A Prospective Randomised Study of Comparative
were inserted in required spaces. In first group, the abdomen was closed en masses or with tension suturing; where as in second group, a strip of sterile polyprolene (Marlex mesh) of wound size was anchored with either rectus sheath or skin with Prolene- 00 as interrupted sutures circumferentially and wound was dressed. In this second group no drains were placed in the peritoneal cavity. After 24 hours a pre-sterile zipper was sutured in the middle of mesh after dividing it in the middle. This zip could be unzipped to inspect the peritoneal cavity and for debridement of necrotic materials, for irrigation of abdominal cavity. As the sign of sepsis abated, the zipper and mesh were removed and the abdomen was closed either en masse or putting tension sutures under general anaesthesia. Post operatively we analyzed the incidence of wound dehiscence, burst abdomen, and death. This study was conducted with the aim to establish whether zipper mesh technique has any
advantages over conventional closure en mass or not, so that a protocol of its management could be devised to minimize the morbidity and mortality.
OBSERVATION
There was a male predominance in both groups with mean age of 33 years in zipper-mesh group as opposed to 36 years in conventional closure group (table-1). In mesh laparostomy and zipper group, 50%
had undergone single surgery, 28.57% had two surgeries, whereas 14.28% had three surgeries and 7.14% had four surgeries. This figure was 64.28% for single surgery, 28.57% had two and 7.14% had three surgeries in conventional group (table-2). Total ten surgeries were performed through the zip, single surgery in 5 patients, twice in one and thrice in one patient.
In conventional group,7(50%) patients had residual abscesses, which was detected either by ultrasonography or on re-exploration of abdomen. Out of seven patients,4 had single,3 had two pocket of collections. The 5 patients were operated and 1 patient was kept on conservative line of management, while one patient died on the day of diagnosis (Table-3).
Table 3. Comparision of Residual Abscesses In Conventional Group
Number of Total Operated Conservative Residual Patients
Abscess
0 7 0 7
1 4 3 1
2 3 2 1
3 0 0 0
In mesh laparostomy and zipper group, as all patients had frequent intra-peritoneal lavages, the incidence of collection was nil. The average hospital stay in mesh laparostomy group was 34 days, as compared to 30 days in conventional group. The incidence of intestinal leak complications in mesh
laparostomy group were high (n=6) as compared to conventional group (n=4), although the rate of burst abdomen and basal atelactasis incidence were higher in conventional group (table-4). One patient in mesh laparostomy group developed DVT, who died later on due to pulmonary embolism.
Table 4.
Complications Mesh Laparostomy Conventional
&Zipper Group Group
Intestinal Leak 6 4
Burst Abdomen 2 5
Residual Abscesses 0 7
Skin Dehisence 4 4
Deep Vein
Thrombosis 1 0
Basal Atelactasis 5 7
The mortality observed in case of mesh laparostomy group was 35.71% as opposed to 50% in conventional group. The majority of the expired patients were with APACHE score more than 20 Table-5. The cause of death in majority of the patients in both groups was multiple organ failure, except one
8 Ashutosh 32-35.pmd 33 8/27/2012, 6:39 PM
patient of mesh laparostomy patient, who died due to deep vein thrombosis and pulmonary embolism.
Table 5. Showing comparison of mortality in relation to APACHE II score
Patient APACHE II Mesh Conventional
Number Score laparostomy Gr. Gr.
1 22 A D
2 27 D D
3 14 A A
4 14 A A
5 25 D D
6 12 A A
7 16 A A
8 22 A D
9 13 D A
10 23 D D
11 29 D D
12 15 A A
13 18 A D
14 14 A A
D=Dead, A-Alive
DISCUSSION:
Despite the advent of powerful parenteral antibiotics, technologically advanced surgical intensive care units, the management of peritonitis is still individual and it depends on several factors like severity of disease, host factors, the amount and type of peritoneal contaminations. Recently, newer approach of temporary closure of abdomen with zipper, slide fasteners and Velcro analogues have tried to facilitate daily exploration, drainage and cleaning of peritoneal cavity. Selection of patients for proper application of the technique is an important factor.
