ORIGINAL ARTICLE

Comparative study of open abdomen treatment: ABTheraTM

vs. abdominal dressingTM

C. Olona • A. Caro • E. Duque • F. Moreno •

J. Vadillo • J. C. Rueda • V. Vicente

Received: 30 July 2013 / Accepted: 10 April 2014 / Published online: 23 April 2014

� Springer-Verlag France 2014

Abstract

Introduction Negative pressure therapy (NPT) is a widely

recognised procedure for the temporary closure of open

abdominal wounds. In this study, we compare two NPT

products, the V.A.C.� abdominal dressing (AD) system

and the new ABTheraTM (ABT) system, in terms of the

primary closure rates achieved, types of closure, and the

associated morbidity.

Methods We employed a retrospective comparative study

of open-abdomen patients treated with NPT using either

AD or ABT. The indications for treatment were damage

control surgery, abdominal compartment syndrome, or

severe abdominal sepsis.

Results The group of patients treated with ABT showed a

higher percentage of primary closures (41 vs. 11 %) and

required fewer days of NPT (17 vs. 26 days) than the AD

group. Differences were statistically significant. In addi-

tion, only 4 % of patients in the ABT group exhibited

enteroatmospheric fistulae, compared to 17 % in the AD

group.

Conclusions Compared to the AD system, ABT can

achieve faster primary closure after open abdomen treat-

ment with only minor complications.

Keywords Negative pressure therapy � Open abdomen �Abdominal closure

Introduction

The open abdomen (OA) technique is a practice that has

spread rapidly over the last 20 years and can now be

indicated with greater accuracy. Current indications are

based on three principal settings: treatment of abdominal

compartment syndrome, damage control surgery for poly-

trauma with abdominal injury, and treatment of abdominal

sepsis [1].

Open abdomen procedures are challenging for surgeons,

and many different techniques are described for abdominal

closure. These procedures must achieve several goals,

including haemostasis, reduction of abdominal pressure,

reduction of visceral oedema, protection of abdominal

contents, minimisation of respiratory pressure, mainte-

nance of tissue perfusion, and prevention of fascial

retraction to allow successful midline closure. Negative

pressure systems have been found to be one of the most

successful options for achieving these goals [2] and

reducing the associated morbidity [3].

Our department has performed NPT using the V.A.C.�abdominal dressing system (KCI, San Antonio, USA) since

2006 [4] and the new ABTheraTM system (KCI, San

Antonio, USA) since 2011. Both techniques utilise poly-

urethane foam and continuous suction to manage the OA.

The new ABThera system has a different inner layer design

consisting of a polyurethane film-covered central foam

structure with six arms that can provide more uniform

levels of negative pressure throughout the abdomen, par-

ticularly at the level of the paracolic gutters and Douglas’

space, and that evacuate more fluid than the V.A.C.�system during in-vitro testing [5].

C. Olona (&) � A. Caro � E. Duque � F. Moreno � J. Vadillo �J. C. Rueda � V. Vicente

Digestive and General Surgery Department, University Hospital

Joan XXIII Tarragona, 4th Dr. Mallafre Guasch St. 3th floor,

43007 Tarragona, Spain

e-mail: drcarlesolona@gmail.com

123

Hernia (2015) 19:323–328

DOI 10.1007/s10029-014-1253-5

Objectives

The main aim of this study was to analyse the time to

closure of the abdominal wall with the use of each system.

The secondary aims were to examine the type of closure

achieved and the complications and fistulae observed.

Materials and methods

A retrospective comparative study of patients treated with

open abdomen NPT between January 2006 and January

2013 was conducted at the general and digestive surgery

unit of a University Hospital Joan XXIII of Tarragona.

The decision to proceed with an open abdomen was

taken at the discretion of the surgeon, according to the

presence of coagulopathy, hypothermia, and acidosis in

patients with abdominal haemorrhage, intestinal ischemia,

severe peritonitis, hemodynamic instability, or abdominal

compartment syndrome.

The devices used to apply NPT in this study were the

V.A.C.� abdominal dressing (AD) system and ABTheraTM

(ABT) system, both developed by KCI, San Antonio, USA.

The abdominal dressing system (Fig. 1) consists of a first

micro-perforated silicone inner layer with an internal

sponge, designed to be placed in direct contact with the

viscera. A macroporous foam dressing is placed in contact

with the abdominal wall and subcutaneous tissue and

covered with an occlusive adhesive sheet attached to the

tubing that connects to the vacuum unit. The new AB-

TheraTM system comprises the same elements, but with an

inner layer that covers the entire abdominal viscera and an

inner sponge with a radial form that extends to the edges of

the sheet to facilitate the extraction of peritoneal fluids and

more uniform application of negative pressure (Fig. 2).

