1079-6061/00/4802-0201

The Journal of Trauma: Injury, Infection, and Critical Care

Copyright 2000 by Lippincott Williams & Wilkins, Inc.

Vol. 48, No. 2

Printed in the U.S.A.

Vacuum Pack Technique of Temporary Abdominal Closure:

A 7-Year Experience with 112 Patients
Donald E. Barker, MD, Henry J. Kaufman, MD, Lisa A. Smith, MD, David L. Ciraulo, DO, MPH, Charles L. Richart, MD,
and R. Phillip Burns, MD
Background: Temporary abdominal wound closure after celiotomy for trauma is often desirable. The ideal method of
temporary closure should allow rapid closure, easy maintenance, and allow reexploration and wound repair with minimal
tissue damage. Over the past 7 years, we have successfully used
a vacuum closure system (the vacuum pack) for temporary
management of the open abdomen.
Methods: Medical records of trauma patients undergoing exploratory celiotomy from April of 1992 to February of 1999
were reviewed. Demographic data as well as indications for
open-abdominal management and complications of open-abdominal management were collected.
Results: Two hundred sixteen vacuum packs were performed
in 112 trauma patients. Of the 216 vacuum packs placed, 2.8%
were placed for increased intra-abdominal pressure, 5.3% for
inability to achieve tension-free fascial closure, 20% for damage
control, 55% for reexploration, and 16.7% for a combination of

factors. Sixty-two patients (55.4%) went on to primary closure

and 25 patients (22.3%) underwent polyglactin mesh repair of
the defect followed by wound granulation and eventual skin
grafting. Twenty-two patients (19.6%) died before abdominal
closure was attempted. Five patients (4.5%) developed enterocutaneous fistulae. Five patients (4.5%) developed intra-abdominal abscesses. There were no eviscerations. Three patients
(2.7%) required further explorations after abdominal closure.
Overall mortality rate was 25.9%, none related to the vacuum
pack.
Conclusions: The vacuum pack is the temporary abdominal
wound closure of choice in patients undergoing open abdominal
management at our institution. Primary closure is achieved in
the majority of patients with a low rate of complication. The
technique is simple and easily mastered. Technical complications are rare and easily repaired.

used it in the management of the open abdomen in the trauma

patient.1,2

emporary abdominal wound closure after celiotomy for

trauma is desirable when tension-free primary approximation of the abdominal wall tissues is impractical or
when reexploration is planned. Attempts at abdominal closure in patients with marked visceral edema, retroperitoneal
hematoma, or packing of the peritoneal cavity may result in
increased intra-abdominal pressure and abdominal compartment syndrome (ACS), with subsequent detrimental effects
on pulmonary, cardiac, and renal function. When reexploration is planned for control of intra-abdominal contamination,
inspection for visceral viability or after damage control procedures, temporary closure facilitates access to the peritoneal
cavity.
The ideal temporary abdominal wound closure should provide containment of the intra-abdominal viscera, protect the
viscera from mechanical injury, prevent bowel dessication,
minimize abdominal wall tissue damage, prevent contamination of the peritoneal cavity, control egress of peritoneal fluid,
be rapidly applied, lend itself to multiple applications, and be
relatively inexpensive. We have developed a temporary abdominal wound closure technique that we believe meets these
criteria for temporary abdominal wound closure and have

MATERIALS AND METHODS

Technique
After the completion of abdominal exploration, a polyethylene sheet is perforated multiple times with a scalpel blade
(Fig. 1). It is then placed over the peritoneal viscera and
beneath the peritoneum of the abdominal wall (Fig. 2). Next,
a moist sterile surgical towel(s) is folded to fit the abdominal
wall defect and is placed over the polyethylene sheet (Fig. 3).
The edges of the towel are positioned below the skin edges.
Placement of the towel edges below the peritoneum is helpful
if viscera is protruding through the abdominal wall defect.
Two 10-French flat silicone drains are placed on top of the
towel. The tubing from the drains is tunneled beneath the skin
to exit 3 to 5 cm away from the superior pole of the wound
(Fig. 4). The exit sites can be buttressed with gauze sponges
to prevent pressure necrosis of the skin from the drain tubing.
The adjacent skin is sponged dry and painted with tincture of
benzoin. The benzoin-painted skin is kept dry until covered
with a plastic polyester drape backed with iodophor-impregnated adhesive.
Each drain tube is connected to a bulb suction. Each bulb
suction is connected to a limb of a Y-adapter (Fig. 5). The
Y-adapter is connected to a suction source at 100 to 150 mm
Hg continuous negative pressure. A distinctive high-pitched
sound is created by air flow through the drains. This sound is
present anytime the negative pressure seal is broken. While
suction is applied to the drains, the plastic polyester adhesive

