Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed? A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy

Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed?
A Critical Reappraisal 15 Years After the Introduction
of Laparoscopic Cholecystectomy
George H. Sakorafas · Dimitrios Milingos ·
George Peros
Received: 13 December 2005 / Accepted: 12 January 2006 / Published online: 28 March 2007
C
Springer Science+Business Media, Inc. 2007
Abstract Asymptomatic cholelithiasis is increasingly
diagnosed today, mainly as a result of the widespread use of
abdominal ultrasonography for the evaluation of patients for
unrelated or vague abdominal complaints. About 10–20%
of people in most western countries have gallstones, and
among them 50–70% are asymptomatic at the time of
diagnosis. Asymptomatic gallstone disease has a benign
natural course; the progression of asymptomatic to symptomatic
disease is relatively low, ranging from 10–25%.
The majority of patients rarely develop gallstone-related
complications without first having at least one episode of
biliary pain (“colic”). In the prelaparoscopy era, (open)
cholecystectomy was generally performed for symptomatic
disease. The minimally invasive laparoscopic cholecystectomy
refueled the discussion about the optimal management
of asymptomatic cholelithiasis. Despite some controversy,
most authors agree that the vast majority of subjects should
be managed by observation alone (expectant management).
Selective cholecystectomy is indicated in defined subgroups
of subjects, with an increased risk for the development of
gallstone-related symptoms and complications.Concomitant
cholecystectomy is a reasonable option for good-risk patients
with asymptomatic cholelithiasis undergoing abdominal
surgery for unrelated conditions. Routine cholecystectomy
for all subjects with silent gallstones is a too aggressive
management option, not indicated for most subjects with
asymptomatic cholelithiasis. An in-depth knowledge of the
natural history of gallstone disease is required to select the
optimal management option for the individual subject with
G. H. Sakorafas ( ) · D. Milingos · G. Peros
4th Department of Surgery, Athens University, Medical School,
“ATTIKON” University Hospital, Arkadias 19–21,
GR-115 26 Athens, Greece
e-mail: georgesakorafas@yahoo.com
silent gallstones.Management options should be extensively
discussed with the patient; he or she should be actively
involved in the process of therapeutic decision making.
Keywords Silent gallstones . Laparoscopic
cholecystectomy . Porcelain gallbladder . Incidental
cholecystectomy . Concomitant cholecystectomy .
Gallbladder carcinoma . Cancer
Introduction
Cholelithiasis constitutes one of the most common causes
of hospitalization due to gastrointestinal problems in
developed countries and accounts for an important part of
health care expenditure. It shows a worldwide distribution
and a high incidence. especially among particular nations
and geographic areas in the world. The definite treatment
of choice for gallstone disease is cholecystectomy. Until the
introduction of laparoscopy, surgery (open cholecystectomy)
was generally indicated only for patients with symptomatic
and complicated disease [1, 2]. However the establishment
of laparoscopic cholecystectomy as the gold standard for the
treatment of cholelithiasis has created new interest for the
management of patients with silent gallstones. As a minimally
invasive technique, with many well-known advantages
over open cholecystectomy, laparoscopic cholecystectomy
renewed the interest and fueled the discussion regarding the
optimal management of asymptomatic gallstone disease.
Today, asymptomatic cholelithiasis is a very common
clinical entity; the surgeon sees an increasing number of
such subjects, owing to the widespread availability and
use of abdominal ultrasonography for the investigation
of a variety of abdominal diseases or vague abdominal
complaints and in cases of routine checkup. Management of such incidentally discovered gallstones poses a real dilemma
for both the physician and the patient; conclusive evidence
of benefits of cholecystectomy is lacking [3].
The aim of the present study was to critically discuss and
summarize currently available data regarding optimal management
of asymptomatic patients, taking into account the
natural history of asymptomatic cholelithiasis, the potential
for the development of complicated gallstone disease, and
the potential morbidity and mortality of cholecystectomy.
Asymptomatic cholelithiasis: the extent
of the problem
When discussing asymptomatic cholelithiasis, the first priority
is to define this entity. Asymptomatic cholelithiasis exists
when gallstones are detected in the absence of gallstonerelated
symptoms, such as history of biliary pain (pain in the
epigastrium or right upper abdominal quadrant that may radiate
to the patient’s back or to the right scapula), or gallstonerelated
complications such as acute cholecystitis, cholangitis,
or pancreatitis (Rome Group for the Epidemiology and Prevention
of Cholelithiasis [GREPCO]) [4]. Other nonspecific
symptoms or vague dyspeptic problems, such as epigastric
discomfort, dyspepsia, flatulence, nausea, abdominal gurgling
noises, or pain outside the right hypochodrium, cannot
be considered as symptomatic cholelithiasis and could easily
be attributed to other gastrointestinal diseases (such as peptic
ulcer disease, irritable bowel syndrome) [5, 6]. Therefore,
and when discussing surgery under this situation, the patient
should understand that these symptoms may persist following
cholecystectomy. However, the fact that patientswith that
kind of nonspecific symptomatology may sometimes benefit
from cholecystectomy could indicate that cholelithiasis
contributes, at least to some extent, to that vague clinical
picture (see Selective Cholecystectomy—Vague Dyspeptic
Symptoms) [7].
In 1992, it was estimated that 10–15% of the adult population
in the USA had gallstones (which amounted to more
than 20 million people),withwomen suffering twice asmuch
as men [4, 5, 8–10]. About one million patients are newly diagnosed
annually (10) and among them 50–70% are asymptomatic
at diagnosis (6, 8). Approximately 600,000 patients
underwent cholecystectomy in 1991 in the USA [11] and
about 4–7% of those operated had asymptomatic cholelithiasis
[12]. The annual cost for the treatment of those patients
had been estimated to be around $5 billion (estimates from
1993) [10].
Similar results have been reported in Europe. The Rome
Group for the Epidemiology and Prevention of Cholelithiasis
found gallstones in 8% of Roman male civil servants
between the age of 20 and 69 years. Fewer than 8% had
a history of symptoms compatible with biliary colic [13,
14]. The same group found a prevalence of as high as 25%
in female civil servants in the 60- to 64-year age group
[13, 14]. One third reported at least one episode of biliary
pain over a period of 5 years [4]. In the Italian Multicenter
Italian Study on Cholelithiasis, 29,739 participants were
examined by ultrasound and questionnaire with respect to
the presence of gallstones and related symptoms [15]. The
prevalence of gallstones for women was 10.5% and for men
6.5%. This increased to 18.9% and 9.5%, respectively, when
subjects who had already undergone cholecystectomy were
added. A linear increase in prevalence was noted with age in
both genders. The vast majority of subjects with gallstones
were asymptomatic (84.9% of women and 87% of men).
Similar numbers were found in a Scandinavian study, where
the overall prevalence of gallstones was 15%, with women
having a higher prevalence both at 40 and at 60 years of age
as compared with men (11% and 25% versus 4% and 15%,
respectively) [16]. In the United Kingdom, around 5,500,000
people have gallstones and more than 50,000 cholecystectomies
are performed each year [17].
It therefore appears that the overall prevalence of gallstone
disease in industrialized countries is between 10% and 20%.
The prevalence rises with age in both genders (close to 10
per 1,000 subjects per year) [18]. At the age of 65, about
30% of women have gallstones, and by the age of 80, 60%
of both men and women have them [19]. These data confirm
the high prevalence of gallstone disease and also shows that
most patients are unaware of it.
Natural history of asymptomatic gallstones
There is no innocent gallstone
—William J. Mayo, MD, 1904
It is unfortunate that so few appreciate from what small
causes diseases come.
—Charles H. Mayo, MD, 1902
About 100 years after the above-noted Mayo dictum about
gallstones, there is now enough evidence that most incidentally
discovered, clinically silent gallstones rarely have
clinical significance [3, 20–24]. In most Western countries,
the majority of patients with asymptomatic cholelithiasis
remain asymptomatic throughout their life, and do not require
any treatment [25]; in fact, these subjects live and
die with their gallstones having never caused pain or other
medical problems. Autopsy studies showed that more than
90% of autopsied patients with gallstone disease died from
unrelated causes. Death as the ultimate complication from
asymptomatic gallstones is very rare (∼3–7% of deaths),
usually in the elderly as a consequence of biliary or postoperative
complications [26–28].

