosure® Tension Relief System is anefficient and safe management method for the open abdomenafter liver transplantation in children with a small abdominalcavity and a relatively large-for-size liver graft. DOI: 10.20892/j.issn.2095-3941.2018.S107