Submitted for publication September 25, 1999.

Accepted for publication November 15, 1999.
From the Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee.
Presented at the 59th Annual Meeting of the American Association for the
Surgery of Trauma, September 16 18, 1999, Boston, Massachusetts.
Address for reprints: Donald E. Barker, MD, University of Tennessee
College of Medicine, Chattanooga Unit, Department of Surgery, 979 E.
Third Street, Suite 401, Chattanooga, TN 37403.

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The Journal of Trauma: Injury, Infection, and Critical Care

February 2000

FIG 1. The polyethylene sheet is perforated multiple times with a scalpel blade.

drape is placed over the wound and adjacent abdominal wall

skin. Air and liquid is sucked from the surgical towel between
the two plastic sheets, and the dressing becomes semirigid
(Fig. 6). Just before transport, the tubing is clamped between
the suction source and the Y-adapter. Suction is then disconnected. Suction is reconnected to the drains once transport is
complete and maintained until reexploration is required.
The materials necessary for the vacuum pack are readily
available from standard stock in most operating rooms (Table
1). Cost of materials for each vacuum pack at our institution
is $47.64.
FIG 3. A moist surgical towel(s) is folded to fit the abdominal wall defect, placed
over the polyethylene sheet, and positioned below the skin edges.

Patients
The medical records of trauma patients undergoing open
abdominal management by using the vacuum pack technique
at a designated Level I trauma center from April of 1992 to
February of 1999 were reviewed. Demographic data including age, sex, mechanism of injury, Injury Severity Score,
intra-abdominal injury, and reason for open abdominal management were identified. Data regarding the use of the vacuum pack and any associated complications were collected.

ACS was diagnosed clinically per physician progress notes,

and peak ventilatory pressures, bladder pressures, and/or oliguria were noted if obtained. Postvacuum pack wound management data were also noted. Hospital mortality data were
collected, and causes of death were noted.
RESULTS
The vacuum pack technique was used 216 times in 112
trauma patients requiring open abdominal management during the review period. The initial indications for open abdominal management are listed in Table 2. The indications for
each vacuum pack placement are listed in Table 3.
Patient ages ranged from 5 years to 80 years (mean, 38.9
16.85 years). There were 27 (24.1%) female and 85 (75.9%)
male patients. Mechanisms of injury were blunt in 77 patients
(68.8%) and penetrating in 35 patients (31.2%) and are shown
in Table 4. Mean Injury Severity Score was 27.5 (range, 5 to
75 14.09). Twenty-nine patients died for an overall hospital mortality of 25.9%.
Fifty-six patients (50.0%) had a single vacuum pack application, which remained in place from 1 to 6 days (mean,
1.9 days 1.10). Excluding patients who died after a single
vacuum pack placement, mean time to closure was 2.2
1.12 days (range, 1 to 6 days). Fifty-six patients (50.0%) had
multiple applications over 1 to 34 days (mean, 7.1 6.19

FIG 2. The polyethylene sheet is then placed over the peritoneal viscera and
beneath the peritoneum of the abdominal wall.

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Vol. 48, No. 2

FIG 4. Two 10-French flat silicone drains are placed on top of the towel, and
tubing from the drains is tunneled beneath the skin to exit 3 to 5 cm away from the
superior pole of the wound.