According to the 1992 NIH Consensus Conference report
[10], 10% of patients develop symptoms during the first 5
years after diagnosis and 20% by 20 years. Similar findings
were reported by Zubler et al. [29], who found that only 10-
18% of asymptomatic patients ever become symptomatic;
the annual risk for developing biliary pain (misnamed as
biliary colic) is 1–4% [17, 30] (Table 1). One could extrapolate
that after 20 years, approximately two thirds of patients
will remain symptom free [25]. These rates are in sharp
contrast with those in symptomatic cholelithiasis, where the
annual rates of developing complications and biliary pain
are 1.2% and 50%, respectively [17]. According to the Italian
GREPCO study, the annual complication rate of initially
asymptomatic patients is 0.3–1.2% [31]. In this study, 151
subjects identified to have gallstones during the GREPCO–
1984 study [4] were followed over a period of 10 years. At
the beginning of the study, 118 patients were asymptomatic.
The cumulative probability of developing complications after
10 years was 3% in the initially asymptomatic group and
7% in the symptomatic group.
In the significant study by Gracie and Ransohoff [32],
123 Michigan University faculty members (110 men and 13
women) found to have gallstones through routine screening
were followed for 15 years. At 5, 10, and 15 years of followup,
10%, 15%, and 18%, respectively, became symptomatic.
The approximate rate at which the subjects developed biliary
pain was 2% per year for the first 5 years without a
subsequent decrease over time. Three patients in this study
developed biliary complications, all of which were preceded
by biliary colic. Based on these results, the authors concluded
that prophylactic cholecystectomy for asymptomatic
cholelithiasis is not justified.
A longitudinal follow-up study of asymptomatic gallstones
showed that over a 20-year period only18%of patients
developed biliary pain and that the mean yearly probability
of the development of biliary pain is 2% during the first
5 years, 1% during the second 5 years, 0.5% during the third
5 years, and 0% during the fourth 5 years. None of these
individuals died because of gallstone disease [33].
According to Hermann [34], 40–60% of persons with
cholelithiasis remain asymptomatic, 60–70% present with
mild symptoms of chronic cholecystitis (among them, 20%
have manifestations that are difficult to interpret), 20% develop
acute cholecystitis, and 10% develop complicated
acute cholecystitis (i.e., cholecystitis accompanied by jaundice,
cholangitis, or pancreatitis). Hermann concluded that
the longer patients live with gallstones, the more likely they
are to experience pain or complications [34].
In Japan, Wada and Imamura [35] found that 20% of patients
with asymptomatic cholelithiasis turned symptomatic
after a median follow-up of 13 years. Patients over the age
of 70 were more likely to become symptomatic than patients
under 70. McSherry et al. [36] followed 135 asymptomatic
men and women with gallstones who were subscribers to the
Health Insurance Plan of Greater New York. Ten percent developed
symptoms and only 7% required cholecystectomy
over a median follow-up of 46.3 months. Cucchiaro et al.
[37] followed 125 asymptomatic patients for a period of
5 years. Fifteen patients developed symptoms during that
time and two underwent emergency surgery for gallstone
complications. Fifty-four patients died during that period
because of unrelated causes (malignancies, cardiovascular
disease, renal insufficiency).
Friedman et al. [38] observed 123 asymptomatic patients
over 25 years in a prepaid health plan; serious or mild events
(acute cholecystitis, acute biliary pancreatitis, obstructive
jaundice) occurred in 4% of these asymptomatic patients.
Wacha and Ungeheuer in their review [39] reported higher
rates of conversion from asymptomatic to symptomatic state;
according to these authors, as many as 50% of individuals
with asymptomatic gallstones will be operated on or develop
symptoms within 10–20 years after the initial diagnosis.
Aging is found to be associated with the development of
symptoms or complications, and in particular if the followup
is long enough, in an increasing percentage of patients,
up to 30–50% [34, 36, 40, 41]. The incidence of choledocholithiasis
at the time of cholecystectomy is directly related
to age (9% in those 31–40 years old to 96% in those 80–90 years old) [5]. As is well known, choledocholithiasis
may be associated with potentially serious complications,
such as acute cholangitis and/or pancreatitis. This is of particular
practical importance for the patient and the physician,
because patients with advanced age exhibit higher morbidity
and mortality rates, whereas themanagement of complicated
gallstone disease may require more complicated procedures
than simple laparoscopic cholecystectomy. However, this issue
remains controversial; other authors observed that the
probability of developing symptoms and/or complications
fell steadily over time [10, 25, 31–33]; according to these investigators,
the longer patients were asymptomatic, the less
likely they were to develop symptoms.
In summary,most studies (conducted mainly in the 1980s)
indicate that the progression of asymptomatic to symptomatic
disease is relatively low, ranging from 10–25% [42–
45]. The major concern when discussing the natural history
of asymptomatic cholelithiasis is the possible development
of a severe, potentially life-threatening complication, such as
severe (necrotizing) pancreatitis or acute suppurative cholangitis.
Existing data show, however, that the majority of patients
rarely develop complications without first having at
least one episode of biliary colic pain [5, 10, 17, 32, 36];
biliary colic usually occurs within the first 5 years of the initial
diagnosis [20]. From a practical point of view, it would
be very important for both the patient and the physician if
we could recognize the subgroup of asymptomatic patients
who will become symptomatic. Unfortunately, it is impossible,
using local (such as number, size, nature, alteration in
wall thickness or gallbladder contractility) or general factors
(such as age, gender, associated comorbidities) to predict
who—among asymptomatic patients—will ever develop
symptoms or complications and when [3]. Some authors tried
to classify asymptomatic patients into two groups: a low-risk
group and a high-risk group. The low-risk patients are those
with a functioning gallbladder whose calculi are >3 mm
but <2 cm in diameter and radiolucent, and who are free
of concomitant serious disease [5]. The high-risk patients
are those more likely to develop acute cholecystitis, acute
pancreatitis, or other complications of cholelithiasis and include
those with large stones (>2.5 cm) and those with small
multiple calculi (microlithiasis, stones <3 mm in diameter),
biliary sludge, or both, who tend to develop acute cholangitis
or pancreatitis [46–48]. The risk of complicated cholelithiasis
is admittedly higher when the cystic duct is chronically
obliterated [5].
Management of asymptomatic cholelithiasis
Treatment options for asymptomatic cholelithiasis include
expectant management (observation alone) and cholecystectomy
(laparoscopic), which can be performed either selectively
(for selected subgroups of patients with asymptomatic
cholelithiasis), routinely (for all patients with asymptomatic
cholelithiasis), or concomitantly during another intraabdominal
operation for an unrelated pathologic condition (e.g.,
cancer of the colon).
Expectant management (observation alone)
Because the majority of patients with asymptomatic
cholelithiasis remain asymptomatic throughout their life,
most authors agree that expectant management (watchful
waiting) is the most reasonable treatment for the majority of
these patients [3, 17, 20–23, 49–51). This approach avoids
overtreatment (an unnecessary surgical procedure under general
anesthesia) in the vast majority of asymptomatic patients
who will never develop symptoms. The disadvantage of this
approach is that no one can guarantee the patient that he
or she will never suffer a potentially severe or even lethal
complication of gallstone disease, such as gallbladder cancer
or severe acute pancreatitis, usually at a more advanced
age (Table 2). In this case, emergency surgery for a serious
complication of cholelithiasis may be needed at a later date.
Moreover, in such a setting, the operation ismuch more complicated
and it is performed more frequently by laparotomy,
which may increase morbidity and mortality, especially in
older patients with comorbidities [5]. However, the patient
should recognize that this theoretical possibility is rare. Usually
the conversion from the asymptomatic to symptomatic
state happens by the occurrence of a biliary colic, thereby
indicating the need for surgery in the—then symptomatic—
patient. In conclusion, and considering that the vast majority
of asymptomatic patients remain asymptomatic throughout
their life and that most asymptomatic patients develop symptoms
before the occurrence of complications, prophylactic
surgical therapy is not justified—with a few exceptions (see
Selective Cholecystectomy). According to the NIH Consensus
Conference report [10] “the availability of laparoscopic
cholecystectomy should not expand the indications for gallbladder
removal.”
Surgical management (cholecystectomy)
Currently, laparoscopic cholecystectomy is the gold standard
in the management of cholelithiasis, given the safety
and ease of performance and the many well-known advantages
of this approach over the conventional open cholecystectomy,
including short hospital stay, lesser need for
postoperative analgesia, better cosmetic results, fast recovery
to full preoperative activity, and avoidance of long-term
complications (i.e., incisional hernia) [52, 53]. Conversion to
open cholecystectomy may be required for a small percentage
of patients when the laparoscopic approach is associated
with operative difficulties or when the operating surgeon feels at surgery that laparoscopic cholecystectomy cannot be
performed safely for a variety of reasons (e.g., presence of
firm adhesions owing to previous abdominal operations, difficulty
in identifying vital anatomical structures, etc). About
15 years after its introduction, laparoscopic cholecystectomy
is considered to be a safe operation, with low morbidity and
overall mortality ranging from 0.14–0.50% in different studies,
depending on the age and fitness of the patients [54].
However, despite the fact that morbidity has decreased as the
years go by, as more operative experience is gained, and experienced
in laparoscopy surgeons are involved in the training
of the new generation of surgeons [55], complications—
potentially severe—do exist and should not be neglected
(Table 3).
Routine cholecystectomy
As discussed previously, most authors agree that routine
cholecystectomy is not indicated for asymptomatic cholelithiasis. Some, however, maintain that all asymptomatic
patients should routinely be operated. The main argument
is that surgery can be performed much more safely
before the development of potentially serious or even fatal
complications (such as acute cholecystitis, cholangitis, pancreatitis),
something that usually occurs at a more advanced
age and may demand urgent surgery in older patients, with
higher morbidity and mortality [5, 40–43, 56]. In contrast,
in young, low-risk patients, laparoscopic cholecystectomy
is an almost innocuous procedure with low morbidity and
practically no mortality [5]. According to this surgical philosophy,
precluding or postponing laparoscopic cholecystectomy
may be more risky than undertaking an elective operation
[5]. Even in the prelaparoscopic cholecystectomy era,
Glenn stated that “It is reasonable to strongly recommend
an early (open) cholecystectomy for gallstones, whether or
not they cause symptoms, unless there is a contraindication
to operation. The optimum treatment for asymptomatic
cholelithiasis is elective cholecystectomy without undue
delay” [40, 41]. Laparoscopic cholecystectomy is easier in
asymptomatic than in symptomatic patients, with lesser operative
time (92.1 versus 106 minutes), lower conversion rate
to open cholecystectomy (1.57% versus 4.6%), and lesser
morbidity (4.72% versus 8.80%) (p < 0.05) [57]. Although
mortality after laparoscopic cholecystectomy is 0.6% for all
age groups, it increases with aging, mainly because of the
presence of significant comorbidities in older patients (0.14–
0.4% in patients <50 years, and 4.5% in those >65 years)
[19, 58]. Operative mortality also increases after a “difficult”
cholecystectomy (defined as an operation performed
after a biliary complication, usually acute cholecystitis or
choledocholithiasis, has occurred, even if the acute event has
subsided) compared to a “simple” cholecystectomy (prophylactic
cholecystectomy or cholecystectomy after an episode of uncomplicated biliary pain) (mortality, 0.4% for patients
with chronic cholecystitis, 1.2% for those with acute cholecystitis,
1.2–1.6% after choledochotomy and common bile
duct exploration) [5, 32, 58]. Interestingly, in the study by
Morgenstern et al. [59] all the deaths after cholecystectomy
occurred in patients older than 66 years (mean age, 80.5
years). These authors confirmed also that the mortality increased
threefold when choledochotomy become necessary
[59]. Table 4 summarizes the advantages and disadvantages
of elective (routine) cholecystectomy in patientswith asymptomatic
cholelithiasis.
Selective cholecystectomy
Laparoscopic cholecystectomy can be performed in selected
subgroups of patients with asymptomatic cholelithiasis, who
are at greater risk for the development of symptoms or complications
(Table 5) [5, 11, 50–52, 60].
Chronic hemolytic syndromes
Patients suffering from chronic hemolytic syndromes (such
as sickle cell disease [SCD]) are at risk for gallstone development
at a young age (as a result of repeated hemolytic
crises). Pigment gallstones are reported in 58% of patients
with homozygous SCD and in 17% of patients with heterozygous
types of hemoglobinopathies [61, 62]. Two thirds
of patients with gallstones have symptoms, although it is
often difficult to distinguish between a sickle cell crisis and
acute cholecystitis [63]. Patients with other hemolytic anemias
are also at risk for gallstone development and many
will become symptomatic [64]. Laparoscopic cholecystectomy
should be considered for asymptomatic patients with
chronic hemolytic syndromes for many reasons [65, 66]:
Biliary complications of gallstone disease and vasoocclussive
crisis both present with similar manifestations (nausea, abdominal pain, fever, leukocytosis, and
cholestatic jaundice) and therefore differential diagnosis
may be difficult.
The onset of gallstones at a young age in SCD raises
the lifetime risk of biliary complications, and therefore,
cholecystectomy following the diagnosis of asymptomatic
gallstones in patients with SCD is advisable and justified.
Interestingly, the approach of elective cholecystectomy
for asymptomatic cholelithiasis in SCD patients was not
generally accepted until recently; in the past, surgery in SCD
was associated with a high morbidity and mortality owing
to vaso-occlusive crises [61, 67]. However, with the introduction
of laparoscopic cholecystectomy, the establishment
of its safety in patients with SCD and cholelithiasis, and
the significant improvement of anesthetic techniques, more
patients (adults and children) are being referred for laparoscopic
cholecystectomy [68, 69]. Pediatricians have started
screening their patients for gallstones and referring them
for laparoscopic cholecystectomy before the development
of symptoms and/or complications of the disease [70]. Reduction
of Hb-S to a level lower than 50% by preoperative
partial exchange transfusion is believed to be associated with
a lower risk of veno-occlusive crises [61, 71]. Avoiding open
cholecystectomy during acute crises or acute cholecystitis
has been advocated [65]. In the laparoscopic era, although
surgery should be avoided during veno-occlusive crises, laparoscopic
cholecystectomy for acute cholecystitis is not a
contraindication provided that all the precautions to guard
against a veno-occlusive crisis are taken [3].
Transplantation
Prophylactic cholecystectomy should be strongly considered
for patientswith asymptomatic gallstoneswaiting to undergo
solid organ transplantation [72, 73]. Prophylactic cholecystectomy
can be performed either during the pretransplant
period or—when appropriate—at the time of transplantation.
The theoretical basis for this recommendation is that
these patients are more likely to become symptomatic, especially
in the first 2 years after transplantation [73].Moreover,
because of immunosuppression, diagnosis of complications
of cholelithiasis may be more difficult; these complications
are associated with increased morbidity and mortality. The
aim of prophylactic cholecystectomy is to remove of a possible
septic focus that carries a high potential for severe
complications in immunosuppressed patients [72, 73]. The
mortality rate associated with emergency cholecystectomy
in patients who have received a heart transplant is high,
up to 36% in the review by Begos et al. [74]. Finally, cyclosporine
and tacrolimus (FK 506), used as immunosuppressive
agents, are prolithogenic because of decreased bile
salt export pump function [19]. Episodes of acute cholecystitis
