Temporary Abdominal Closure Techniques
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Over the past two decades, the way in which trauma surgeons approach a patient with multiple severe injuries has undergone an evolution. Trauma surgeons no longer attempt to fix everything during the initial operation. The literature reflects their cumulative experience, which confirms that conservative operative techniques and short operating times, even when all organ repairs have not been completed, increase survival in civilian and military patients with multiple trauma. These principles hold true for all affected regions of the body, including the abdominal cavity and its contents, which constitute the focus of this article. [1, 2, 3]
Damage-control principles are typically applied to patients who have multiple severe injuries. These patients are commonly hypothermic, acidotic, and coagulopathic. Under these circumstances, a deliberate, staged, reoperative approach is optimal.
The three commonly recognized stages of damage-control celiotomy are as follows:
Those who may require damage-control celiotomy are patients who are hypotensive (blood pressure [BP] <90 mm Hg) with the following abdominal or pelvic traumatic injuries:
Although the organ-specific operative techniques are beyond the scope of this article, patients who undergo damage-control celiotomy are at risk for the development of multiple life-threatening complications in the early postoperative period. The chief complication in the postoperative period is abdominal compartment syndrome (ACS).
Abdominal compartment syndrome (ACS) is a condition that elevates intra-abdominal pressure (IAP), adversely affects end-organ physiology, and disrupts patient homeostasis. ACS was described as early as the 1800s; however, only in the past 15-20 years has it been consistently recognized in the surgical and medical patient population. The reported incidence of ACS is 10-15%, and if it is left untreated, it is uniformly fatal. With diagnosis and treatment, the mortality is 46-66%.
ACS is most often encountered during the early postoperative course and is commonly discovered in patients who have undergone damage-control celiotomy with primary fascial closure and intra-abdominal packing for coagulopathy. ACS may develop in people with the following conditions:
The aforementioned conditions may lead to decreased blood flow to the abdominal wall and organs. This derangement of cellular perfusion initiates cytokine release, destabilizing cell membranes and ultimately leading to cellular edema and cell death if not reversed. This process is clinically manifested by organ swelling, leading to secondary pressure effects on the respiratory, cardiovascular, and central nervous systems when the IAP rises above a critical level. (See the images below.)
Additional causes of elevated IAP include the following:
The aforementioned conditions either directly or indirectly increase IAP in patients who are critically ill with ACS.
Cerebral changes
Elevated IAP results in elevated intrathoracic pressure, leading to elevated central venous pressure (CVP) and causing an increase in intracerebral pressure. The Monroe-Kellie doctrine states that this increase in intracranial blood volume results in elevation of intracranial pressure (ICP).
During resuscitation and vascular volume expansion, intracerebral pressure and cerebral perfusion pressure (CPP) may increase transiently; however, these pressures will ultimately fall if abdominal pressure continues to increase. Because of a concomitant decrease in caval venous return, this will ultimately cause a fall in cardiac output that will negatively impact intracerebral perfusion pressure.
This fall in ICP may be transient as well if intrathoracic pressure increases as a consequence of increased IAP. This can cause increased intracerebral pressure resulting from increased internal jugular/superior caval venous pressure.
In a porcine model, Bloomfield et al demonstrated significant effects of elevated IAP on the central nervous system (CNS); elevated IAP resulted in increased ICP and decreased CPP. [4] The mechanism is a functional obstruction of jugular venous drainage due to the elevated pleural pressures and CVP. As previously mentioned, the increase in intracranial blood volume results in elevation of the ICP (the Monroe-Kellie doctrine).
Abdominal decompression has resulted in a return toward baseline for ICP and an improvement in the CPP. Head injury and concomitant abdominal injury is a frequently encountered clinical scenario. This observation (confirmed clinically) is important. Decompressive celiotomy in patients such as these has resulted in a dramatic reduction in ICP. Abdominal decompression in these patients has resulted in a return toward baseline for ICP and an improvement in CPP.
Ophthalmologic changes
Increased IAP can cause the rupture of retinal capillaries, resulting in the sudden onset of decreased central vision (Valsalva retinopathy). Valsalva retinopathy has been described in a number of settings where a sudden increase in IAP or intrathoracic pressure has occurred. The retinal hemorrhage usually resolves within days to months, and no specific treatment is necessary. If a patient with ACS develops visual changes, Valsalva retinopathy should be considered and an appropriate ophthalmic examination performed.