Hedderich et al9 had given more emphasis on extent and severity of intra-abdominal infection as well as age and status of patient, whereas Walsh et al10 and Garcia et al11 had given more emphasis on the APACHE score. High APACHE II score indicate late presentation of the patients and also the advance stage of the disease process. The mean APACHE II score in this present study was 19 points excluding arterial blood gas analysis predicting a mortality of 42%. In case of zipper technique, daily lavage was possible, along with direct visual examination of the peritoneal cavity. Residual abscesses were easily detected during daily lavage through zipper. While in conventional group ultrasound abdomen was required for detection of intra-peritoneal collection and another re-exploration was required to drain the collection. Walsh reported the formation of adhesions even when the abdomen was being lavaged thrice daily. In contrast we have found only filmy adhesions, which were fragile and
broken without significant bleeding. These findings were also encountered by Singh et al12. We had not used drain in mesh laparostomy and zipper technique group. Some authors recommended & reported that these were helpful in removing irrigation fluid during and after lavage(?), but Walsh and Chiasson10 considered the use of drains as redundant.
The average closure of abdominal wall in our study was 8th day; Teichmann et al 13 closed the wound on an average of 12th day. The primary closure of wound was preferred in 79% of cases by Teichmann et al, Whereas Walsh et al allowed the wounds to close by secondary intention. We performed closure in 9 patients in mesh laparostomy with zipper group; out of these 9 patients 5 under went for tension suturing and 4 patients for mass closure. In mass closure 2 developed wound dehiscence and 2 burst abdomen, which was treated by subsequent secondary suturing. The mass closure was performed in 12 patients in conventional group, out of which 6 died postoperatively. Out of 6 alive patient of mass closure, 5 developed burst abdomen and1 skin dehiscence. The skin dehiscence was treated by delayed suturing after the clearance of infection.
Burst abdomen after definitive closure was more in conventional group might be due to abdominal tension present during closure. Basal atelectasis was more in conventional group. We did not encountered spontaneous or traumatic fistulization due to mesh or zipper, used in our study. The patients with mesh laparostomy & zipper technique were kept on both hyper- alimentation or Ryle’s tube feeding or jejunostomy feeding as in conventional treatment, because lavages did not precipitate or unduly prolong the paralytic ileus. In mesh laparostomy & zipper group, patients can be made ambulatory postoperatively earlier as compared to conventional group. The outcome of patients in whom the initial standard surgery associated with first attempt mesh and zipper insertion was better than the patient in whom mesh was used in subsequent surgeries.
CONCLUSION
The mesh was applied to those patients who had gross sepsis, compromised anastomosis, high APACHE II scores or tension at closure. These patients were compared with conventional group where abdomen was closed after exploration, definitive surgery and peritoneal lavage. Comparison was done in patients with same APACHE II scores in both groups. The results were same with conventional and mesh laparostomy group with low APACHE II scores, whereas with high APACHE II scores the result of mesh laparostomy has an edge over the conventional group. Intra-abdominal residual abscesses and secondary pathology could be easily detected on daily
exploration during lavage in mesh laparostomy group, while in conventional group 35.71% patients underwent re-exploration for residual abscesses and secondary pathology, which was detected after a significant time lapse. The mean hospital stay was almost equal in both groups, 34 days in mesh laparostomy as oppose to 30 days in conventional group. We found better survival outcome in mesh laparostomy group. The mortality was 50% in conventional group, whereas it was as low as 35.71%
in mesh laparostomy group.
Since the mesh laparostomy allowed effective continuing drainage of the septic abdomen, better prognosis and almost equal hospital stay; the mesh laparostomy group had some edge over the conventional group. Although this is a very small study to propagate mesh laparostomy as an ideal procedure for abdominal wall closure in case of acute bacterial peritonitis, but there is some scope for its further trials and other re-modalisation of this technique.
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