during episodes of maximum immunosuppression or
during rejection episodes have been reported.
Not all authors, however, concur with this aggressive surgical
philosophy in transplant patients [75–79]. Greenstein
et al. [76] follow 21 renal transplant patients with silent
gallstones for 4 years. Thirteen patients (87%) remained
asymptomatic, and 3 patients (1 had diabetes) developed
acute cholecystitis and underwent laparoscopic cholecystectomy
with no complications. Similarly, Courcoulas
et al. [79] followed up 26 transplant patients (including
renal, heart, double lung, and heart–lung recipients) who
underwent laparoscopic cholecystectomy; 73% of these
patients had symptomatic gallstones. These authors found
that laparoscopic cholecystectomy is as safe in the transplant
population as in the general population and the advantages of
short hospital stay, low morbidity and early return to preoperative
routines remain equivalent. Melvin et al. [78] found
that in renal transplant patients, when surgery for gallstones
is needed, it was associated with a low risk and does not
represent an increased rate of complications in renal transplant
patients with 1-, 2-, and 5-year graft survival or 98%,
96%, and 80%, respectively. According to these authors,
expectant policy should be exercised in transplant patients
with silent gallstones. Once gallstones become symptomatic,
laparoscopic cholecystectomy can be safely performed
with no adverse effect on morbidity, mortality or graft
survival.
Gallbladder carcinoma
Gallbladder cancer, although rare in most Caucasian populations,
is amongst the most frequently observed cancers
in native populations of North and South America, and in
the Maori population of New Zealand, possibly as a result
of early onset of gallstones [80–83]. The increased incidence
of gallstones (at an early age) in these ethnic groups
may be due to the presence of cholesterol lithogenic genes
that are highly prevalent in these populations [83]. North
American Indianwomen develop gallbladder carcinomawith
a greater frequency than heavy smokers develop pulmonary
cancer [5, 84]. In all populations, there is a strong correlation
between gallstones and gallbladder cancer. The risk
of gallbladder cancer is approximately four times higher in
cases with than in those without gallstones. It is estimated
that about 80% of patients developing gallbladder carcinoma
have gallstones, especially large stones (≥3 cm) [27]. The
risk of underlying malignancy is also high in patients with
gallbladder polyps larger than 10 mm in diameter [81, 85–
87]. Calcified or porcelain gallbladder is associated with
carcinoma in 13–25% of patients [8, 88–90]. Recently, some
authors questioned the association of porcelain gallbladder
with gallbladder carcinoma [91, 92]. According to these authors,
a calcified gallbladder is indeed associated with an increased risk of gallbladder cancer, but at a much lower
rate than previously estimated [91]. Interestingly, Stephen
et al. [91] found that the incidence of cancer depends on
the pattern of calcification, with selective mucosal calcification
being associated with a greater risk compared to diffuse
intramural calcification.
When examining the role of cholecystectomy as a therapeutic
strategy to prevent the development of gallbladder
carcinoma, the surgeon and the patient should acknowledge
that—despite the association of gallstones with gallbladder
carcinoma—the risk of developing cancer in all patients
with asymptomatic gallstones is less than 0.01%, less than
the mortality associated with cholecystectomy [12, 17].
Therefore, prophylactic cholecystectomy is not indicated
for the general population with asymptomatic cholelithiasis
to prevent future gallbladder cancer [12, 17, 27, 64, 93,
94]. Nevertheless, based on the above data, prophylactic
cholecystectomy to prevent gallbladder carcinoma should
be strongly considered in selected subgroups of patients
with silent gallstones, such as in patients of some ethnic
groups living in areas where gallbladder carcinoma is
prevalent (American Indians and Mexican Americans,
Colombia, Chile, Bolivia) [33, 80–83, 95, 96]. Indications
for cholecystectomy should be liberalized in these high-risk
populations [5]. The increasing frequency of laparoscopic
cholecystectomy in these geographic areas, and the lower
threshold for referral, probably will lower the incidence and
mortality rates for this lethal disease [81, 97]. Moreover,
prophylactic cholecystectomy is indicated in patients with
gallbladder polyps larger than 10 mm in diameter and in patients
with large gallstones (>3 cm) (see above) [27, 33, 81,
85–87, 97] (Table 5). Finally, and despite some controversy
[91, 92], most authors recommend selective prophylactic
cholecystectomy for patients with porcelain gallbladder to
prevent the development of gallbladder carcinoma [8, 11, 12,
88–90].
Diabetes mellitus
Prophylactic cholecystectomy has been recommended for
diabetic patients with silent gallstones [5]. This approach
has been based on the belief that diabetic patients belong to
the high-risk group for the development of complications of
gallstone disease (such as infected bile, gangrenous changes
and perforation of the gallbladder), that are more severe than
in the general population [98, 99]. Earlier reports found that
the risk of acute cholecystitis and subsequent perioperative
morbidity and mortality was significantly higher in diabetic
compared to nondiabetic patients [5, 100, 101]. It is believed
that the autonomic neuropathy in diabeticsmay mask the pain
and other clinical signs associated with acute cholecystitis
[102], thereby delaying accurate diagnosis and appropriate
management. Therefore, in the past surgeons were urged to
consider a diabetic as a high-risk group and prophylactic
cholecystectomy was recommended [5, 94, 100].
Recent evidence, however, has shown that the natural history
of gallstones in diabetics is generally more benign than
thought in the past, with a low risk of a major complications
[103]. The cumulative percentage of initially asymptomatic
non–insulin-dependent diabetic patients who presented with
symptoms and complications was small (14.9% and 4.2%,
respectively) [103]. Also, diabetes as an independent risk
factor for the formation of gallstones has been questioned
[104] and the prevalence of gallstones was found to be similar
among diabetic patients (14.4%) and control subjects
(12.5%), in a case-control analysis [105, 106]. Moreover,
the rates of operative morbidity and mortality for biliary
surgery in diabetics currently are comparable, with rates
in nondiabetics once other comorbidities such as cardiovascular
and renal disease are taken into consideration [98,
107–109]. Therefore, there is no clear benefit to prophylactic
cholecystectomy in diabetic patients with asymptomatic
gallstones, because surgery does not appear to increase either
the duration or quality of life, but may in fact reduce
it [11, 32, 98, 103, 107, 109–111]. Consequently, diabetic
patients should be managed expectantly with the same criteria
as the general population [3, 98, 110, 112]. However,
early elective cholecystectomy is advocated once symptoms
develop [105].
Vague dyspeptic symptoms
Although patients with gallstones who complain of nonspecific
dyspeptic symptoms (such as vague abdominal pain,
bloating, fullness, and/or belching) without biliary colic are
less likely to improve following cholecystectomy, a large
percentage (up to 70%) of them still benefit from surgery
[6, 113]. This suggests that indeed these vague, dyspeptic
symptoms may be caused by gallstones; therefore, laparoscopic
cholecystectomy is expected to improve significantly
the quality of life in patients with asymptomatic
cholelithiasis who reported vague symptoms [6]. An important
practical question, however, is if these patients are truly
“asymptomatic” and if gallstones are really “silent.”
Other indications for selective cholecystectomy
in asymptomatic cholelithiasis
Asymptomatic cholelithiasis in association with stones in
the common bile duct is another indication for selective prophylactic
surgery, because the presence of ductal stones predispose
to potentially severe complications in a significant
percentage of patients (up to 50%) [114, 115].
Selective cholecystectomy should also be considered for
patients with silent gallstones living in a part of the world
very remote from medical facilities. These patients may be at risk for an adverse outcome should a complication of
gallstone disease develop.
Incidental, concomitant cholecystectomy
for asymptomatic cholelithiasis during another
abdominal operation
Concomitant cholecystectomy for asymptomatic cholelithiasis
(diagnosed either preoperatively or intraoperatively) during
a planned abdominal operation is a common clinical
scenario. Several studies showed a high (up to 70%) incidence
of symptoms and/or complications from the biliary
system (such as biliary colic, acute cholecystitis, jaundice)
in patients with asymptomatic cholelithiasis following laparotomy
for unrelated conditions; cholecystectomy was required
in a large percentage (up to 40%) of these patients
within 1 year of the initial operation [116–121]. The aim of
incidental cholecystectomy in this case is to prevent postoperative
cholecystitis or the later development of symptoms.
Of course the addition of cholecystectomy should not
add risks to the patient. In most patients, cholecystectomy
“en passant” can be performed safely [119, 121]; therefore,
concomitant cholecystectomy during another intraabdominal
procedure is a reasonable option for the vast majority of
patients [116, 121], unless specific contraindications exist.
Ideally, gallstones should be detected preoperatively by ultrasonography;
this allows the discussion with the patient before
surgery to obtain his or her consent for cholecystectomy. The
discussion should emphasize the safety and purpose of the
procedure and not dismiss the possible complications, albeit
rare, as with any additional surgical procedure. In addition,
preoperative diagnosis of silent gallstone disease allows a
better planning of the incision [121].
Cholecystectomy-related complications can be avoided
by using the proper surgical technique, including proper exposure,
by performing an uncomplicated primary operation,
and by proper patient selection taking into account comorbidities
and general health [122]. Obviously, this strategy
is not recommended for high-risk patients, with significant
comorbidities, where a minimal operating and anesthesia
time is required for an uneventful recovery. Clinical judgment
at the time of surgery and caution are required from
the part of surgeon to select the optimal management option
for the individual patient. Local conditions (eg, presence
of a shrunken or scarred gallbladder, cirrhosis, extensive
firm adhesions, and/or tissue scarring) should be taken
into consideration. Incidental cholecystectomy for asymptomatic
cholelithiasis is contraindicated when a prosthetic
material (such as vascular graft, mesh for incisional hernia
repair) is used during surgery [123]. The performance
of concomitant cholecystectomy may be more difficult in
the case of a pelvic (gynecologic) procedure, because it
may require an additional or extended incision. However,
this poses no problem if the pelvic procedure is conducted
laparoscopically [3].
Comments
Laparoscopy not only simplified the treatment of cholelithiasis,
because of the many and clear advantages of the minimally
invasive approach compared to the open method, but
also resulted in a broadening of the indications of cholecystectomy
and in a decrease of “the surgical threshold”
for the surgical management of patients with asymptomatic
cholelithiasis. This caused a worldwide increase of the number
of cholecystectomies by 18.7% between 1989 and 1993,
with an increase of 25% in the age group of 45–64 years
[17, 99, 124–125]. This may reflect a change in surgeons’
attitude toward some of the indications for cholecystectomy,
including asymptomatic gallstones [99, 124]. Surgeons may
be treating asymptomatic gallstone disease or resorting to
laparoscopic cholecystectomy as a “diagnostic therapeutic
test” [127]. This liberal surgical attitude has been further
promoted by a lower referral threshold by general practitioners
and gastroenterologists asking for surgical treatment
by laparoscopic cholecystectomy, as a result of the enhanced
perceived benefits of laparoscopic cholecystectomy. These
referring physicians often warn patients that they are at an
increased risk for the development of severe and potentially
lethal complications, causing an unnecessary anxiety to them
and suggesting surgery despite the lack of sufficient data to
support such an aggressive management approach. Based on
existing evidence, physicians should frame their discussions
with patients in such a manner as to inform them of the relative
risk of an expectant approach versus cholecystectomy,
thereby allaying unfounded fears of the expectant management
approach. Another significant reason for the increase
of the number of (laparoscopic) cholecystectomies is the
increased acceptability and demand of minimally invasive
surgery by patients, so that few patients refuse surgical treatment,
especially after the diagnosis of a “potentially lethal”
disease is discussed with the referring physician [124].
Minilaparotomy (open) cholecystectomy is another alternative,
but worldwide most surgeons (and patients) prefer
the laparoscopic approach. Unfortunately, often both the referring
physician and the patient do not take into account
the natural history of asymptomatic cholelithiasis and the
operation/anesthesia-related potential morbidity and mortality.
The end result is the unnecessary overtreatment of a
large percentage of subjects with asymptomatic cholelithiasis
and the very long lists of patients waiting to undergo
cholecystectomy [52]. Among these, of course, are included
patients who are symptomatic and who have absolute indication
for surgery; the long waiting lists may delay surgery
for these symptomatic patients with potential adverse effects  (development of complications, higher conversion rates to
open cholecystectomy, increased morbidity/mortality, prolonged
hospitalization, etc) [128, 129]. The increased cost
and workload for the health system, because of a costly and
unnecessary operation not indicated for most patients with
asymptomatic cholelithiasis, is another factor that should be
taken into consideration when discussing such a controversial
issue [130]. Given the high prevalence of gallstones, the
cost of prophylactic cholecystectomy is almost four times
that of expectant management. It has been estimated that the
average cost in Britain is about 5.89 million euros/10,000
patients with asymptomatic cholelithiasis [30]. Considering
these numbers and the limited financial resources in health
care, and taking into account the natural history of asymptomatic
cholelithiasis, it appears unreasonable to treat every
patient diagnosed with silent gallstones with cholecystectomy
[11].
All patients with asymptomatic cholelithiasis should be
fully informed about the natural history of silent gallstone
disease and about management options. Existing data support
a conservative approach for the large majority of patients
with asymptomatic cholelithiasis. Surgery should be
offered to selected subgroup of asymptomatic patients with
gallstone disease (see Table 5). A careful analysis of hepatobiliary
and systemic risk factors (such as advanced age
and significant comorbidity) should precede any decision
regarding cholecystectomy for asymptomatic cholelithiasis.
Patient preferences should be taken into consideration by
the surgeon, because the decision for surgery remains an
individual decision. Patients unwilling to accept the minimal
but real possibility of complications of gallstone disease
may prefer to undergo laparoscopic cholecystectomy, but—
at the same time—they should acknowledge the morbidity
and mortality of the procedure and general anesthesia, albeit
minimal. The surgeon should emphasize to the patient
that the majority of patients with asymptomatic cholelithiasis
rarely develop complications without having at least
one episode of biliary colic. Consequently, laparoscopic
cholecystectomy can be performed as an elective procedure
for the—then symptomatic—cholelithiasis, allowing a
more optimal and reasonable timing for surgery. With modern
surgical and anesthetic techniques, cholecystectomy—
after symptoms develop—results in a mortality rate almost
equivalent to elective cholecystectomy.
In conclusion, the evolution of laparoscopy should not alter
the indications of cholecystectomy. Becausemost asymptomatic
gallstones remain clinically “silent,” routine laparoscopic
cholecystectomy is not indicated for the vast majority
of subjects with asymptomatic cholelithiasis. Laparoscopic
cholecystectomy is a costly procedure performed under general
anesthesia and is associated with the potential of morbidity
(sometimes serious) and mortality. The risks of the
operation outweigh the complications if stones are left in
situ. However, laparoscopic cholecystectomy should be performed
in selected subgroups of patients with asymptomatic
cholelithiasis (see above). Patients should be fully informed
about the natural history and available management options,
their advantages and disadvantages, and be actively involved
in the decision making.