Cardiovascular changes
Increased IAP may cause the following problems:
An increase of IAP to greater than 15 mm Hg results in the following:
Pulmonary changes
ACS may lead to pulmonary complications, as follows:
Renal changes
ACS can lead to acute renal failure:
Increased IAP causes the following:
Ureteral obstruction does not occur with increased IAP.
Increased IAP upregulates the juxtaglomerular apparatus, causing the following:
Changes involving abdominal wall and viscera
Increased IAP results in the following:
Monitoring and measuring IAP
The most direct and accurate measurements of IAP are obtained via a cannula placed percutaneously into the peritoneum.
Indirect IAP is monitored through transfemorally placed inferior vena cava lines, nasogastric tubes, rectal tubes, and, most commonly, Foley catheters. The most accurate and simple way to determine the IAP is indirectly by measurement of the bladder pressure via a Foley catheter. The bladder pressure is essentially equivalent to the IAP.
To measure the bladder pressure, the following steps must be completed:
Release of abdominal compartment syndrome
Morris et al and other investigators have noted that the sudden release of ACS may lead to an ischemia-reperfusion injury, causing acidosis, vasodilatation, cardiac dysfunction, and cardiac arrest. [5] Morris et al have also recommended that before the abdominal cavity is released, the patient should be preloaded with 2 L of 0.45% normal saline, 50 g/L of mannitol, and 100 mEq of sodium bicarbonate crystalloid solution. [5] Vasodilators, such as dobutamine or phosphodiesterase inhibitors, may also be beneficial.
Leaving the abdominal incision open during surgery prevents abdominal compartment syndrome (ACS). ACS more commonly presents in the early postoperative period (24-72 hours); however, it can present later than this time frame.
The techniques of temporary abdominal closure (TAC) are varied, and each has its own advantages and disadvantages. All of them face a similar challenge: management of the open abdomen. To date, no prospective randomized studies have compared the effectiveness of these various techniques or validated the concept of the open-abdomen protocol. However, retrospective data in the form of case and cohort studies do exist, and they consistently show that maintaining the open-abdomen protocol in high-risk groups has been effective in reducing mortality in a clinical setting.
The benefits of TAC include the following:
With a damage-control celiotomy, the trauma surgeon must decide to convert to a limited procedure within 5 minutes of starting the operative procedure. This decision is based on the initial physiologic state of the patient and a rapid initial assessment of the internal injuries. It is imperative not to wait for evidence of metabolic failure to manifest. This decision is vital for the patient’s survival. The intent of damage-control surgery is to accomplish the following:
The trauma surgeon should be familiar with different TAC techniques, including their indications, their advantages, and their disadvantages.
The patient is reevaluated in 24-36 hours. The trauma surgeon must maintain a low index of suspicion for delayed or occult injuries, particularly in patients with blunt polytrauma.
Every effort is made to spare the fascia to the extent possible. Repeated attempts at TAC that use the aponeurotic fascia cause recurrent direct and indirect (ischemic) tissue damage. This damage degrades the native tissue, decreasing its tensile and elastic capacity, and increases the potential for delayed incisional hernia.
Definitive closure should be attempted within 7-10 days. After this time frame, loss of abdominal domain and lateral retraction of the recti and aponeurotic edges tend to be maximal. [6]
One of the simplest and fastest forms of temporary abdominal closure (TAC) is towel-clipping of the skin edges. Towel clips are placed 1 cm apart and 1 cm away from each side of the skin edge. As many as 30 standard perforating towel clips may be required to close an incision. The incision may then be covered with an adherent plastic drape (eg, Vi-Drape, Steri-Drape). Covering the incision decreases manipulation of the towel clips while the patient is being transferred.
This technique may be used in the rapid temporary closure of thoracic or groin incisions in patients with trauma injuries who are in unstable condition and in patients undergoing general surgery. (See the images below.)