The devices were applied as described in previous

studies [6]. The abdominal cavity was washed with saline

solution and the perforated non-adhesive sheet applied

beneath the anterior abdominal wall, covering the entire

abdominal viscera. Next, one or two pieces of polyurethane

foam dressing were applied, depending on the thickness of

the abdominal wall, and adjusted to the open wound edges.

The dressing was sealed with the adhesive sheets and an

opening of 2–3 cm was made for the TRACpad, which is

connected to the pump that applies negative pressure to the

wound. An initial pressure of 125 mmHg was applied.

If an intestinal resection is carried out, the anastomosis

is protected among the intestinal loops, away from the

polyurethane film, in order to prevent the appearance of

enterocutaneous fistulas. If intestinal fistulae occur while

using NPT, they can be excluded by applying a V.A.C.�WhiteFoam dressing [6] or by using baby bottle nipples

and soft drainage tubes to isolate the fistula [3]. Addi-

tionally, the intensity and continuity of the negative pres-

sure applied to the wound is reduced (-50 mmHg

intermittently).

Fig. 1 V.A.C.� abdominal dressing (AD) system Fig. 2 ABTheraTM (ABT) system inner layer

324 Hernia (2015) 19:323–328

123

Dressings were changed every 48–72 h in the operating

room and afterwards in the ICU once the patient’s condi-

tion improved.

Closure was performed once the causes of the instability

had been corrected. Where possible, primary closure was

performed 7–10 days after surgery. In those cases where

extended NPT was required, closure was performed by

Chevrel’s technique [7] or by two-sided component sepa-

ration if the muscle margins were widely separated. Both

techniques employed a light polypropylene prosthesis in

the onlay position. If the therapy was too prolonged and led

to a frozen abdomen, a secondary closure was carried out

in which definitive closure was deferred for 9–12 months

and the abdomen was closed with a ventral hernia repair.

To facilitate the analysis, diagnoses were classified into

four principal categories: peritonitis, mesenteric ischemia,

abdominal compartment syndrome, and visceral trauma.

We analysed the characteristics of the patients in each

treatment group, the treatment duration, the number of

changes, the type of definitive closure performed, the

complications observed, and the associated mortality.

Categorical variables were described as absolute (N) and

relative frequencies (%), and quantitative variables as

mean and standard deviation. Percentage differences

between ABT and AD were calculated using the two-pro-

portion z test. Age and days of treatment were compared

between groups using the one-sample t test. Statistical

significance was set at p \ 0.05. The statistical analysis

was carried out using the SPSS 17.0 software.

Results

Between 2006 and 2012, a total of 73 patients with open

abdomens were treated with NPT. Abdominal dressing

(AD) was used until 2010, and then ABThera has been

used from 2011 to the present. Of these, 27 (37 %) were

treated with ABT and 46 (63 %) with AD (Fig. 3), with no

differences in age or sex between the two groups (Table 1).

The diagnoses leading to treatment with NPT were 38

cases of severe peritonitis, 10 cases of mesenteric ischemia,

14 cases of ACS, and five cases of polytrauma with

abdominal injury, with no differences between groups

(Table 1). The group treated with AD also contained three

patients with acute pancreatitis and three patients under-

going post-operative care for abdominal aortic aneurysm;

these were excluded from the analysis in order to maintain

the uniformity of the groups.

Intestinal resection and anastomosis were studied to

determine if there is any relationship between intestinal

resection and fistula formation. Intestinal resection was

carried out in 41 patients (56 %), 22 in the AD group and

19 in the ABT group, with intestinal anastomosis in 23

cases (13 in the AD group and 10 in the ABT group), and

ostomy in 18 cases (nine in each group), with no differ-

ences between groups.

The average time to abdominal closure was 26 days in

the AD group and 17 days in the ABT group, and differ-

ences were statistically significant (Table 2); the mean

Total Patientsn= 73

Abdominal Dressingn=46

ABTheran= 27

Lost follow-up

Exitus n=15MOF n=10Sepsis n=4Myocardial Infarction= 1

Lost follow-up

Exitus n=4

MOF n=2Sepsis n=2

Analyzed n=40

Excluded from analysisn=6

Pancreatitis n=3Aortic Aneurysm n=3

Analyzed n=27

Excluded from analysisn=0

REGISTRY

ALLOCATION

FOLLOW-UP

ANALYSIS

Fig. 3 Allocation and follow-up of patients flow diagram CONSORT

(Consolidated Standards of Supporting Trials)

