Case 1
A 69-year-old male presented to the emergency department (ED) with complaints of abdominal pain and a tense and distended abdomen. His previous medical history included stage 4 lung cancer, stomach cancer, and previous treatment with chemotherapy and radiation therapy. Previous surgical procedures included the placement of an internal carotid and a coronary artery stents, cervical spine surgery, and skin biopsy. Hematological assays noted an elevated white blood cell count and a clinical picture suggestive of early sepsis/septic shock. A thoracic CT scan revealed a large left pleural effusion, and a CT scan of the abdomen confirmed pneumoperitoneum.
The patient was taken to the OR and underwent an exploratory celiotomy (Figure 3A). A 0.7 mm perforated duodenal ulcer was found with extensive peritoneal contamination, which required abdominal debridement and washout. Upon inspection, the gallbladder and appendix were noted to be inflamed, and given the risk for delayed cholecystitis or appendicitis, an appendectomy and cholecystectomy were performed without any complications and with minimal additional operative time. After the closure of the perforated duodenum, irrigation of the abdomen was performed using 3 L of normal saline (NS) followed by 2 L of hypochlorous acid solution with a 10-minute dwell time. Temporary abdominal closure was achieved via OA-NPT (-125 mm Hg) using the next-generation OA-NPT foam dressing. The 3 layers of OA-NPT were applied immediately postoperatively.
Following the initial visit to the OR, the patient was transferred to the surgical ICU/shock trauma unit. Abdominal compartment pressures were measured. The patient was tachycardic, hypotensive, and demonstrated low central venous pressure despite being administered 4 L of intravenous fluids in the ED and intraoperatively. The patient was aggressively resuscitated with crystalloids and 25% albumin. Broad spectrum antibiotics were initiated.
On postoperative day (POD) 3, the patient was returned to the OR for an exploratory celiotomy, revision and repair of the contained duodenal leak, and omental mobilization. The next generation OA-NPT foam dressing was applied (Figure 3B); no appreciable increase in IAP was noted.
A third exploratory celiotomy was performed on POD 4, no clinical leak was seen and careful inspection of the abdominal cavity showed that no fibrin deposition or abscess were noted. Abdominal washout with 0.9NS and hypochlorous acid solution with a 10-minute dwell time, placement of adhesion barrier membrane, and primary abdominal closure were done. The clean, closed incision was managed for 7 days with closed incision negative pressure therapy (ciNPT; PREVENA Incision Management System; KCI, now part of 3M) (Figure 3C).
The patient continued to improve and was discharged to hospice on POD day 12, with stable vital signs, tolerating a general diet and ambulation.
Case 2
A 24-year-old female presented to the ED with complaints of severe abdominal pain, distention, lower back pain, dizziness, and a near syncopal episode. The patient was noted to be febrile, tachycardic (140 beats per minute [bpm]), and hypotensive (systolic blood pressure at 60’s mm Hg). On physical examination, she had a distended abdomen and left lower quadrant tenderness. A continuous wave, obstetrical Doppler ultrasound revealed an early intrauterine pregnancy (11-week gestation) and a fetal heart rate of 135 bpm. The patient had leukocytosis (18.9) and a neutrophil count of 84. A Focused Assessment with Sonography for Trauma (FAST) was done, and free fluid in the pelvis and right upper quadrant was noted. After rapid intravenous fluid administration in the ED, the patient was stabilized, and an abdominal CT scan revealed dilated loops of small bowel with diffuse thickness, consistent with edema, and a fluid-filled abdominopelvic cavity. She was taken to the OR for a diagnostic laparoscopy (Figure 4A), which was converted to an open exploration after scope insertion revealed bloody ascites and loops of necrotic small bowel.
An internal hernia was noted with a small bowel volvulus. This required intestinal detorsion and prompted a resection of 300 cm of ischemic small bowel. The bowel was left in discontinuity and an OA-NPT dressing was placed within the OA for TAC using the technique previously described (Figure 4B). No appreciable increase in IAP was noted.
The patient was admitted to the surgical ICU for management of an OA, pain control, metabolic acidosis, septic shock, and hypovolemia with fetal demise. On POD 2, the patient returned to the OR for abdominal lavage, a stapled, jejunal-colonic, end-to-end anastomosis, appendectomy, placement of a nasoenteric tube, and PFC.
The patient was discharged home on POD 7, with good pain control, tolerating a regular diet, ambulation, and twice daily wet-to-dry dressing changes on her abdomen. One-week post-discharge, the patient was evaluated at a follow-up appointment with fascial suture line that was intact and no clinical evidence of infection (Figure 4C).