Advantages
Natural history of asymptomatic gallstones is benign
Only 1–4% of patients per year develop symptoms (biliary “colic”)
Only 10 and 20% of patients will develop symptoms 5- and 20-years after the initial diagnosis
Acute biliary symptoms occur in 3%
Almost all patients develop some symptoms (usually biliary colic) before complications arise
Avoidance of a procedure that represents overtreatment for the majority of asymptomatic patients
Avoidance of surgery/anesthesia-related morbidity and mortality
Avoidance of unnecessary cost/workload for the health system
The patient can be operated if and when he or she becomes symptomatic (usually after an episode of biliary colic)
Avoidance of unnecessary surgery/anesthesia in patients with significant comorbidity/advanced age
Disadvantages
Theoretical potential (albeit small) for the development of serious complications of gallstone disease (such as pancreatitis or development of
gallbladder cancer)
About 20% of patients will develop symptoms after 20 years
Compared to elective, emergency surgery is associated with increased morbidity and mortality; mean operating time, mean hospitalization
and conversion (to open cholecystectomy) rates are higher in emergency surgery
Expected management is contraindicated for selected subgroups of patients with asymptomatic cholelithiasis (see Table 5)


Table 3 Complications of laparoscopic cholecystectomy
Common bile duct injury (1%)
Bile leak (3%)
Bleeding (as in open cholecystectomy)
Retained (undetected) stones and/or bile and stone spillage (with the
potential for abscess formation)
Wound infection (1–2%)
Injury to organ/vessels during trocar insertion or during surgery
(very rare)
Complications due to pneumoperitoneum (i.e., gas embolism,
subcutaneous emphysema) (very rare)
General postoperative complications (ie, deep vein thrombosis,
pulmonary embolus, pneumonia, myocardial infarction,
atelectasia—pneumonia, stroke) (as in open cholecystectomy)


TABLA 4
Advantages
Definitive cure of the patient from a disease with a “benign” natural history, but with the potential for
the development of serious and even fatal complications (albeit rare) (including the development of
gallbladder cancer)
Very safe procedure, with low morbidity and virtually no mortality among low-risk patients. Patient’s
problem can be relieved by undergoing a safe operation, which becomes even safer for patients with
asymptomatic cholelithiasis, owing to favorable local conditions (ie, absence of inflammation,
adhesions)
Disadvantages
Overtreatment of a large number of asymptomatic patients who will never develop symptoms or
complications
Potential morbidity and even mortality of surgery/anesthesia
Increased cost/workload for the health system

TABLA 5
Clear indications
Suspicion/risk of malignancy
Gallstones associated with gallbladder polyps >1 cm in diameter
Calcified (porcelain) gallbladder
Some ethnic groups or subjects living in areas with high prevalence of gallbladder cancer associated
with gallstones (American Indians, Mexican Americans; Colombia, Chile, Bolivia, Maori
population of New Zealand)
Presence of large (≥3 cm) gallstones
Asymptomatic cholelithiasis associated with choledocholithiasis
Transplant patients (before or during transplantation)
Chronic hemolytic conditions (sickle cell anemia)
Relative indications
Increased risk of conversion from asymptomatic to symptomatic disease
Life expectancy >20 years
Calculi >2 cm in diameter
Calculi <3 mm and patent cystic duct
Nonfunctioning gallbladder
Diabetes mellitus
Vague dyspeptic symptoms in the presence of gallstones
Questionable indications
Patient living in an area remote from medical facilities
Incidental (concomitant) cholecystectomy during another abdominal operation

: Systematic Review A systematic literature review on the use of vacuum assisted closure for enterocutaneous fistula