Open packing of the abdomen is a form of TAC that has been used for more than two decades at the Detroit Receiving Hospital. The abdominal-wall defect and the exposed viscera are covered with rayon cloth. This rayon cloth is then covered with gauze dressing. Widely spaced retention-type sutures are placed, encompassing all layers of the abdominal wall, and are tied above the gauze packing.
As bowel edema diminishes, the gauze dressing is removed, and the retention sutures are gradually tightened until the incision can be closed. Bender et al reported successful fascial closure in 15 of 17 patients who survived beyond the initial 24 hours. [7]
First described by Leguit in 1982, [8] zipper closures (see the image below) were popularized by Stone et al in their open-abdomen approach to pancreatic abscesses. [9]
The approach using the Wittmann Patch (STARSURGICAL, Inc, Burlington, WI) was first reported by Teichman et al, [10] Wittmann et al, [11] and Aprahamian et al. [12] As bowel edema resolves, the excess Velcro-biocompatible patch material is removed and the fascial edges approximated. Tension closure is accomplished by the adherence of the overlapping Velcro-like sheets.
The major advantage of this approach is the ease of access for repeated surgical interventions and the capacity for applying tension to the midline fascia, which helps prevent lateral retraction of the aponeurotic edges, permitting definitive delayed primary closure in most cases (see the images below).
Polytetrafluoroethylene mesh
The polytetrafluoroethylene (PTFE) 2-mm biocompatible prosthetic abdominal-wall graft is strong and watertight and creates a bed for granulation tissue, which may be covered with a split-thickness skin graft when the prosthesis is removed. PTFE is expensive, and similar outcomes may be achieved with less costly absorbable mesh or Silastic (silo) dressing changes. (See the image below.)
Polypropylene-polyethylene mesh
Several authors have reported the use of polypropylene-polyethylene mesh in the setting of a contaminated wound (eg, fasciitis, intra-abdominal sepsis). (See the image below.) Healing has been reported, even in wounds where frank purulent discharge is present.
Although short-term successes have occurred, numerous long-term complications have been reported with this mesh, including the following:
The experience recorded by Voyles et al, [13] Stone et al, [9] and Jones et al [14] strongly suggests that permanent rigid-type prosthetic mesh should not be inserted in the setting of abdominal-wall defects with associated contamination from the gastrointestinal tract secondary to trauma, intra-abdominal sepsis, or necrotizing infections involving the abdominal wall. (See the image above.)
Absorbable mesh
Synthetic absorbable mesh has been used extensively in TAC. Polyglactin and polyglycolic acid have been in the surgical armamentarium for approximately 25 years. This type of prosthetic mesh implant has been used for repair of traumatic liver, splenic, and renal injuries and for pelvic floor repair in the setting of abdominal peroneal resection of the rectum. Although early burst strength (at 8 weeks) is comparable to that of permanent mesh, as the mesh is absorbed (at 10-12 weeks), hernias inevitably develop in most patients.
As described by Bender et al, the mesh is applied loosely over the abdominal contents and then covered with fine-mesh gauze packing, with the bowel maintained below the absorbable mesh and within the abdominal contents. [7] This may decrease bowel-wall distention, thinning, and subsequent desiccation, thereby potentially reducing the incidence of enterocutaneous fistula.
The choice between polyglactin mesh and polyglycolic acid mesh is primarily determined by the surgeon’s preference. However, Brasel et al have reported some advantage to the use of polyglycolic acid mesh. [15] This mesh has wider interstices, which Brasel et al believe may allow more efficient drainage of intra-abdominal fluid and thus may decrease potential delayed complications (eg, abdominal distention, ileus, and abscess). (See the images below.)
A presterilized (gas) soft 3-L plastic cystoscopy fluid irrigation bag is cut and shaped to cover the abdominal incision and extruded viscera. This bag is either stapled to the skin edges of the wound with a standard (wide) skin-stapling device or sutured with monofilament nonabsorbable suture material, thus preserving the fascia. Sterile antibiotic-soaked towels (using Kantrex) may be applied over the silo, which is then covered with an iodine-impregnated adhesive plastic drape.
An alternative is to apply sterile towels over the silo and then secure them with a Montgomery abdominal wound binder, being careful not to create increased abdominal pressure while securing the dressing. The wound is inspected and the dressing is changed every 24 hours (or as needed). Intravenous (IV)/cystoscopy bag silos may be replaced in the intensive care unit (ICU) setting by means of standard sterile surgical technique and equipment.