FIG 5. Each drain tube is connected to a bulb suction, which is connected to a limb
of a Y-adapter.

days). Individual vacuum packs in this group remained in

place from 1 to 11 days (mean, 2.5 1.53 days). For patients
with multiple vacuum packs, the mean number of vacuum
packs was 2.9 1.58 (range, 210).
Eleven patients (9.8%) developed abdominal complications after vacuum pack placement during hospitalization.
Five patients developed enterocutaneous fistulas. There were
three small bowel fistulas, one pancreatic fistula, and one
gastric fistula. Fistula formation was not directly related to
the vacuum pack. Intra-abdominal abscesses were diagnosed
in five patients. One patient developed ACS.
Eighty-eight patients underwent eventual abdominal
wound closure (Table 5). Twenty-two patients (19.6%) died
before abdominal wound closure. Seven patients (6.3%) died
after closure. Sixty-two patients (70.5%) underwent fascial
wound closure. Patients closed primarily had a mean time to
closure of 3.1 1.79 days (range, 19 days). One patient
(1.1%) had skin closure alone. Twenty-seven patients
(30.0%) underwent split-thickness skin graft after a granulation bed had been achieved. Of these 27 patients, 25 patients
(27.8%) had polyglactin mesh placed at the fascial level at the
time of removal of last vacuum pack and before wound
granulation. Mean time to split-thickness skin graft was
32.5 25.3 days (range, 12141 days) and 27.3 10.28
days (range, 1252 days) excluding the single outlier.

DISCUSSION
Open abdominal management is reserved for those patients in
whom abdominal closure would result in excessive intraabdominal pressure or who require early return to the operating room for reexploration. Several techniques for temporary abdominal wound closure have been proposed, including
skin closure alone or use of various biosynthetic materials
sutured to the skin or fascia. Placement of polypropylene
mesh in temporary closure of the abdomen has been well
documented.39 It has been used with and without a zipper
mechanism
to
allow
for
sequential
abdominal
reexplorations.10 16 Underlying viscera may adhere to the
mesh and become injured during subsequent reexploration.16
The mesh, if left long enough, may erode into the bowel.17
Repetitive suturing of biosynthetic material to fascial edges
damages the fascia and may be a causative factor in development of fascial necrosis.9
Several techniques have been described for temporary closure of the abdominal wall. These include the use of expanded polytetrafluoroethylene, Silastic sheets, and zipper
fasteners.16 20 Although these materials are less adherent to
underlying viscera, their use requires suturing of the prosthetic material to the abdominal wall tissues. Management of
peritoneal fluid is still a problem unless a drainage system is
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The Journal of Trauma: Injury, Infection, and Critical Care

February 2000

TABLE 3. Indications for open abdominal management at time of each vacuum

pack placement

incorporated. Closure of the skin only can result in leaks of

peritoneal fluid, which saturates dressings and potentially
allows contamination of the peritoneal cavity.
The vacuum pack is a sutureless closure that avoids mechanical trauma to the tissues of the abdominal wall. PlaceTABLE 1. Standard vacuum pack materials
Hospital
Cost (%)

Quantity

Polyethylene sheet
Surgical towels
Silicone drains (10 French flat with
bulb reservoir)
Y-connector
Plastic polyester adhesive drape
Total Hospital Cost

1
15
2

4.20
6.09
23.98

1
1

1.13
12.24
$47.64

Number

Increased intra-abdominal pressure

Damage control
Inability to close
Planned reexploration
Combination
Total

5
35
6
34
32
112

4.5
31.2
5.4
30.3
28.6
100.0

Increased intra-abdominal pressure

Damage control
Inability to close
Planned reexploration
Combination
Total

6
43
11
120
36
216

2.8
20.0
5.3
55.0
16.7
99.8

TABLE 4. Mechanism of injury

Parameter

Blunt abdominal trauma (n 77)

Motor vehicle collision
Pedestrian vs. car
Bicycle vs. car
Motorcycle collision
Fall
Tractor rollover
Total
Penetrating abdominal trauma (n 35)
Gunshot wound
Shotgun wound
Stab wound
Total
Total no. of patients

