Successful Salvage of Infected and Exposed Non-absorbable Mesh Following Decompressing Laparostomy after Emergency Repair of Ruptured Abdominal Aortic Aneurysm using Vacuum-assisted Closure System
Article Outline
Infection and skin dehiscence over prosthetic graft materials, especially with methicillin resistant staphylococcus aureus (MRSA), usually requires en-bloc excision to facilitate eradication and skin closure. We report a case of the successful use of a Vacuum-assisted closure system in the management of MRSA infected non-absorbable mesh following decompressing laparostomy after emergency repair of a ruptured abdominal aortic aneurysm.
Keywords: Vacuum-assisted closure (VAC) system, Methicillin-resistant Staphylococcus aureus (MRSA), Abdominal aortic aneurysm (AAA), Mesh, Laparostomy
Introduction
Infection and skin dehiscence over prosthetic graft materials, especially with methicillin-resistant staphylococcus aureus (MRSA), requires usually en-bloc excision to facilitate eradication and skin closure. Vacuum-assisted closure (VAC) has proved very effective in complex wound closure. We report a case of successful management of infected prosthetic mesh with MRSA following decompressing laparostomy after emergency repair of abdominal aortic aneurysm (AAA) using VAC therapy.
Case Report
A 60 year old male presented with a ruptured 10
cm infrarenal aortic aneurysm and proceeded to laparotomy and repair using a straight dacron graft. On day two post-operatively on the intensive care unit he was requiring increasing levels of respiratory and inotropic support, with deteriorating renal function. The abdomen was significantly distended and abdominal compartment syndrome was suspected. The intra-abdominal pressure was measured at greater than 20cm H20. He returned to theatre for a decompressive laparostomy. A polypropylene (MARLEX) mesh was sutured to the external oblique aponeurosis and the skin left open covered with packs. Following decompression his cardio-respiratory and renal function improved. One week later he underwent closure of the anterior abdominal skin defect over the mesh by undermining the skin edges and direct closure over 3 drains.
Despite marked improvements in the general status the wound edges showed signs of inflammation followed by necrosis along with wound dehiscence and exposure of the mesh (Fig. 1). Repeated swab from the wound and the exposed mesh cultured MRSA. He was treated with intravenous vancomycin, wound debridement and application of the VAC system for 36 days. At this point only a small clean granulating skin defect remained (Fig. 2). A further culture swab from the defect was negative for MRSA. At 1 month the skin over the anterior abdominal wall was completely healed with no evidence of residual infection. At 2 year follow-up this year he had no problems in relation to the abdominal wound, deep seated prosthetic mesh or the aortic graft.
Fig. 1
Dehiscence with visible mesh in base.
Fig. 2
Complete closure after VAC therapy.
Discussion
Abdominal compartment syndrome (ACS) is an increasingly recognized entity, especially following ruptured aortic aneurysm repair. The definitive treatment of ACS is abdominal decompression and laparostomy. The resultant defect in the anterior abdominal wall following decompressive surgery can prove difficult to reconstruct. A variety of techniques of temporary abdominal wall closure have been described in the literature. A recognized method is to suture mesh to the fascial edges as carried out in this case. In the original sandwich technique,1 a polypropylene mesh (Marlex [Registered]) was sutured to the surrounding fascia and the wound covered by an adhesive polyurethane drape wound dressing with interposition suction tubes for drainage.
The use of prosthetic material increases the risk of infection, especially in a critically ill patient in an intensive care setting. Following attempt at closure of the skin defect over the mesh to prevent infection a week later, it became complicated with MRSA infection with exposure of mesh and sinus tract formation. This increases the risk of spread of infection to the underlying aortic graft which would be catastrophic to the patient. In a few cases, systemic antibiotics with frequent wound irrigation will solve the problem. In others, however, extended wound debridement and removal of prosthetic material will be necessary.2
To salvage the exposed MRSA – infected mesh laparostomy wound, we tried the use of the Vacuum – assisted closure (VAC) system (KCI Medical, Witney, Oxfordshire, UK) with successful healing of the wound. The VAC system has been used for complex acute and chronic wounds.3 It has also been used on four patients with abdominal wound dehiscence and prosthetic mesh exposure following incisional hernia surgery.4
The VAC system is thought to work by several different mechanisms. Vacuum suction results in the active removal of excess interstitial fluids, increases local tissue perfusion and improving supply of oxygen and nutrients for tissue repair. The increased blood flow speeds up granulation tissue formation by 63% over non – VAC treated wounds.5 Mechanical stress may also play a part by increasing cellular proliferation ad angiogenesis.5 The VAC also leads to reduced bacterial colonization by 1000-fold compared with non-negative pressure exposed wounds after four days of treatment.5
In conclusion, this case report describes the successful treatment of infected and exposed non-absorbable mesh following decompressing laparostomy after emergency AAA resection using VAC system.
References
- . The ‘sandwich technique’ in the management of the open abdomen. Br J Surg. 1986;73:369–370
- . Pathophysiology, prevention, and management of prosthetic infections in hernia surgery. Surg Clin North Am. 1998;78:1105
- . Vacuum assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563–576
- . Vacuum-assisted closure for abdominal wound dehiscence with prosthesis exposure in hernia surgery. Plast Reconstr Surg. 2003;112:1188–1189
- . Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc. 1997;6:284–286
PII: S1533-3167(07)00034-9
doi:10.1016/j.ejvsextra.2007.08.004
© 2007 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Successful Salvage of Infected and Exposed Non-absorbable Mesh Following Decompressing Laparostomy after Emergency Repair of Ruptured Abdominal Aortic Aneurysm using Vacuum-assisted Closure System , 10 December 2007