Discussion
This systematic review has demonstrated that there is limited evidence, exclusively from a few level IV studies, that VAC therapy has been used with some success to treat patients with ECF. The estimated median closure rate using VAC therapy of 64.6% within 58 (12-90) days is encouraging but is comparable to the 50% spontaneous closure reported recently in the literature (4). It is therefore debatable at the moment whether the theoretical benefits of VAC therapy accelerates or contributes to the closure of ECF or whether the fistula would close spontaneously with conservative measures. Nevertheless, VAC may have a use as a temporary preoperative measure protecting the skin and improving the patient’s nutritional status ahead of more definitive therapy.
Studies investigating factors affecting closure using VAC have identified several important considerations. D’Hondt et al showed a statistically significant beneficial effect on closure rates in the absence of visible intestinal mucosa at the site of the fistula (p=0.0015). (23) Gunn et al reinforced this observation; 11 patients without visible mucosa achieved VAC-assisted ECF closure, whereas all four patients with visible mucosa did not. (24) They suggested that the reason might be that visible intestinal mucosa suggests epithelialisation at the mucocutaneous junction, which if present would mean that no conservative therapy can achieve closure.
The results of this review also showed that success of VAC depends on the output of the fistula. The higher the output, the less likely it was to close, with the proportion of fistulae closing halving from 85.7% in the low output group to 42.1% in the high output group. This observation is reinforced by D’Hondt et al, who showed that an output of <500mL/day is significantly associated with a higher closure rate using VAC (p=0.0147) (23). It is, however, worth mentioning that a high output fistula is generally accepted to be a negative predictor of closure with conservative and surgical therapy, regardless of the use of a VAC device. (4)
Streimitzer et al used Octreotide for a median of 5 (2-9) days in the initial stage of treatment to help establish fistula control with the VAC method. The authors believe that its success is independent of the use of Octreotide, but Octreotide may be initially helpful in gaining control of the fistula and reducing its output. (22) Somatostatin was used in the high output cases in one study, but its effect is not commented on. In this study no high output fistula closed, regardless of the use of Somatostatin. (23)
Several studies have also identified additional benefits relating to the use of VAC in patients with ECF. One of the most important immediate benefits is the ability to contain the effluent, protect the skin around the fistula and to prevent further tissue breakdown and improve dermatitis. (18, 21) One of the studies specifically mentioned that 7-15 days after the start of VAC therapy the wound was noted to be clean, dry and granulating (25).
Another study showed that in 89 (97.8%) of 91 cases oral or enteral feeding could be reintroduced within a mean of 3.4 days without significant increase in the fistula output. The same study also showed that 69% of 84 patients treated with VAC regained mobility within 20 days of starting treatment (21). Unfortunately no specific comparison with conservative therapy could be found.
While a former cost analysis was not done in any of the studies, it would be reasonable to assume that VAC treatment, whether as a definitive measure or as a pre-operative one, could be more cost-effective than conservative treatment and/or surgery, due to the reduced use of medical treatment such as Octreotide, expensive surgical measures, and the possibility of outpatient care, especially for low output fistulae. (21, 24)
There is little information on the possible adverse effects of VAC. A recent paper suggested that when further fistulation occurs, mortality after formation of the secondary fistula increases and if so VAC treatment for ECF may increase overall mortality. (26) The authors acknowledged, however, that the number of patients in the study was too small to allow this to be firmly established. (26) A UK national prospective study of 578 patients found that VAC use for open abdominal wounds was not associated with an incidence of fistulation through the wound (relative risk = 0.83, 95% confidence interval: 0.44-1.58). Indeed in a paired matched cohort of 187 pairs, VAC therapy showed an absolute reduction of risk of 1.6% compared with other methods of wound care. (27) NICE guidance agrees with these results and does not warn of an increased rate of fistulation with VAC therapy. Whether fistulation occurs more often with VAC in certain conditions such as sepsis or wound dehiscence is unclear and there is therefore no specific guidance to avoid the use of VAC in these situations. (15) In another study, 40% of patients experienced short term pain due to the treatment and 14 out of 59 patients at long term follow-up encountered the complication of abdominal wall disruption, while one patient had a significant distal obstruction (20). It is, however worth mentioning that it is unclear whether or not these long term effects were secondary to the use of VAC treatment. Recurrence of ECF after VAC is yet to be compared to the reported 21% recurrence rate after surgery alone. (28)
Clearly the reviewed studies, while informative, have a number of gross limitations that prevent them from being used as strong evidence in favour of VAC of ECF. All but one contained small numbers of 15 or less. All were of evidence level IV, and retrospective case series or single case studies. Some of the included studies did contain greater numbers which were split into groups depending on what specific ECF treatment they received, but statistical comparisons within these groups were not demonstrated and, perhaps more importantly, there was no control group. Some studies also used other medical treatment, such as octreotide, somatostatin or TPN which rendered the data non-comparable. Further studies investigating the roles of these nutritional aids would be valuable. The studies are also characterised by heterogeneity, as all but one of the patients in all 10 studies developed the fistula following surgery. Many of the studies also lack a number of specific details and do not show individual parameters in the case series, making it difficult to estimate the relevance of some results.
Despite the limited evidence, available the literature suggests, nevertheless, that VAC therapy may be used safely to treat patients with ECF resulting from surgery either as a definitive tool to achieve closure or as a bridge to definitive surgery. Due to the scarcity and heterogeneity of available literature on the subject, further retrospective and prospective studies are required to assess its true role and to identify patients that may benefit the most.

El abdomen que no se cerrará

CAPÍTULO

El abdomen que no se cerrará  Descargar PDF 

• MD Heidi N. Overton
• Hay Kent A. Stevens MD, MPH

Terapia quirúrgica actual , 1259-1266

El principio de control de daños ha cambiado la práctica de la cirugía dramáticamente en las últimas 2 décadas y se ha convertido en una de las prácticas centrales y dominantes en la cirugía de trauma y cuidados agudos. Como resultado, la morbilidad y mortalidad asociadas con el síndrome del compartimento abdominal (SCA), la coagulopatía dilucional, la hipotermia, la acidosis y una miríada de otras complicaciones de reanimación se han reducido drásticamente. Sin embargo, con todos los avances significativos vienen nuevos desafíos. Con la práctica generalizada de la cirugía de control de daños (DCS) y la laparotomía abreviada, los cirujanos deben estar preparados para manejar un abdomen abierto con un cierre abdominal temporal (TAC), así como el abdomen que no se cerrará.

Este capítulo revisa las técnicas de TAC, el manejo de pacientes con abdomen abierto (OA), el posterior cierre definitivo del abdomen y las opciones de reconstrucción a largo plazo en pacientes que desarrollan hernias como resultado del manejo de OA.

Indicaciones para dejar el abdomen abierto

Inicialmente descrito por los cirujanos de trauma, DCS es una de las razones más comunes para dejar un abdomen abierto. Originalmente se reservó para un subconjunto de pacientes con lesiones máximas, definidos como aquellos con (1) al menos una lesión vascular mayor (p. Ej., Vena cava inferior), (2) al menos dos lesiones viscerales y (3) shock profundo. Los primeros resultados de DCS fueron muy impresionantes. La supervivencia de estos pacientes con lesiones máximas aumentó del 11% al 77%, y el uso de DCS se extendió posteriormente a pacientes con lesiones menos graves. Sin embargo, muchos ahora creen que el péndulo se ha movido demasiado y, en algunos casos, los riesgos asociados con dejar el abdomen abierto superan los beneficios. Por lo tanto, la selección del paciente es vital. En general, hay cinco grupos distintos de pacientes en los que el abdomen debe dejarse abierto de forma aguda.

• 1. 
  Pacientes con o en riesgo de hipertensión intraabdominal (IAH) y posterior SCA. Este grupo incluye pacientes sometidos a operaciones electivas importantes, ya que aquellos que requerirán una reanimación masiva están en riesgo de sufrir ACS primario. Del mismo modo, los pacientes que requieren reanimación sustancial debido a una enfermedad médica grave o un trauma que requiere descompresión abdominal corren el riesgo de sufrir un SCA secundario y están incluidos en este grupo.
• 2. 
  Pacientes sometidos a DCS. Este grupo incluye pacientes sometidos a DCS por traumatismo abdominal masivo, como un paciente con una herida de bala a través de un vaso principal (p. Ej., Arteria renal), un órgano sólido (p. Ej., Riñón) y múltiples segmentos del intestino. Una vez que la lesión del vaso mayor y la lesión del órgano sólido se han controlado y se ha derramado el contenido de la lesión intestinal, el paciente puede ser demasiado inestable para la reconstrucción del intestino y el cierre de la fascia. En este caso, DCS permite el truncamiento rápido de la laparotomía antes de que el paciente ingrese a la "tríada letal" de hipotermia, acidosis y coagulopatía. Una vez que el daño ha sido controlado, el paciente puede ser llevado a la unidad de cuidados intensivos (UCI) para su reanimación y estabilización. Es importante decidir sobre la necesidad de realizar DCS al principio de la operación. Los predictores de la necesidad de un paciente de DCS incluyen: temperatura inferior a 34 ° C, pH inferior a 7,2, pérdida de sangre estimada superior a 4 L, necesidad de transfusión de más de 10 unidades de glóbulos rojos empaquetados, presión arterial sistólica inferior a 70 mm Hg, niveles de lactato superiores a 5 mmol / L, déficit base mayor de −6 en pacientes mayores de 55 años o mayor de −15 en pacientes menores de 55 años, y / o tiempo de protrombina mayor de 1.6. También se puede requerir DCS en pacientes sometidos a cirugía general electiva con pérdida de sangre abrumadora o hallazgos intraoperatorios inesperados que requieren una mayor estabilización / reanimación. déficit base mayor de −6 en pacientes mayores de 55 años o mayor de −15 en pacientes menores de 55 años, y / o tiempo de protrombina mayor de 1.6. También se puede requerir DCS en pacientes sometidos a cirugía general electiva con pérdida de sangre abrumadora o hallazgos intraoperatorios inesperados que requieren una mayor estabilización / reanimación. déficit base mayor de −6 en pacientes mayores de 55 años o mayor de −15 en pacientes menores de 55 años, y / o tiempo de protrombina mayor de 1.6. También se puede requerir DCS en pacientes sometidos a cirugía general electiva con pérdida de sangre abrumadora o hallazgos intraoperatorios inesperados que requieren una mayor estabilización / reanimación.
• 3. 
  Pacientes cuya fascia no se puede cerrar. Esta categoría incluye pacientes que pueden ser fisiológicamente estables pero que tienen contenido abdominal inflamado debido a una reanimación continua (p. Ej., DCS) o pérdida del dominio fascial de modo que no pueden cerrarse principalmente. La figura 1 muestra a un paciente que requirió TAC mientras esperaba que se resolviera el edema intestinal. El último ejemplo debe mantenerse abierto hasta que el paciente esté listo para un cierre definitivo con malla u otras modalidades.

