Modified triple-layer peritoneal-aponeurotic transposition: A new strategy to close the "open abdomen".

I leaving the abdomen open after a laparotomy was used intermittently for several decades. More recently, the widespread use of staged laparotomy in damage-control surgery hasmade the ‘‘open abdomen’’ a standard part of the trauma/ acute care surgeon’s armamentarium. General indications for the open abdomen after completing a laparotomy can be grouped into three categories, namely, anatomic, logistic, and physiologic. Anatomic indications are frequently seen in patients who have an unbridgeable abdominal wall and impending risk of abdominal compartment syndrome. A less frequent cause is trauma-induced injuries to the abdominalwall, which producemassive tissue loss. A logistic indication for the open abdomen allows easy access for serial surgical interventions while preserving the fascia. In the physiologic indication category, severe systemic derangement requires damage-control/bailout strategies. Management of the open abdomen involves temporary abdominal closure to protect the underlying fascia and viscera, decrease fluid losses, and prevent loss of abdominal domain if possible. Advancements in temporary abdominal closure techniques have increased definitive closure rates significantly. Nevertheless, patients with open abdomens still incur serious complications including enteroatmospheric fistulas, fascial retraction with loss of abdominal domain, and massive incisional hernias. Moreover, physical and social functioning are significantly worse in patients discharged with a chronic incisional hernia compared with patients discharged with primary fascial closure. A recent systematic review and meta-analysis involving more than 3,000 patients with open abdomens showed that the average primary fascial closure rate was 62%. The results, after adjusting for heterogeneity, indicated that primary fascial closure had a significant role in mortality reduction. Furthermore, primary closure also resulted in fewer complications and shorter hospital stay. Considering that the mean time to primary closure in open abdomens ranges from 2.2 days to 14.6 days, there is only a small window of opportunity for success. If that brief period is missed, patients will likely require repair of difficult ventral/incisional hernias. Primary suture repair is rarely possible in those types of hernias, with recurrence rates in excess of 50% in long-term follow-up. Despite various techniques for repair of incisional ventral hernias and significant improvement in mesh construction, surgical correction of this condition remains a challenge. The Lázaro da Silva technique, also known as longitudinal peritoneal-aponeurotic transposition, uses the fibroperitoneal tissue of the hernia sac and the rectus sheath to create three overlapping layers for incisional hernia repair. The hernia sac is opened in the midline, followed by two longitudinal incisions in the rectus sheath, one in the anterior sheath and the other in the posterior sheath on the contralateral side. Consequently, the medial edges of the rectus abdominis muscles advance toward the midline, and tension in the suture line is reduced despite reconstruction of the linea alba by the layers that overlap in different planes. Previous reports showed low recurrence rates with this procedure and with a variation using a single mesh placed as an underlay. Given the large size of abdominal wall defects in ‘‘open abdomens’’ and the absence of a fibroperitoneal hernia sac, definitive closure of those defects frequently involves separation of the abdominal wall layers, release of myofascial planes, and the use of mesh. In this study, we describe a new strategy for definitive closure of the open abdomen, which follows the same principles of the triple-layer peritoneal-aponeurotic transposition conceived by Lázaro da Silva for incisional hernia repair except for the use of two meshes as replacement for the hernia sac.