This technique is a variation of the silon (silo) closure used for the repair of gastroschisis and omphalocele. In hospitals in Colombia, South America, IV bag closure (also known as the Bogotá Bag) has been used extensively and successfully. (See the images below.)
The video below explains the benefits of using Silastic closures for TAC.
Silastic closures are fast and effective temporary closure modes and have some significant cost benefits, as reported by Fernandez et al. [16] (See the images below.)
Primary delayed fascial closure (at 5-10 days) may be attempted if the abdominal cavity can be closed without significant elevation of intra-abdominal pressure (IAP). A high index of suspicion for recurrent abdominal compartment syndrome (ACS) must be maintained.
Elevated peak airway pressure or plateau pressures (>30 mm Hg), increased urinary catheter bladder pressures (>25 mm Hg), and accompanying deteriorating clinical parameters (eg, abdominal distention or decreased urine output) should prompt a careful reevaluation of the patient and consideration for decompressive celiotomy.
These types of patients are challenging both from a pathophysiologic and from a surgical technical standpoint. Optimal care is best achieved through a multidisciplinary approach that is led by the surgeon in close collaboration with the anesthesia and intensive care unit (ICU) teams and conducted in a staged manner. Two published algorithms, by Fernandez [6] and by Coccolini et al, [17] outline the step-by-step surgical decision-making more commonly involved in the care of the patient with an open abdomen. (See the images below.)
Fabian et al published their experience with their eponymous protocol, [18] after which the patients are subsequently brought back for definitive reconstruction, usually within 6-12 months. The stages are as follows:
The Sure-Closure skin-stretching system (MedChem, Woburn, MA) is a patented, disposable, molded device made of stainless steel and plastic parts and used to provide sufficient skin in advance of closures for fasciotomies and trauma repairs of various types, including closure of the open abdomen. Use of the Sure-Closure system can minimize the need for more extensive secondary wound closure techniques.
The device is attached intraoperatively by first inserting needles parallel to the wound edges. These needles serve to distribute tension forces over the length of the incision. Gauges on the device monitor the applied forces, ensuring a safe and permanent skin stretching. The device allows the surgeon to take advantage of the inherent viscoelastic properties of the skin by mechanically stretching the skin and allowing it to relax under tension; the surgeon then has sufficient skin to affect a suitable closure.
The device comes in sizes of 50 mm and 75 mm. The 50-mm device is designed for smaller skin defects with uneven surfaces, whereas the 75-mm device is designed for larger skin defects with relatively flat, even surfaces.
The Sure-Closure skin-stretching system was first described by Hirshowitz et al and has been used extensively in the plastic, orthopedic, cancer, general surgical, and trauma patient populations. [19]
In a clinical study comparing the Sure-Closure system with more conventional wound closure techniques, Narayanan et al were able to demonstrate a cost-reduction trend in their study cohort. [20] Their cost analysis included the costs of the following: operating room time, operating room supplies, anesthesia, monitoring, recovery room time, wound care supplies, pharmacy charges, and hospital room and board. They also noted above-average healing of the wounds at 1 month and 3 months, with better cosmesis than was seen in comparable conventionally closed wounds. This experience has been confirmed by other reported clinical studies.
Using the Sure-Closure device potentially offers the following:
By using the Sure-Closure skin-stretching system, the surgeon is able to close most cases of skin defects that would more commonly require secondary wound closure techniques, such as myocutaneous flaps or skin grafts.
The Sure-Closure device accomplishes skin stretching by using two intradermal needles in conjunction with a tension rod that connects two self-aligning U-arms. (See the images below.) The device contains a graduated tension indicator that registers after 1 kg of force is applied. There is a built-in safety clutch mechanism that prevents excessive tension by limiting the total force to 3 kg.
The Sure-Closure system is used in the following settings:
Fascial Vacuum Assisted Closure® (V.A.C.®) Therapy (Kinetic Concepts, San Antonio, TX) is a more recently developed concept in the management of the open abdomen that enables fascial closure as long as 1 month after the initial laparotomy. This avoids the need for abdominal-wall reconstruction in the future, as well as the attendant operative risks incurred with such reconstruction.