  Figura 1

  El sistema ABThera VAC (Kinetic Concepts, Inc.) presenta una espuma que se extiende lateralmente para ayudar a eliminar el volumen.

  Cortesía de KCI, una compañía de Acelity.
• 4. 
  Pacientes con infecciones intraabdominales graves o fascitis necrotizante de la pared abdominal. Esto incluye pacientes con pancreatitis necrotizante, una infección de tejidos blandos o una gran cantidad de material purulento en el abdomen que requiere lavados repetidos.
• 5. 
  Pacientes que tienen una exploración planificada repetida o una segunda cirugía. Estos son pacientes con patología intraabdominal que requieren otra laparotomía en las próximas 48 a 72 horas. Por ejemplo, un paciente de cirugía vascular con isquemia mesentérica que se somete a una resección del intestino delgado, y 48 horas después, debe ser reexplorado para verificar si hay isquemia intestinal adicional.

Una vez que se ha tomado la decisión de dejar al paciente abierto, se realiza un TAC y el paciente se transporta a la UCI para su posterior tratamiento. En algunas situaciones, como con una lesión hepática masiva, las vísceras abdominales pueden estar empaquetadas con almohadillas de laparotomía para presión directa para controlar el sangrado antes de un TAC. Como se enfatizó anteriormente, se debe evitar la práctica de cerrar la fascia bajo tensión para prevenir IAH y ACS y para prevenir complicaciones de heridas que surgen de la isquemia y la presión, como infección y dehiscencia. Para los pacientes hemodinámicamente estables que presentan desafíos para el cierre abdominal primario durante el caso índice, existen varias opciones para lograr un cierre abdominal libre de tensión, algunos de los cuales se destacan más adelante en este capítulo.

Cierre abdominal temporal

Una vez que se ha tomado la decisión de dejar el abdomen abierto, se debe utilizar la técnica TAC más óptima según lo permitido por los recursos locales. El método ideal para TAC debería evitar la pérdida de dominio, limitar la contaminación, permitir la salida del líquido peritoneal y evitar la formación de adherencias. Se han descrito muchas técnicas de TAC en los más de 20 años desde que Rotondo y Schwab acuñaron el término cirugía de control de daños , y todas comparten los siguientes atributos:

• ▪ 
  Abarca fácilmente las vísceras intestinales y abdominales.
• ▪ 
  Permite el agrandamiento de la cavidad abdominal en situaciones de intestino grueso, tejido o edema retroperitoneal sin inducir IAH y al mismo tiempo prevenir el SCA
• ▪ 
  Es expansible pero también lo suficientemente resistente como para permitir el efecto de taponamiento de empacar el hígado u otras superficies sangrantes
• ▪ 
  No daña la fascia y evita la retracción fascial
• ▪ 
  Contiene y cuantifica la pérdida de líquidos.
• ▪ 
  Previene la formación de adherencias entre las vísceras y la fascia abdominal.
• ▪ 
  Promueve la eliminación de materiales infecciosos.
• ▪ 
  Es rápido de aplicar y quitar
• ▪ 
  Tiene una buena tasa de cierre fascial primario (65% en una revisión sistemática de series solo de trauma por van Hensbroek et al.)

Las opciones se pueden dividir en técnicas de aproximación de la piel (cierre con clip de toalla, la bolsa de Bogotá, la técnica del silo), técnicas de cierre fascial que utilizan un material de injerto de interposición suturado a la fascia abdominal (por ejemplo, el parche de Wittmann) o terapia de heridas con presión negativa (NPWT ) (Paquete de vacío de Barker, dispositivos de cierre asistido por vacío [VAC] disponibles en el mercado). La Tabla 1 compara los métodos más comunes de TAC.

TABLA 1

Varios métodos de cierre abdominal temporal

Técnica de cierre	Descripción	Ventajas	Desventajas
Aproximación de piel
Cierre de toalla	Aplicación en serie de pinzas de toalla o sutura	Rápido	No previene IAH; puede interferir con la radiografía o la angiografía
Bogotá bag	Bolsa IV de 3L, Steri-Drape, bolsa Silastic, bolsa de plástico unida a la piel	Barato, inerte, no adherente	Riesgo de evisceración, pérdida del dominio abdominal, riesgo de IAH; pérdidas de fluidos difíciles de cuantificar
Cierre fascial
Malla absorbible	Sutura de malla absorbible a bordes fasciales	Se puede aplicar directamente sobre el intestino; permite el drenaje del líquido peritoneal	Pérdida rápida de la resistencia a la tracción (en caso de infección), hernia ventral tardía potencialmente de gran volumen; riesgo de fístula intestinal; daño a los bordes fasciales por suturas repetidas
Parche de Wittmann (Star Surgical)	Sutura de rebabas artificiales (p. Ej., Velcro) a la fascia, cierre abdominal por etapas mediante la aplicación de tensión controlada	Buena resistencia a la tracción, permite una fácil reexploración y eventual cierre fascial	Mal control del líquido del tercer espacio, adherencia del intestino a la pared abdominal, potencial de fístulas
Terapia de heridas de presión negativa
Paquete de vacío de Barker	Intestino cubierto con sábanas de plástico y toallas o almohadillas para laparotomía; drenajes planos unidos a la succión de la pared y la capa adhesiva externa	Barato, utiliza materiales disponibles; control moderado de fluidos; la succión proporciona una tracción medial constante, evitando la pérdida de dominio; alto éxito en cierre fascial	Difícil de cuantificar la succión; se desconoce si se obtienen todos los beneficios de la terapia de presión negativa
Sistema de vendaje abdominal VAC	Apósito de espuma de poliuretano reticulado sobre la cubierta plástica del intestino; la presión negativa se controla con una bomba de vacío controlada por computadora que aplica una presión constante y regulada a la superficie de la herida y un dispositivo de detección para evitar el drenaje no controlado de líquidos (por ejemplo, sangre)	Aumento del flujo sanguíneo, reducción de la tensión de la pared abdominal, reducción del tamaño del defecto de la pared abdominal, disminución del edema de la pared intestinal y posible eliminación de sustancias inflamatorias que se acumulan en el abdomen durante los estados inflamatorios; el edema y las pérdidas del tercer espacio están controladas	Costoso; no está disponible en todas las instituciones o en todos los entornos de bajos recursos; los mecanismos de acción no se entienden completamente, pero conducen a la hiperossificación; relación completa con la fístula necesita más estudio

IAH, hipertensión intraabdominal; IV, intravenosa; VAC, cierre abdominal al vacío.

Aunque las formas más tempranas de TAC, el clip de toalla y los cierres de bolsas de Bogotá, se mencionan en la tabla, estos han sido reemplazados en gran medida por técnicas mejoradas. La Conferencia Internacional de Consenso 2014 sobre Abdomen Abierto en Trauma recomienda NPWT siempre que sea posible. Estos dispositivos crean un silo de presión negativa que contiene el contenido abdominal, es algo expansible y permite la extracción de líquidos mensurables. La presión negativa se aplica medialmente hacia arriba a través del abdomen abierto, minimizando la retracción fascial y la pérdida del dominio abdominal. Estos apósitos también son muy rápidos y fáciles de aplicar y se pueden usar en situaciones de hinchazón intestinal masiva. Aunque existen varias variaciones de los TAC de presión negativa, la mayoría incluye las siguientes características clave.

• 1. 
  Membrana interna semipermeable (fenestrada), no adherente. La capa más interna de plástico fenestrado o esponja cubierta de plástico actúa para proteger las vísceras del dispositivo de succión suprayacente y simultáneamente permite la evacuación del líquido intraabdominal.
• 2. 
  Esponja embutida. La capa media del dispositivo VAC consiste en una esponja porosa, a menudo hecha de poliuretano, colocada en una posición de incrustación entre los bordes fasciales y al ras del nivel de la piel. Esta capa transmite el efecto de succión sobre la membrana interna para eliminar el líquido intraabdominal. El efecto de succión en la esponja incrustada también produce una contracción de la herida y una suave reposición del borde fascial con el tiempo.
• 3. 
  Capa exterior impermeable adhesiva. La capa externa del apósito VAC es una capa adhesiva e impermeable que se usa para crear un sello alrededor de los bordes de la herida y para anclar el apósito a la piel peri-herida y permitir una tensión suave o una contracción de la herida.
• 4. 
  Dispositivo de succión o máquina. Finalmente, el dispositivo o máquina de succión típicamente se conecta al vendaje a través de un adaptador colocado sobre un defecto creado intencionalmente en la capa externa impermeable para permitir la transmisión de presión negativa directamente sobre la capa de esponja media.

Las figs. 1–3 ilustran el dispositivo ABThera VAC (Kinetic Concepts Inc.). La figura 4 ilustra el apósito Barker, que utiliza materiales fácilmente disponibles en el quirófano para crear un apósito de vacío. La Sociedad Mundial de Cirugía de Emergencia también recomienda NPWT con tracción fascial continua como el método preferido para el TAC, pero reconoce que el TAC sin presión negativa (p. Ej., La bolsa de Bogotá) se puede aplicar en entornos de bajos recursos aceptando una tasa de cierre fascial retrasada más baja y un intestino más alto tasa de fístula

Figura 2

Colocación de la capa más interna para el ABThera VAC (Kinetic Concepts, Inc.), que se combina con una espuma incrustada que se despliega lateralmente, lo que facilita su aplicación y también ayuda a eliminar el líquido paracólico lateral y la eliminación de efluentes.

Fig. 3

Apósito de cierre asistido por vacío al paciente en la unidad de cuidados intensivos quirúrgicos. Este apósito se aplicó fácilmente a pesar de un intestino extremadamente hinchado y un abultamiento retroperitoneal masivo.

Fig. 4

Técnica de envasado al vacío de Barker. (A) La lámina de polietileno se perfora varias veces con una cuchilla de bisturí. (B) La lámina se coloca sobre las vísceras y debajo del peritoneo / pared abdominal. (C) Se coloca una toalla húmeda sobre el poliuretano y se coloca debajo de los bordes de la piel. (D) Se colocan drenajes de succión. (E) Se aplica un apósito adhesivo externo y los desagües se conectan a la succión de la pared.

Cortesía de Donald H. Barker, MD, Departamento de Cirugía, Universidad de Tennessee, Chattanooga.