Table 1 Age, sex, and diagnosis leading to treatment with NPT

Characteristic ABD

dressing

(n = 46)

ABThera

(n = 27)

p

Sex

Male 13 (28.2 %) 9 (33.3 %) 0.964

Female 33 (71.7 %) 18

(66.6 %)

0.964

Age mean (sd) 63 (12.3) 64.1 (15.5) 0.716

Diagnosis

Peritonitis 22 (47.8 %) 16

(59.2 %)

0.925

Mesenteric ischemia 6 (13 %) 4 (14.8 %) 0.742

Abdominal compartment

syndrome

9 (19.5 %) 5 (18.5 %) 0.931

Polytrauma 3 (6.5 %) 2 (7.4 %) 0.646

Pancreatitis 3 (6.5 %)

AAA 3 (6.5 %)

Hernia (2015) 19:323–328 325

123

number of dressing changes was eight in the AD group and

five in the ABT group.

Primary fascial closure of the abdominal wall was per-

formed in five (11 %) patients treated with AD and 11

(41 %) patients treated with ABT, whereas secondary

closure was performed in 19 (48 %) of the AD group and

six (22 %) of the ABT group. These differences were also

statistically significant (Table 2).

No complications related to NPT or minor complica-

tions classified as Clavien grade I–II [8] were observed in

17 of the patients treated with AD (42 %) and 22 patients

of the patients treated with ABT (81 %). Fistulae, classified

as Clavien grade III, were observed in eight patients (20 %)

in the AD group and only one patient (4 %) in the ABT

group. Differences were not statistically significant. Multi-

organ failure, classified as Clavien grade IV, occurred in

two patients in the ABT group and ten in the AD group,

although this was related to the general conditions of the

patient and not directly to the application of NPT.

No deaths occurred as a direct result of NPT, but during

follow-up, 15 patients (33 %) in the AD group and four

patients (15 %) in the ABT group died due to the wors-

ening of the underlying condition.

Discussion

Open abdomen technique is a practice that has spread

rapidly over the last 20 years, leading to a reduction in the

initial mortality rate [9] in damage control surgery for

polytrauma and ACS. In recent years, particularly in Eur-

ope, the technique has also been applied in the treatment of

severe abdominal sepsis in the context of damage control

surgery [10]. There are various techniques for the tempo-

rary closure of the open abdomen, including the Bogota

bag, the sandwich technique, and zipper systems, among

others. Systematic reviews have identified the Wittmann

patch and NPT as the techniques that achieve the highest

fascial closure rates [11] and lowest mortality [12]. NPT is

a non-suture closure method that prevents mechanical

damage to the abdominal tissue, leaving surfaces intact for

more effective closure. It also stabilises the abdominal

wall, improves patients’ respiratory function, allows for

quantification and drainage of fluids, and reduces con-

tamination by creating an interface between the abdominal

cavity and the exterior. The negative pressure applied to

the foam dressing transmits mechanical forces uniformly to

the wound edges and prevents fascial retraction [13].

In this study, we compared AD—the first method for the

treatment of open abdomen with NPT, applied in our

hospital from 2006 to 2010—to the new ABTheraTM sys-

tem, designed by the same firm and currently applied in our

centre. The main different between the two systems is that

ABTheraTM uses a radial sponge configuration covered by

the protective sheet applied to the viscera. This allows for

better evacuation of peritoneal fluid and stabilises wound

contraction, as described in a recent experimental study

[14].

These outcomes were confirmed in our study by the

observation of a significant increase in primary closures

(reaching 40 %) and a reduction in treatment time. How-

ever, we believe that the improvement is due not only to

the greater control of the wound that the new devices

provides, but also to the experience that we have acquired

in the treatment of open abdomen patients. We would

stress, like many other authors, that it is particularly

important to close the abdominal wall in the first 7–10 days

of treatment [15]. By avoiding unnecessary delay, we

prevent the emergence of complications in the wound, the

intestine, and the patient’s general condition, and improve

patient recovery, as has been observed by Ioannis et al [16].