The main functional component of V.A.C.® Therapy is the use of a nonadherent, polyethylene sheet to cover the exposed viscera and the placement of a polyurethane sponge under controlled negative pressure. The polyethylene sheet helps prevent visceral–abdominal wall adhesions that inhibit movement of the abdominal wall. The polyurethane sponge, when placed under negative pressure (suction), provides the countertraction required to inhibit abdominal-wall retraction and creates an environment where approximation of the abdominal wall may occur.
Miller et al reviewed 646 patients with trauma injuries who underwent laparotomies, of whom 148 required management of an open abdomen over a 5-year period (1996-2001), and reported excellent results. [21] Of the 148 patients, 85 survived to closure. Patients treated with the open-abdomen technique who were unable to undergo fascial closure by the early postoperative period (postoperative day 9) were treated with fascial V.A.C.® Therapy. Patients treated with planned hernia (HERNIA group, Fabian protocol) were compared with those undergoing fascial closure 9 or more days after the initial laparotomy (LATE group), all of whom underwent fascial V.A.C.® Therapy.
Fifty-nine patients underwent fascial closure, 37 of them before postoperative day 9 and the remaining 22 on or after postoperative day 9. [21] Mean time to fascial closure in the LATE group was 21 days (range, 9-49 days). Injury severity scores, admissions base deficit, number of fistulas, number of operations, and mortality were similar between the HERNIA group and the LATE group. The incidences of abscess, wound dehiscence, and fistula were nearly identical in the two groups. The differences between the groups were not significant with respect to time in the ICU, total hospital stay, incidence of acute respiratory distress syndrome (ARDS), multiple organ failure, and death.
The fascial closure rate (71.08%) reported by Miller et al [21] compared favorably with the results previously published by Barker et al in their large review of fascial closure rates using the standard vacuum pack technique; the fascial closure rate in the earlier study was 70%. [22]
Bruhin et al published evidence-based recommendations for the use of negative-pressure wound therapy (NPWT) in the open abdomen. [23]
Case study
In the following case study, Dennis E Weiland, MD, and John M Stein, MD (Scottsdale Health Care-Osborn, Scottsdale, AZ), illustrate the capabilities of abdominal V.A.C.® Therapy.
A 25-year-old man was admitted with two gunshot wounds to the abdomen. Repair of liver laceration with abdominal washout was accomplished (see the image below).
Postoperatively, the patient developed severe abdominal distention and respiratory distress. He required a decompression laparotomy for ACS. He was placed on suction drainage for 2 days. V.A.C.® Therapy was initiated on day 3. The wound was closed by delayed primary closure 12 days after the initial decompression laparotomy.
The diagnosis was ACS secondary to a gunshot wound to the abdomen. The prognosis was excellent once the skin was closed over the fascia.
V.A.C.® Therapy was provided as follows:
After discharge, the patient continued to have follow-up visits in the wound clinic.
The open skin over the fascia will be closed either by contraction or by secondary closure. The original wound measured 30 cm × 15 cm at the time of the decompression laparotomy. The wound now measures 20 cm × 3-4 cm. (See the image below.)
In an excellent review article from 2012, Demetriades provided operating surgeons with some best-practice advice regarding the application of NPWT with the ABThera™ device (ABThera Open Abdomen Negative Pressure Therapy; KCI USA, San Antonio, TX). [24] This advice included the following:
In 2009, a guideline statement regarding the use of the ABThera™ Open Abdomen Negative Pressure Therapy System and its application in the open abdomen patient was developed by an international consensus group of expert surgeons. [25] The main outcomes from this meeting included the development of a new classification system, which could be used as a model of care in the management of the open abdomen. [26] This system was further refined in 2016 (see Table 1 below). [27]
Table 1. Amended 2016 Classification of Open Abdomen [27] (Open Table in a new window)
1A – Clean
1B – Contaminated
1C – With enteric leak; enteric leak controlled by closure, exteriorization into stoma, or permanent enterocutaneous fistula is considered clean
2A – Clean
2B – Contaminated
2C – With enteric leak
3A – Clean
3B – Contaminated
Among the trauma patient population, the more common indications for reoperations include the following:
The management of the severely contaminated abdomen, severe peritonitis, and intra-abdominal sepsis by an open approach has been discussed in the literature. First proposed by Steinberg, the intraperitoneal silo approach has been applied in several settings and surgical patient groups. [28]
Fernandez et al described a technique that evolved from their experience with the use of the Silastic silo closure for patients with ACS. [29] They used the extraperitoneal silo in the intraperitoneal (IP) position in selected patients who did not have ACS and whose injuries would benefit from a second-look procedure (see the image below).