Consejos prácticos para el uso del apósito de cierre VAC como cierre abdominal temporal

Lateralice al máximo la capa protectora visceral interna

Para evitar que las vísceras se escapen por los bordes de la esponja embutida, es importante lateralizar al máximo la capa protectora visceral interna. Esto también evita la adhesión de las vísceras a la superficie inferior de la pared abdominal, lo que podría dificultar el cierre abdominal eventual. Puede ser útil desmontar el ligamento falciforme, así como cualquier adherencia secundaria a la pared abdominal anterior. Una técnica es usar un retractor de la pared abdominal para facilitar la colocación adecuada.

Coloque las anastomosis intestinales profundamente en la cavidad abdominal

La Conferencia Internacional de Consenso 2014 sobre Abdomen Abierto en Trauma mencionó anteriormente que OA y NPWT no dañan las anastomosis intestinales siempre que estén enterradas profundamente dentro de la pelvis o el abdomen central bajo múltiples asas intestinales o hacia afuera lateralmente debajo de la pared abdominal.

Evitar fugas

Las fugas de aire, típicamente en los bordes de la herida o en los pliegues de la piel y los sitios de ostomía, son el talón de Aquiles de la terapia de VAC. Es importante utilizar una superposición adecuada de adhesivo, al igual que las pruebas de fugas intraoperatorias antes de abandonar la sala de operaciones. El uso de adhesivos líquidos auxiliares, como la tintura de benzoína o Mastisol puede facilitar un buen sellado, especialmente en áreas difíciles de adhesión. Se debe evitar tirar y colocar el apósito externo bajo tensión, ya que puede provocar ampollas epidérmicas y problemas de la piel a largo plazo.

Grapas para la aposición de la esponja de la piel

La esponja de poliuretano daña la epidermis cuando se hace contacto directo bajo presión negativa; sin embargo, la esponja incrustada debe llegar a una posición al ras con el borde de la piel para maximizar la efectividad del apósito. Una solución es usar grapas de la piel para fijar temporalmente la esponja incrustada en los bordes de la herida durante la aplicación del apósito y la succión inicial, aunque este no es un paso necesario. Estas grapas luego se retiran en el próximo cambio de vendaje VAC.

Ostomías superpuestas con capa externa adhesiva

La terapia de VAC en presencia de una ostomía crea un problema muy difícil para el manejo de heridas. Si la ostomía está cerca de la herida o si el paciente tiene una fístula enteroatmosférica en el medio de la herida, existen otras posibles soluciones para asegurar un buen sellado del apósito VAC. Con el aparato de ostomía apagado, se puede colocar una capa de capa externa adhesiva sobre el sitio del estoma, con un pequeño orificio cortado para permitir que el estoma pase. El aparato de ostomía se vuelve a aplicar sobre la capa adhesiva y simplemente se cambia cada 48 horas con el apósito.

Agujero apropiado para dispositivo de vacío

Aunque simple, el uso de un agujero de tamaño apropiado en la capa adhesiva externa es un paso crítico. Al menos un agujero de 2 × 2 cm es apropiado y permite una transmisión eficiente de la presión negativa.

La cantidad de presión negativa depende de la condición clínica

La cantidad terapéutica óptima de presión negativa que maximiza el crecimiento del tejido es de aproximadamente 125 mm Hg, con cierta flexibilidad basada en las condiciones clínicas y el tiempo de manejo. Si se sospecha una hemorragia activa causada por coagulopatía, el nivel de presión debe ser más bajo, aproximadamente negativo 75 mm Hg, para disminuir el riesgo de hemorragia.

OA Cuidado postoperatorio

Después de DCS, los pacientes requieren tratamiento en una unidad de cuidados críticos con monitorización hemodinámica agresiva. El período postoperatorio inmediato debe consistir en recalentamiento; corrección de coagulopatía, acidosis y alteraciones metabólicas, y probablemente reanimación continua. Durante esta fase temprana de "búsqueda de líquidos", los pacientes no deben ser restringidos en términos de administración de líquidos debido a las preocupaciones sobre el edema intestinal o el cierre fascial final. Las soluciones cristaloides hipertónicas para la infusión y la terapia de bolo durante la fase de reanimación pueden proporcionar una expansión de volumen duradera al tiempo que restringen el edema en cierto grado. Todos los pacientes que sufren heridas abdominales penetrantes deben recibir una dosis preoperatoria de antibióticos profilácticos de amplio espectro. En presencia de una lesión de víscera hueca, La literatura apoya el uso de antibióticos profilácticos durante no más de 24 horas. Sin embargo, hay una falta de evidencia con respecto a la necesidad de continuar los antibióticos únicamente en pacientes con OA. Sin embargo, si se cree que el paciente tiene sepsis, se deben iniciar y reducir los antibióticos de amplio espectro según corresponda según los resultados del cultivo y el curso clínico. Debe reconocerse que los pacientes con OA se encuentran en una condición hipermetabólica y que el soporte nutricional adecuado es obligatorio. Se prefiere la nutrición enteral temprana si el tracto gastrointestinal está intacto y viable. Otros objetivos para la reanimación están bien delineados en la literatura de DCS, así como en el capítulo sobre control de daños en este texto. En breve,

Traslados posteriores a la sala de operaciones

A intervalos de 1 a 3 días, el paciente debe regresar al quirófano para irrigar el abdomen, cambiar el vendaje abdominal VAC y realizar las maniobras terapéuticas necesarias (p. Ej., Anastomosis intestinal, drenaje de colecciones purulentas) y evaluar cierre abdominal En nuestra institución, los cambios en el apósito abdominal de VAC solo se realizan al lado de la cama si el paciente está inestable y no puede tolerar un viaje a la sala de operaciones. La estrecha colaboración entre el equipo de cuidados críticos y el equipo quirúrgico permitirá la diuresis temprana de pacientes elegibles y, a su vez, un cierre abdominal más temprano. Los datos sugieren que los pacientes que permanecen abiertos en el día 8 tienen pocas probabilidades de tener un cierre primario y tienen un mayor riesgo de complicaciones graves, incluidas infecciones de heridas y fístulas.

Cierre definitivo del abdomen.

Una vez que el paciente está listo para el cierre abdominal, el mejor de los casos es el cierre fascial primario. Generalmente colocamos suturas pesadas, interrumpidas y absorbibles en forma de figura de 8. En un entorno de perforación colónica o contaminación fuerte, la piel debe dejarse abierta. Algunos autores sugieren el uso de suturas de retención, pero no las colocamos rutinariamente. Las suturas de retención no evitan la dehiscencia fascial, pero pueden ayudar a prevenir la evisceración intestinal si se produce la dehiscencia. Además, se pueden colocar donde la infección de la herida y la posterior dehiscencia son motivo de preocupación. Debe reiterarse que la fascia no debe cerrarse bajo tensión, ya que esto puede conducir a IAH y ACS.

La investigación sobre el manejo de la OA ha encontrado que el cierre directo generalmente es posible cuando los bordes fasciales están separados aproximadamente por 3 a 7 cm. Cuando esto no se puede lograr, se deben considerar diferentes técnicas quirúrgicas. Los colgajos de piel se pueden levantar para ganar algo de longitud medial en la fascia. La fascia también se puede avanzar liberando los oblicuos laterales; sin embargo, no se recomienda una separación completa de componentes para el cierre agudo de un abdomen abierto. Para los pacientes que necesitan malla para cerrar una brecha entre los bordes fasciales, las opciones incluyen productos biológicos como la matriz dérmica acelular humana (HADM), malla absorbible como Vicryl (Ethicon) y mallas compuestas. Dos posibles técnicas para el manejo en esta etapa se describen en la siguiente sección.

Si la fascia no se puede cerrar pero la piel de la pared abdominal es lo suficientemente laxa como para cerrar en la línea media, se puede colocar una malla biológica subyacente para salvar el defecto fascial. La piel suprayacente se puede cerrar para proporcionar cobertura para la malla. En esta situación, el método de cierre o reaproximación de la piel puede ser asistido por la terapia VAC. La capa subyacente de la malla biológica generalmente se coloca en una posición intraperitoneal y se fija a la pared abdominal mediante técnicas de sutura transfascial.

Donde ni la fascia ni la piel tienen la capacidad para el cierre de la línea media, habitualmente usamos un cierre temporal de malla Vicryl (poliglactina) con la colocación retrasada de un injerto de piel de espesor dividido. Esta malla absorbible temporal se coloca en una posición subyacente, intraperitoneal. Los apósitos estándar de solución salina húmeda a seca se colocan dos veces al día durante aproximadamente 2 a 4 semanas hasta que aparezca tejido de granulación satisfactorio en el lecho de la herida. En este momento, se puede colocar un injerto de piel de espesor parcial para cubrir la herida. Se debe aconsejar al paciente que evite la actividad extenuante y el trabajo pesado durante los varios meses de convalecencia, y se puede considerar una carpeta abdominal para soporte externo. Aunque esta técnica no es novedosa ni atractiva estética o funcionalmente, es una estrategia probada en el tiempo para evitar catástrofes de AA. Con el advenimiento de las técnicas modernas de reconstrucción de la pared abdominal, a estos pacientes se les puede ofrecer una oportunidad genuina y bastante confiable para restaurar la continuidad de la pared abdominal, aunque en una fecha posterior una vez que hayan completado la convalecencia por su enfermedad aguda. Por lo general, esto se logra después de un mínimo de 6 a 12 meses, lo que permite suavizar las adherencias intraabdominales y la recuperación de lo que probablemente sea una estadía prolongada en la UCI, el hospital y el centro de rehabilitación. El beneficio de este enfoque es que la musculatura nativa de la pared abdominal no se viola y permanece intacta, lo que permite una serie de posibles técnicas de cierre definitivo de intervalo. aunque en una fecha posterior una vez que hayan completado la convalecencia por su enfermedad aguda. Por lo general, esto se logra después de un mínimo de 6 a 12 meses, lo que permite suavizar las adherencias intraabdominales y la recuperación de lo que probablemente sea una estadía prolongada en la UCI, el hospital y el centro de rehabilitación. El beneficio de este enfoque es que la musculatura nativa de la pared abdominal no se viola y permanece intacta, lo que permite una serie de posibles técnicas de cierre definitivo de intervalo. aunque en una fecha posterior una vez que hayan completado la convalecencia por su enfermedad aguda. Por lo general, esto se logra después de un mínimo de 6 a 12 meses, lo que permite suavizar las adherencias intraabdominales y la recuperación de lo que probablemente sea una estadía prolongada en la UCI, el hospital y el centro de rehabilitación. El beneficio de este enfoque es que la musculatura nativa de la pared abdominal no se viola y permanece intacta, lo que permite una serie de posibles técnicas de cierre definitivo de intervalo. La figura 5 describe un algoritmo para manejar un abdomen abierto.

