Component separation in abdominal trauma
A 51-year-old male received a penetrating stab wound to the abdomen and underwent an immediate emergency laparotomy. Findings at laparotomy were splenic hilar injury, a through-and-through enterotomy of the stomach and transection of the left renal vein. The stomach was repaired, a splenectomy was performed and ligation of the left renal vein was undertaken with temporary clamping of the aorta. The abdomen was packed, and a temporary topical negative pressure closure of the abdomen was undertaken. The patient required 24 units of packed red cells, 20 units of fresh frozen plasma and 4 units of platelets to achieve resuscitation. Twenty-four hours later, the patient was returned to the operating room for a relook laparotomy. The transverse colon had patchy ischaemia, so a damage control resection of the colon was undertaken. Minor bleeding points on the abdominal wall were controlled. The topical negative pressure closure was reapplied. On the fourth postoperative day, a second relook laparotomy was undertaken. The colon was anastomosed. The abdomen was unable to be closed, and the topical negative pressure dressing was reapplied. On the ninth postoperative day, a further attempt was made to close the abdomen but this was not successful. The topical negative pressure closure was reapplied.\nOn the 11th postoperative day, a component separation was performed. The topical negative pressure dressing was removed leaving the defect shown with the anterior sheath retracted away from the midline (see Fig. . The overlying skin was released bilaterally from the abdominal wall, and the anterior rectus sheath was released. To achieve this, the external oblique was incised at Point A, and the incision taken high to the costal margin and as low as possible to allow maximal release. The internal oblique is then exposed (Point B), and the released edge is visible at Point C (see Fig. ).\nA posterior sheath release was then performed to provide medial movement of the sheath, so that it could be closed in the midline (see Fig. . A 25 × 25-cm biologic mesh (Strattice™ Reconstructive Tissue Matrix,–LifeCell Corp.) was rotated to a diamond shape and secured in the pre-peritoneal space, to the lateral fascia (see Fig. . The rectus muscle was closed, and the component separation allowed for the anterior sheath to be closed in the midline (see Fig. . Primary skin closure was undertaken, and the patient returned to the ward.\nOn the 16th postoperative day, he suffered a witnessed ventricular fibrillation cardiac arrest. He was resuscitated and subsequently anticoagulated. The following day a computed tomography scan revealed a large abdominal wall haematoma anterior to the rectus sheath. He returned to theatre on the 17th postoperative day. The fascia was found to be intact, and the haematoma evacuated. Topical negative pressure was reapplied. On the 21st postoperative day, the skin was reclosed. He returned to the ward and was discharged on the 49th postoperative day, following implant of a cardiac defibrillator, with an intact wound (see Fig. ).