In our unit, primary fascial closure is only considered in

those cases where the procedure can be performed without

placing tension on the wound edges and without increasing

intra-abdominal pressure. When these conditions cannot be

met, abdominal wall reconstruction using component sep-

aration or the Chevrel technique is preferred along with

permanent light-weight onlay polypropylene mesh repair

[6]. The definitive closure will have a better chance of

success if the patient and the abdominal wall are in optimal

condition. The NPT applied by the ABT system can reduce

oedema and inflammation of the abdominal wall, and its

contents may make it possible to carry out all the standard

surgical options. In cases where fascial closure was not

possible, vacuum-assisted NPT was used to achieve

delayed closure in 48 % of patients in the AD group and

22 % of patients in the ABT group, allowing a hernia to be

created for subsequent ventral hernia repair and definitive

closure nine months of more after completion of NPT. The

longer a patient waits, the further the fascia separates, and

the more the bowel agglutinates to the abdominal wall

(thus preventing re-approximation of the fascia), and

Table 2 Days to closure and techniques for abdominal wall closure

ABD dressing(n = 40)

ABThera(n = 27)

p

Days to abdominalclosure mean (range)

26 (6–92) 17.3 (2–80) 0.026*

Abdominal wall closure

Primary fascial closure 5 (12.5 %) 11 (40.7 %) 0.007*

Chevrel onlay technique 16 (40 %) 2 (7.4 %) 0.005*

Component separationtechnique

0 (0 %) 8 (29.6 %) 0.001*

Secondary closure 19 (47.5 %) 6 (22.2 %) 0.055

Asterisks indicate statistically significant values

326 Hernia (2015) 19:323–328

123

therefore, the less chance there is of carrying out a com-

ponent separation. Consequently, there was greater use of

the Chevrel onlay technique. Other techniques used for

progressive fascial closure have been published, including

a combination of NPT with a temporary mesh, tightened

every few days until the fascial defect is under control,

when the mesh is removed and the fascia is closed pri-

marily [17]. Another recently described technique is pro-

gressive closure using a dynamic fascial suture [18].

One of the most common complications of open

abdomen, and perhaps that of greatest concern to sur-

geons, is the appearance of enteroatmospheric fistulae, as

they add to the difficulty of the procedure and lengthen

treatment time [19]. One of the key improvements

obtained with ABT is the reduction in the appearance of

enteroatmospheric fistulae, which were observed in only

one patient (4 %) compared with 20 % in the AD group.

This is particularly notable given that 19 patients under-

went some form of intestinal resection and 10 underwent

intestinal anastomosis during NPT, and the patient who

presented with a fistula in the ABT group did not have

intestinal anastomosis. The almost complete absence of

fistulae in the ABTheraTM group could be associated with

the improved distribution of negative pressure by the

dressing and that fact that it is not applied directly to

exposed bowel loops, as is shown by Bjarnason [20] in

the analysis of the pressure distributions applied by AB-

TheraTM on the open abdomen. The risk of enterocuta-

neous fistulae has been associated with the friction and

dryness of the intestine, and comorbidities in the patient

such as mesenteric ischemia, infections and MOF; how-

ever, in cases requiring intestinal anastomosis, the anas-

tomotic line was kept as far as possible from the plastic

sheet of the dressing to prevent the NPT from encourag-

ing the appearance of these fistulae.

The limitations of this study include its retrospective

non-randomised design and the different use of either

technique by year of study. This difference in the appli-

cation time of each treatment may influence the results

because we have been gaining experience and knowledge

of the biodynamics of the abdominal wall. Although the

complexity and severity of the cases considered would

make it difficult to include patients in a randomised trial,

the groups were comparable in terms of patient type,

diagnosis, and surgery type. We have excluded from the

analysis those patients with pancreatitis and aortic aneu-

rysm in the AD group who were not included in ABT

group. An additional limitation is the small number of

patients included in the study, which, as in similar publi-

cations, is due to the fact that the treatment in question is

only required in severe cases with highly specific charac-

teristics such as abdominal sepsis, ACS, or indications for

damage control surgery.

By achieving higher primary closure rates, NPT with

ABTheraTM reduces the need for abdominal wall recon-

struction and may improve patient recovery and reduce

overall costs.

Acknowledgments We are grateful to the all members of the

General and Digestive Surgery Department for their collaboration, to

the Statistical Service of the IISPV for the statistical analysis, and to

the language service of the Rovira i Virgili University for translating

our original text. This study has not received any form of funding and

the authors of this article do not have any commercial interest.

Conflict of interest C.O. declares no conflict of interest. A.C.

declares no conflict of interest. E.D. declares no conflict of interest.

F.M. declares no conflict of interest. JC. R. declares no conflict of

interest. J.V. declares no conflict of interest. V.V. declares no conflict

of interest.

