38 Optimising infected evisceration with NPWTi and mesh mediate closure—a hernia should no longer be accepted as reasonable result

Abstract Background The infected open surgical abdomen can pose a considerable challenge and often requires multiple stage operations with a combination of temporary and definitive closure techniques with the aim to prevent long-term morbidity caused by the loss of abdominal domain. There is a great range of options of techniques for both temporary abdominal closure commonly the Bogota bag, vacuum-assisted closure (VAC) and similarly with definitive reconstruction such as the use of mesh and components separation. In our case we aimed to demonstrate the use of a novel, modern approach to the closure of a complex infected abdominal wall dehiscence using a negative pressure Negative Pressure Wound Therapy With Instillation (NPWTi ) in association with Abthera@ system. Case Report A 50 year-old presented with a gangrenous caecal volvulus on the background of severe sarcopenia and hypoalbuminaemia. The patient underwent an emergency right hemicolectomy with an end ileostomy. The abdominal wound became infected and also developed large bilateral flank collections with positive yeast and vancomycin-resistant enterococcus which resulted in a day 8 wound dehiscence managed with laparostomy and negative pressure (Abthera). On the third operation the peritonitis and sepsis had improved, ergo the open abdomen and loss of domain was thus managed with mesh mediated traction with NPWTi (negative pressure wound therapy with installation) to aid removal of contamination, closure and granulation of mesh whilst protecting from mesh infection. In the 4th intervention, the mesh was trimmed and tightened for gradual closure. On the subsequent washouts the midline reached the point of easy closure with minimal tension. The closure was obtained by suturing both mesh and midline with 2-0 poliproleme. The mesh became intimately attached to aponeurosis and rectus muscle with subsequent granulation tissue allowing skin was closed with NPWT. Educational Highlights Normal polipropelene was successfully used for closure of infected wound dehiscence.Severely sarcopenic patient had a successful closure and no hernia was found on 1.5 years follow-up so far. Conclusions Usually an infected evisceration is seen as such difficult complication that leaving the abdomen open to heal by second intention and treat the hernia after several months is usually an accepted measure worldwide, but most of the times the hernia became a chronic disease with several recurrences and complex operations. The use of negative pressure with instillation can be seen to improve healing time, removal of contamination and reduce the potential risk of developing incisional hernia. Although an initial short follow up, it is expect with this technique that hernia formation should be avoided.