In the study by Fernandez et al, the approximate total hospital cost of the silo was $15.94, with an approximate patient cost of $57 (see the image below). [29] There was one death in the group. In addition, there was one IP silo failure in a patient who developed a small-bowel dehiscence; this patient underwent IP silo replacement in the intensive care unit (ICU).
The technique of IP silo placement (see the images below) is simple and straightforward, as follows (see the images below):
Several techniques in the surgical armamentarium are available to effect temporary closure of the open abdomen. One of the least expensive and most rapid is the use of the gas-sterilized 3-L plastic cystoscopy irrigation bag. This bag is commonly available, and its application is straightforward. In the author’s opinion, it is the preferred initial method of temporary closure, particularly in patients who may require multiple reoperative interventions in an austere setting.
Of the techniques described within this article, the Sure-Closure skin-stretching system has the potential to obviate split-thickness skin grafting in the setting of the open abdomen, particularly if approximation of the skin can be achieved within the first 7-10 days. The Sure-Closure device facilitates the creation of a ventral hernia that may be repaired at a later date in an elective fashion.
The Wittmann patch, V.A.C.® Therapy, and the ABThera™ Open Abdomen Negative Pressure Therapy System are inherently designed to effect not only a temporary closure but also a permanent fascial closure in most patients. Their cost is small in comparison with the substantial cost and morbidity associated with a second, planned abdominal-wall reconstructive procedure, which would commonly be required in this patient population. These devices represent major advances in surgical technique and are welcome additions to the extant surgical doctrine.
After extensive review of the current literature, it is the author’s opinion that the ABThera™ Open Abdomen Negative Pressure Therapy System represents the state of the art in the management of the open abdomen patient, in that it provides a quick, efficient, effective, and safe form of temporary abdominal closure and, in many cases, enhances primary fascial closure as well.
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1A – Clean
1B – Contaminated
1C – With enteric leak; enteric leak controlled by closure, exteriorization into stoma, or permanent enterocutaneous fistula is considered clean
2A – Clean
2B – Contaminated
2C – With enteric leak
3A – Clean
3B – Contaminated
Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS, KCOEG Assistant Clinical Professor of Surgery/Family Practice, UT Health North East; Adjunct Clinical Professor of Medicine and Nursing, University of Texas; Adjunct Clinical Assistant Professor, Department of Physician Assistant Studies, School of Health Professions, University of North Texas; Chairman Emeritus, Division of Trauma Surgery/Surgical Critical Care, Associate Trauma Medical Director and Chief of Trauma Surgical Critical Care Unit, Christus Trinity Mother Frances Health System; Vice Chairman, State Guard Association of the United States (SGAUS) Medical Academy; Commander Emeritus, Texas Commandery, MOFW; Brigadier General (Ret/HR), Past Commanding General, TXSG Medical Brigade
Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS, KCOEG is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of Law, Medicine & Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan-American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, Undersea and Hyperbaric Medical Society
Disclosure: Received honoraria from KCI for speaking and teaching; Partner received honoraria from PACIRA for speaking and teaching. for: Received honoraria from PACIRA for speaking and teaching: Researcher / Speaker for Steadmed.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology
Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.
John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow
John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.
Medscape Reference thanks Luis G Fernandez, MD, KHS, FACS, FASAS, FCCP, FCCM, FICS, Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Adjunct Clinical Professor of Medicine and Nursing, University of Texas, Arlington; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Trauma Surgical Critical Care Unit, Trinity Mother Francis Health System; Brigadier General, Texas Medical Rangers, TXSG/MB, for assistance with the video contribution to this article.
Temporary Abdominal Closure Techniques
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