TABLE 2. Initial indication for open abdominal management

Placement Indication

Number

ment of the polyethylene drape beneath the peritoneum helps

contain the viscera and prevents adherence to peritoneum
adjacent to the abdominal wound and to the other vacuum
pack layers. This method lessens the chance of bowel injury
at the time of reexploration. Slits cut in the drape before
placement allow removal of excess peritoneal fluid. Peritoneal fluid losses can be quantified and replaced as needed.
The surgical towel(s) placed over the polyethylene drape
provides support to the vacuum pack once suction is applied.
It prevents direct application of suction to the underlying
bowel and absorbs fluid, which can then be removed through
the suction drains. Suction applied through the drains collapses the layers of the vacuum pack making it semirigid.
Application of the adhesive-backed drape stabilizes the dressing in place and seals the wound edges, preventing passage of
fluid in or out of the wound. The surrounding skin is protected and skin soilage is minimized. If the vacuum seal is
broken, the suction drains create a characteristic sound, which
should prompt a search for the leak.
The vacuum pack can be modified for use in both pediatric
and adult trauma patients. Materials are cut to fit the size of
the wound. The youngest patient in our series was 5 years of
age and the oldest was 80 years old.
Indications for open abdominal management included increased volume of intra-abdominal contents, need for a second look to determine bowel viability or after damage control
procedures, and presence of gross contamination. Closure of
the abdominal wound under tension can result in abdominal
wall tissue necrosis with subsequent infection. In the face of
dehiscence, wound-related mortality may reach 90%.6,21,22
Wound infection and tissue necrosis was not observed in
patients with vacuum packs in place.

FIG 6. With 100 to 150 mm Hg continuous negative pressure applied to the drains,
the plastic polyester adhesive drape is placed over the wound and adjacent abdominal wall skin resulting in a semirigid dressing called the vacuum pack.

Item

Placement Indication

204

Total

59
4
1
6
5
2
77

77
8
6
5
3
1
100

25
5
5
35
112

72
14
14
100

Vacuum Pack Technique of Temporary Abdominal Closure

Vol. 48, No. 2

TABLE 5. Management after vacuum pack wound care

Single Pack
Management Methods

Patients undergoing eventual closure

Primary closure
Mesh repair
Skin closure only
Closure by secondary intention
Deaths before closure

Multiple Pack

No. of Patients

88
62
25
1
2
22

Increased intra-abdominal pressure causes ACS, resulting

in cardiac, respiratory, and renal deterioration.2330 Intraoperatively, there are no immediate increases in peak airway
pressures or decreases in blood pressure after application of
the vacuum pack.1 In the postoperative period, clinically
apparent ACS was rare, occurring only in one patient. When
additional space is needed within the peritoneal cavity, the
outer polyester drape can be incised vertically in the midline,
allowing expansion of the abdominal cavity. The incised area
is then covered with adhesive-backed plastic polyester. This
technique was used in the one patient with clinically apparent
ACS. The low incidence of ACS in this series of patients may
be attributed in part to the surgeons willingness to accept
open abdominal management.
Damage control celiotomy is widely accepted for trauma
patients who require temporizing surgery until physiologic
stability is achieved.31,32 In these patients, the vacuum pack
provides a quick means of closure. Reexploration of the
abdomen is facilitated by the ease of vacuum pack removal
and reapplication.
Fistulas are common when the bowel is exposed.21,33,34
None of the five fistulas reported in this series were directly
caused by placement of the vacuum pack. The pancreatic
fistula occurred in a patient with pancreatic injury. The gastric fistula occurred as a result of disruption of a previous
gastrojejunostomy. The small bowel fistulas occurred in a
patient with a high-velocity gunshot wound requiring multiple small bowel resections, in a patient with blunt duodenal
injury, and in a patient with a previous fistula with attempted
resection.
Technical problems with the vacuum pack were rare. Peritoneal fluid leaks were repaired at the bedside by application
of additional adhesive drape over the leak site. Skin excoriation from peritoneal fluid was minimized. The adhesivebacked plastic polyester drape proved durable, and no structural failures were noted.
Fifteen patients had enterostomas in place on the anterior
abdominal wall at the time of vacuum pack closure. The
wounds remained protected from intestinal effluent.
Permanent closure of the abdominal wound was the goal
for all patients. After fascial closure, there were six major
wound complications. Wound dehiscence occurred in four of
these patients. One patient had skin necrosis, and one patient
had fat necrosis. There were no serious wound complications
in patients closed with split-thickness skin grafts.
Absorbable polyglactin mesh was used to contain the abdominal viscera when access to the peritoneal cavity was no