References

1. Mac Lean AA, O’Keeffe T, Augnestien J (2008) Management

strategies for the open abdomen: survey of the American Asso-

ciation for the Surgery of Trauma Membership. Acta Chir Bel

108:212–218

2. Cheatham JL, Safcsak K (2010) Is the evolving management of

intra-abdominal hypertension and abdominal compartment syn-

drome improving survival? Crit Care Med 38:402–407

3. Regner JL, Kobayashi L, Coimbra R (2012) Surgical strategies

for management of the open abdomen. World J Surg 36:497–510

4. Carlson GL, Patrick H, Amin AI, McPherson G, MacLennan G,

Afolabi E, Mowatt G, Campbell B (2013) Management of the

open abdomen: a national study of clinical outcome and safety of

negative pressure wound therapy. Ann Surg 257:1154–1159

5. Cheatham M, Demetriades D, Fabian T, Kaplan M, Miles W,

Schreiber M, Holcomb J, Bochicchio G, Sarani B, Rotondo M

(2013) Prospective study examining clinical outcomes associated

with a negative pressure wound therapy system and Barker vac-

uum packing technique. World J Surg 37:2018–2030

6. Caro A, Olona C, Jimenez A, Vadillo J, Feliu F, Vicente V (2001)

Treatment of the open abdomen with topical negative pressure

therapy: a retrospective study of 46 cases. Int Wound J 8:274–279

7. Licheri S, Erdas E, Pisano G, Garau A, Ghinami E, Pomata M

(2008) Chevrel technique for midline incisional hernia: still an

effective procedure. Hernia 12:121–126

8. De Oliveira ML, Winter JM, Schafer M, Cunningham SC,

Cameron JL, Yeo CJ (2006) Assessment of complications after

pancreatic surgery: a novel grading system applied to 633

patients undergoing pancreaticoduodenectomy. Ann Surg

2446:931–937

9. Navsaria P, Nicol A, Hudson D, Cockwill J, Smith J (2013)

Negative pressure wound therapy management of the ‘‘open

abdomen’’ following trauma: a prospective study and systematic

review. World J Emerg Surg 8:4–8

10. Biondo S (2012) Damage control surgery in non-traumatic

abdominal emergencies. Cir Esp 90:345–347

11. Boele P, Wind J, Dijkgraaf MG, Busch OE, Goslings JC (2009)

Temporary closure of the open abdomen: a systematic review on

delayed primary fascial closure in patients with an open abdo-

men. World J Surg 33:199–207

12. Cheatham ML, Malbrain MLNG, Kirkpatrick A, Sugrue M, Parr

M, De Waele J, Balogh Z, Leppaniemi A, Olivera C, Ivatury R,

D’Amours S, Wendon J, Hillman K, Wilmer A (2007) Results

from the international conference of experts on intra-abdominal

Hernia (2015) 19:323–328 327

123

hypertension and abdominal compartment syndrome II. Recomm

Intensiv Care Med 33:951–962

13. Barker DE, Kaufman HJ, Smith LA (2000) Vacuum pack tech-

nique of temporary abdominal closure: a 7-year experience with

112 patients. J Trauma 48:201–207

14. Lindstedt S, Malmsjo M, Hlebowicz J, Ingemansson R (2013)

Comparative study of the microvascular blood flow in the

intestinal wall, wound contraction and fluid evacuation during

negative pressure wound therapy in laparostomy using he VAC

abdominal dressing and the ABThera open abdomen negative

pressure therapy system. Int Wound J. doi:10.1111/iwj.12056

15. Perez D, Wildi S, Demaritnes N (2007) Prospective evaluation of

vacuum-assisted closure in abdominal compartment syndrome

and severe abdominal sepsis. J Am Coll Surg 205:586–592

16. Pliakos Ioannis, Papavramidis T, Michalopoulos N, Deligiannidis

N, Kesisoglou I, Sapalidis K, Papavramidis S (2012) The value of

vacuum-assisted closure in septic patients treated with laparos-

tomy. Am Surg 78:957–961

17. Petersson U, Acosta S, Byorck M (2007) Vacuum-assisted wound

closure and mesh-mediated fascial traction—a novel technique

for late closure of the open abdomen. World J Surg

31:2133–2137

18. Fortelny RH, Hofmann A, Gruber-Blum S, Petter-Puchner AH,

Glaser K (2013) Delayed closure of open abdomen in septic

patients is facilitated by combined negative pressure wound

therapy and dynamic fascial suture. Surg Endosc. doi:10.1007/

s00464-013-3251-6

19. Rao M, Burke D, Finan PJ, Sagar PM (2007) The use of vacuum-

assisted closure of abdominal wounds: a word of caution. Colo-

rectal Dis 9:266–268

20. Bjarnason T, Montgomery A, Hlebowicz J, Lindstedt S, Peterson

U (2011) Pressure at the bowel surface during topical negative

pressure therapy of the open abdomen: an experimental study in a

Porcine model. World J Surg 35:917–923

328 Hernia (2015) 19:323–328

123