Fig. 5

Algoritmo para el manejo de un abdomen abierto.

Técnicas de cierre de los cojinetes de tensión transfasciales

Una alternativa distinta al cierre estándar para el manejo de la OA es un grupo de técnicas colectivamente denominadas técnicas de cierre transfascial que soportan tensión. Los ejemplos típicos de tales cierres incluyen el parche Wittmann estándar de hojas de velcro y el sistema Canica ABRA. El principio rector en todas estas técnicas es redistribuir la tensión de la pared abdominal a una posición lateral a la vaina del recto en lugar de en la porción medial de la herida abdominal, donde la tensión es más alta en un cierre estándar. Al hacerlo, se postula que estas técnicas producen liberación miofascial alargando gradualmente los grupos miofasciales retraídos oblicuos y transversales del abdomen para recuperar el dominio abdominal.

La aplicación descrita más recientemente de esta técnica ha sido popularizada por el grupo quirúrgico de traumatología y cuidados agudos del Hospital del Condado de Cook en Chicago y se conoce como el método de tracción de la pared transabdominal (TAWT) ( http://www.starsurgical.com ) La técnica TAWT aprovecha una variación del parche Wittmann original mediante el cual se utilizan las mismas láminas de gancho y bucle (Velcro), pero se fijan lateralmente a la vaina del recto mediante suturas pesadas que pasan a través de todas las capas de la pared abdominal y se fijan externamente mediante un hidrocoloide. capa. Las vísceras debajo de las láminas de gancho y bucle están protegidas por una barrera de adhesión de plástico semipermeable. Este sistema se puede apretar gradualmente durante los lavados abdominales en serie y los cambios de barrera de adhesión cada 48 horas. El grupo en el Hospital del Condado de Cook informa un gran éxito con esta técnica y tiene una tasa cercana al 100% de cierre abdominal eventual, con solo un número relativamente pequeño en promedio de procedimientos de apriete y lavado. Se aplica un apósito de succión al vacío estándar en la parte superior de la herida entre los procedimientos de apriete. Una vez que se puede obtener un cierre sin tensión en la línea media con el sistema TAWT, se puede realizar un cierre en capas, ya sea principalmente o mediante un abordaje retrorectus. El espacio rectorectus se desarrolla y la vaina posterior se cierra principalmente. Luego, se puede colocar una malla en la posición retrorectus antes del cierre de la vaina anterior y el manejo asistido por vacío de la porción cutánea abierta de la herida ( Las figs. 6 a 8 ).

Fig. 6

La matriz dérmica acelular humana (AlloDerm) se usa como una malla de interposición donde la fascia no puede cerrarse principalmente. Tenga en cuenta que la matriz dérmica acelular humana se coloca, estira y sutura lo más tensamente posible.

Cortesía de Richard Redett, MD, Johns Hopkins Plastic and Reconstructive Surgery, Baltimore, MD.

Fig. 7

Abra el abdomen después de varios días de un cierre abdominal temporal, donde la fascia no se puede cerrar principalmente y se requiere un cierre de malla.

Cortesía del Dr. Elliott Haut, Johns Hopkins Acute Care Surgery, Baltimore, MD.

Fig. 8

Hernia ventral grande después del cierre de la fascia con malla de Vicryl (Ethicon) y la colocación de un injerto de piel de espesor dividido.

Cortesía del Dr. Richard Redett, Johns Hopkins Plastic and Reconstructive Surgery, Baltimore, MD.

Fig. 9

Técnica de separación de componentes para la reparación de grandes hernias de la pared abdominal. Después de entrar en la cavidad abdominal, los intestinos se disecan libres de la pared abdominal ventral. (A) La piel y la grasa subcutánea (1) se disecan libres de la vaina anterior del músculo recto abdominal (5) y la aponeurosis del músculo oblicuo externo (2) . (B – C) La aponeurosis del músculo oblicuo externo (2) se transmite longitudinalmente a unos 2 cm de la vaina del recto, incluida la parte muscular de la pared torácica, que se extiende al menos de 5 a 7 cm cranealmente del margen costal. (D) El músculo oblicuo externo (2) se separa del músculo oblicuo interno (3) lo más lateralmente posible. (E – F) Si el cierre primario es imposible con una tensión indebida, se puede alcanzar una ganancia adicional de 2 a 4 cm separando la vaina rectal posterior del músculo recto abdominal (5) . Se debe tener cuidado de no dañar el suministro de sangre y los nervios que corren entre los músculos oblicuos internos y transversales. (4) e ingrese al músculo recto abdominal en el lado posterior.

De De Vries Reilingh TS, van Goor H, Rosman C, et al. Técnica de separación de componentes para la reparación de grandes hernias de la pared abdominal. J Am Coll Surg. 2003; 196 [1]: 32–37.

Manejo a largo plazo y reconstrucción definitiva de la pared abdominal

El desarrollo de una hernia ventral significativa es común en los sobrevivientes a largo plazo del tratamiento de la OA. Aunque el desarrollo de la hernia es un factor de riesgo independientemente de la técnica de cierre elegida para el tratamiento agudo de un OA, se espera una hernia en pacientes cerrados con una malla absorbible y un injerto de piel suprayacente. Se requiere una planificación cuidadosa antes de intentar reparar estas hernias, y el paciente debe recuperarse por completo de la enfermedad inicial. El paciente también debe estar bien alimentado y fisiológicamente optimizado.

Otro aspecto importante es permitir tiempo suficiente para la remodelación de cualquier adherencia que pueda haber ocurrido entre la malla o la fascia y las vísceras. En el caso de la malla Vicryl y el posterior injerto de piel, un indicador de remodelación es la capacidad de pellizcar la estructura de malla / injerto de piel lejos del contenido abdominal subyacente. Esta separación indica que el paciente está listo para la reparación de la hernia ventral. Muchos cirujanos generales solicitarán asistencia de cirujanos plásticos, especialmente si se requieren expansores de tejido o reordenamiento de tejido complejo. Los pasos en la reconstrucción son:

• 1. 
  Evaluar la piel suprayacente y colocar expansores de tejido, si es necesario, antes de la cirugía.
• 2. 
  Cortar el injerto de piel y cualquier malla previamente colocada.
• 3. 
  Realizar una lisis extensa de adherencias para liberar vísceras de la fascia suprayacente.
• 4. 
  Fascia aproximada, que puede requerir uno o todos los siguientes:
  • a. 
    Levante colgajos de piel grandes y diseccione la piel y el tejido subcutáneo de la fascia anterior
  • b. 
    Realice la separación de componentes, en la cual la aponeurosis del músculo oblicuo externo se transecte longitudinalmente bilateralmente, permitiendo que la fascia se jale medialmente; la vaina posterior de los recortes se puede cortar de manera similar para ganar más longitud
  • c. 
    Uso de malla; si la fascia no se une, la malla se puede colocar como una capa subyacente (posición retrorectus, por encima de la fascia del recto posterior o intraperitonealmente con solapamiento de la fascia) o como un injerto de interposición (puente del defecto fascial); la mayoría de los autores sugieren el uso de HADM u otros productos biológicos para este propósito
• 5. 
  Malla onlay en la parte superior de la fascia para refuerzo. Si se ha colocado una capa subyacente o interposición HADM, también podemos aplicar una malla de polipropileno como capa superpuesta. Si no se requirió una capa subyacente, se puede colocar un polipropileno como malla onlay para reforzar la fascia.
• 6. 
  Antes del cierre de la piel, los drenajes se pueden colocar en el espacio subcutáneo para extraer el líquido acumulado.
• 7. 
  Cierre primario estándar de la piel con grapas o un sistema híbrido de VAC de la piel según lo descrito por Soares y colegas.

Resumen

En el paciente seleccionado adecuadamente, un OA puede servir como un componente que salva vidas de una estrategia general de control de daños. Las técnicas para lograr el cierre eventual de la OA deben incluir reanimación equilibrada con minimización cristaloide, retornos regulares a la sala de operaciones y un enfoque cuidadosamente seleccionado para el cierre basado en el paciente, el cirujano y los factores institucionales. La mejora continua en las técnicas reconstructivas de la pared abdominal continuará mejorando la mortalidad y la calidad de vida para los pacientes que requieren cirugía de control de daños o para aquellos con SCA.

Lecturas Sugeridas

Barker DE, Green JM, Maxwell RA, et. al .: Experiencia con el cierre temporal de la herida abdominal en paquete de vacío en 258 pacientes con trauma y cirugía general y vascular. J Am Coll Surg 2007; 204: 784–492

Boele van Hensbroek P., et. al .: Cierre temporal del abdomen abierto: una revisión sistemática sobre el cierre fascial primario retardado en pacientes con abdomen abierto. World J Surg 2009; 33: págs. 199-207.

Campbell A., Chang M., Fabian T., et. al .: Manejo del abdomen abierto: desde la operación inicial hasta el cierre definitivo. Am Surg 2009; 75: págs. S1-S22.

Chiara O., Cimbanassi S., Biffl W., et. al .: Conferencia de consenso internacional sobre abdomen abierto en trauma. J Trauma Acute Care Surg 2016; 80: págs. 173-183.

Coccolini F., Roberts D., Ansaloni L., et. al .: El abdomen abierto en pacientes con trauma y sin trauma: guías de WSES. World J Emerg Surg 2018; 13: págs.7.

Goldberg SR, Anand RJ, Como JJ, et al. Uso profiláctico de antibióticos en el traumatismo abdominal penetrante: una guía de gestión de la práctica de la Asociación Oriental para la Cirugía del Trauma. J Trauma Cuidado agudo Surg. 2012; 73 (5 supl. 4): S321 – S325.

Soares KC, et. al .: Reducción novedosa del sistema de manejo de heridas de la morbilidad del sitio quirúrgico después de reparaciones de hernia ventral: un análisis crítico. Am J Surg 2015; 209: 324–332

Referencias

1. Barker et al., 2007 . Barker DE, Green JM, Maxwell RA, et al: Experiencia con el cierre temporal de la herida abdominal en envase de vacío en 258 pacientes con trauma y cirugía general y vascular. J Am Coll Surg 2007; 204:
2. Campbell et al., 2009 . Boele van Hensbroek P., et al: Cierre temporal del abdomen abierto: una revisión sistemática sobre el cierre fascial primario retardado en pacientes con abdomen abierto. World J Surg 2009; 33: págs. 199-207 Referencia cruzada
   
3. Campbell et al., 2009 . Campbell A., Chang M., Fabian T., et