42
37
5
0
1
13

48
88
12
0
4
23

46
25
20
1
1
9

52
54
43
2
4
16

longer needed. Granulating wounds were dressed with petroleum gauze and moist gauze dressings until adequate granulation tissue was present to support a split-thickness skin
graft. Care was taken during dressing changes to prevent
damage to the underlying viscera. Skin grafts were taken
from the dorsolateral thigh in all patients except one, for
whom they were taken from the lateral abdominal wall. A
modified vacuum pack dressing was used to keep the skin
graft in place. Its application provides pressure to all areas of
the skin graft and is particularly useful when the granulation
bed is uneven. The dressing is removed on postgraft day 5.
Skin graft take was judged adequate in all cases.
The major long-term morbidity in patients requiring skin
grafting is the resultant abdominal wall hernia (Fig. 7). Hernias are repaired once the patient has recovered from their
injuries and the skin graft can be easily separated from the
underlying tissue. Repair is usually performed 3 to 6 months
after injury.
CONCLUSION
The vacuum pack seems to be a reliable method of temporary
closure of the open abdomen in trauma patients. There were
no major acute complications directly associated with its use.
The major long-term complication is the large ventral hernia,
which is created in those patients who cannot undergo primary fascial closure.
Acknowledgments
Thanks to Patricia L. Lewis, RN, and Michael D. Biderman, PhD,
for their assistance with this manuscript.

FIG 7. A ventral hernia after skin grafting over the granulation bed.

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February 2000

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DISCUSSION
Dr. Ronald M. Stewart (San Antonio, Texas): Dr. Barker
and colleagues have presented a simple, interesting, and relatively novel technique for early management of the open
abdomen. In the manuscript, they nicely summarize their
results along with their complication rates in detail.
The technique and management plan that they use, I do
believe, was associated with the low complication rate and is
reasonably economical. The potential advantages are decreased blood and bodily fluid exposure and an improved
ability to measure excess fluid losses. We currently do not
use this technique and, compared to how we manage these
patients, I do believe those two factors are real.
The authors, in their conclusions in the abstract, allude to
a high rate of primary closure as an advance to the technique.
And on this point I am considerably more skeptical. The
authors were able to achieve a relatively high closure rate of
55.4% in their patients.
If you look at the indication for the technique, need for
reexploration accounted for 55% of all the vacuum packs.
Damage control was 20%. Inability to achieve a tension-free
closure was 5%. And an increase in intra-abdominal pressure
was 3%. I would hypothesize that the need for reexploration
group had a significantly higher closure rate than the other,
what I would consider more traditional, indications.
So, I really have a couple of straight-forward questions for
the authors. What are your primary closure rates stratified by
indication? And, it is a nice technique. But, do you feel that
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Vacuum Pack Technique of Temporary Abdominal Closure

Vol. 48, No. 2

perhaps you might be overusing the technique with respect to

particularly that need for reexploration group? And the third
question would be, have you compared this technique to any
other of the more commonly used techniques in the early
management of the open abdomen? I would like to thank the
Association for the privilege. Thank you.
Dr. Harvey J. Sugerman (Richmond, Virginia): I guess
what I do not see is the advantage of this over just doing what
we do, which is take a nonsticky hydrate polyvinyl sheet and
staple it with a skin stapler to the skin. I am confused as to the
advantage of this vacuum pack. And perhaps it needs to be a
comparative study of some sort.
Dr. John Sherck (San Jose, California): I would like to
commend the authors and Dr. Barker for popularizing and
refining this very excellent technique.
We have used a very similar approach for over 10 years at
our institution and also found it to be reliable, fast, cheap, and
helpful.
Sometimes we have had leak of fluid from around the
sticky-seal, even though we have a drain in place. Have you
had that problem? And how do you deal with it?
Dr. Ronald J. Simon (Bronx, New York): Just two quick
questions. Eleven days with a gauze in the abdomen. We all
know that after 3 or 4 days they get very, very funky. Is it
possible that your longer packs have the higher incidence of
infectious complications?
We just go right to a Vicryl mesh, and you seem to go to
a Vicryl mesh in a delayed fashion. What is your indication
for switching from this vacuum pack to a Vicryl mesh? Thank
you.
Dr. Scott B. Frame (Cincinnati, Ohio): We use this in our
practice. You lose a lot of fluid that gets sucked out during
this. Do you have any feel for how much protein loss there is
and what adverse effects that may have on the patient insofar
as wound healing and overall catabolic response?
Dr. Kimberly K. Nagy (Chicago, Illinois): Frequently, we
use this in patients who are too sick for various reasons and
you cannot close their abdomen. I am wondering, what do
you do in cases when you cannot get the patient back to the
operating room in a timely fashion because of pulmonary or
hemodynamic instability? How long are you willing to leave
this in place?
Dr. Donald E. Barker (closing): I appreciate Dr. Stewarts questions and comments as well as those from the floor.
Dr. Stewart, to answer your first question about stratifying
primary closure rates by indication, I think the more important thing affecting closure rates is not necessarily indication
for open abdomen management, but is the length of time that
the abdominal wound is managed in an open fashion. If a
patient goes over 6 days, the probability of being able to do
a primary fascial closure is markedly reduced. In fact, I think

weve only had one patient at 7 days and one patient at 9 days
that we were able to primarily close.
We frequently question the issue of overuse, because the
technique is so simple to use. And as you saw, not all the patients
that this technique is used in are trauma patients. It is used in a
lot of general surgery patients. It is the sort of thing that caught
on because it was very simple. We actually do attempt to close
the fascia in a lot of our patients, but we do not close under
extreme tension or if we plan reexploration. We hope we do not
overuse this, but I think it is so easy to use that there is a
tendency for that to happen and we need to guard against that.
We have not compared this to other techniques because it
has been so simple for folks to use that they have all adopted
it very readily and use it regularly. But, I think that would be
an interesting thing to do.
Dr. Sugerman, the advantage over just a simple stapled
piece of plastic on the skin, I think, would be that we are able
to control any sort of fluid leaks we have. We feel like this
maintains itself as a sterile barrier for the complete time that
it is in place.
Dr. Sherck, pertaining to fluid leaks and how we repair
those, generally, if you develop a fluid leak or a leak in the
seal, either the grenade that they are connected to will expand
and it is no longer collapsed or you will develop this very
annoying sound and I guarantee you the nurses will let you
know because they cannot stand to hear it. We generally just
take another piece of adhesive-backed plastic and place that
along the edge of the dressing and that generally takes care of
the problem for us.
Dr. Simon, regarding whether our infection rate is increased if we leave the dressings on for a long period of time,
we watch these dressings very, very closely for any signs of
infection. We monitor the fluid and make sure that we are not
really getting anything purulent out of there. We do not like
to leave the dressings on for long periods of time, but in
patients that are hemodynamically unstable, patients that are
still fighting to keep alive, and are still requiring resuscitation
for long periods of time, were forced to leave those dressings
on.
Dr. Frame, regarding protein loss from the wound, it would be
difficult to determine what contribution the vacuum pack suction
and the draining of the peritoneal fluid impacts on protein loss
because a lot of these patients, again, are requiring a lot of fluid;
they are severely injured. And I think the serum protein levels
and albumin levels are depressed anyhow.
Dr. Nagy, if we have to change the vacuum pack, we can
actually change this at the bedside in the patient that is ventilated. We can use a short-acting neuromuscular blocker and add
pain medication to provide them with some anesthetic.
I appreciate the questions. I thank the Association, again,
for the privilege of the floor.

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