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Significance: The laparotomy is a common surgical procedure with a wide range of indications. Ideally, once the goals of surgery were achieved, the incision edges could then be approximated and the abdomen primarily closed. However, in some circumstances, it may be impossible to achieve primary closure, and instead the abdomen is intentionally left open. This review discusses the indications and objectives for the open abdomen (OA), summarizes the most common techniques for temporary abdominal closure, and illustrates treatment algorithms grounded in the current recommendations from specialty experts. Recent Advances: Still a relatively young technique, multiple strategies, and technologies have emerged to manage the OA. So too have the recommendations evolved, based on updated classifications that take wound characteristics into account. Recent studies have also brought greater clarity on recommendations for managing infection and malnutrition to support improved clinical outcomes. Critical Issues: The status of the OA can change rapidly depending on the patient's condition, the wound quality, and many other factors. Thus, there is a significant need for comprehensive treatment strategies that can be adapted to these developing circumstances. Future Directions: Treatment recommendations should be continuously updated as new technologies are introduced and old techniques fall out of use.

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ABSTRACT Purpose: We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues. Methods: Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined. Results: There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential. Conclusions: The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

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ABSTRACT Introduction: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. Methods: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. Results: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. Conclusion: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

RESUMO Introdução: onfalocele gigante (OG) é uma condição complexa para a qual muitas alternativas terapêuticas foram desenvolvidas; no entanto, não há consenso sobre qual o melhor tratamento. Os benefícios e eficácia da toxina botulínica A (TBA) no reparo de grandes defeitos da parede abdominal em adultos foram comprovados, e o relato de uso em crianças cresceu recentemente. O objetivo deste estudo é descrever uma nova técnica para reparo primário de OG utilizando TBA durante o período neonatal e relatar nossa experiência inicial. Métodos: os pacientes foram acompanhados de agosto de 2020 a julho de 2022. A TBA foi aplicada na parede abdominal lateral nos primeiros dias de vida, seguida de correção cirúrgica do defeito abdominal. Resultados: enquanto aguardavam a cirurgia, os pacientes tiveram mínima manipulação, sem ser exigida ventilação mecânica, permaneceram em alimentação enteral plena e mantiveram contato com os pais. A linha média foi aproximada sem tensão e sem necessidade de técnicas adicionais ou uso de prótese. Os pacientes receberam alta com o defeito reparado. Conclusão: essa abordagem representa um meio-termo entre o reparo estagiado e o tratamento não-operatório. Não requer intervenções agressivas no início da vida, permitindo a manutenção do vínculo materno-infantil e a alta do paciente com defeito reparado sem a necessidade de uso de técnicas adicionais ou prótese. Acreditamos que esta técnica deva ser considerada como um novo possível recurso no manejo desta complexa condição.

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Background: Abdominal trauma is one of the leading causes of death. In Colombia, few studies have evaluated the results on related factors and outcomes when comparing laparotomy versus laparoscopy in the management of penetrating abdominal trauma. Therefore, the aim of this study was to investigate the feasibility and safety of laparoscopy in the treatment of stable penetrating abdominal trauma in a limited resources environment in a middle-income country. Methods: Retrospective cross-sectional study was conducted in Bogota, Colombia from January 2018 to October 2020. Patients over 18 years old, hemodynamically stable with penetrating abdominal trauma without other body parts injuries, that underwent laparoscopy and/or laparotomy surgical exploration and treatment were included. Frequencies, percentages, correlations, and odds ratio were calculated. Results: A total of 52 patients were analyzed (26 laparoscopy vs. 26 laparotomy). Stabbing injuries were more frequent in both groups (76.9%), as well as involvement of the anterior abdomen. None missed enterotomies were reported in the laparoscopy group. Surgical time and bleeding were significantly lower in the laparoscopic approach group (63 vs. 115 min and 65 vs. 992 cc, respectively). The time to oral intake and length of stay in the intensive care unit was significantly shorter in the laparoscopic management group (2 vs. 3 days and 1 vs. 4 days, respectively). Conclusions: Surgical results found a safe scenario in a limited resources environment for the application of the laparoscopic technique to approach penetrating abdominal trauma in stable patients without missed injuries, low threshold of conversion to open approach, and additionally not presenting a higher percentage of complications compared with the laparotomy group in Colombia. Operative time, oral intake, and length of hospital stay were lower in the fully therapeutic laparoscopy group.

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RESUMEN Las lesiones por arma blanca en la región toracoabdominal tienen la posibilidad potencial de dañar dos cavidades anatómicas: tórax y abdomen, con la subsiguiente lesión del músculo diafragma y la producción de una hernia de contenido visceral, asociada o no a lesión visceral. En caso de que esta entidad clínica sea pasada por alto, existe una alta probabilidad de complicaciones que ponen en riesgo la vida; por tanto, realizar un manejo adecuado constituye un reto para el cirujano general, que precisa de un alto índice de sospecha para formular el diagnóstico. Se presentan tres casos de víctimas de agresión con arma perforo-cortante en región toracoabdominal izquierda, atendidos en instalaciones donde se disponía de limitados recursos diagnósticos. Se exponen datos clínicos, pruebas de apoyo al diagnóstico, procedimiento quirúrgico, curso posoperatorio y evolución. El abordaje quirúrgico abdominal es la regla de oro para reparar el diafragma lesionado, y la pleurostomía mínima es eficaz cuando existe compromiso torácico.

ABSTRACT Injuries caused by white arms in the thoraco-abdominal region have the potential to damage both anatomical cavities: thorax and abdomen, with the subsequent injury of the diaphragm muscle and the production of a visceral hernia, associated or not with visceral injury. In case this clinical entity is overlooked, there is a high probability of life-threatening complications; therefore, adequate management is a challenge for the general surgeon, who needs a high index of suspicion to formulate the diagnosis. Three cases of victims of assault with a perforating-cutting weapon in the left thoraco-abdominal region are presented, attended in facilities where limited diagnostic resources were available. Clinical data, diagnostic support tests, surgical procedure, postoperative course and progress are explained. The abdominal surgical approach is the gold rule for repairing the injured diaphragm, and the minimal thoracostomy is effective when there is thoracic involvement.

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Resumen Se presenta el caso de un paciente masculino de 27 años de edad, con abdomen abierto, diagnóstico de sepsis abdominal severa y falla multiorgánica asociada a una pancreatitis aguda recurrente. Con presencia de dolor abdominal agudo, distensión abdominal, obesidad, taquipnea, xantomas en piel, signos de secuestro de líquidos. Triglicéridos 3450 mg/dL, amilasa 1212 U/L. Tomografía abdominal mostró proceso inflamatorio pancreático con índice de severidad estadio E (4 puntos), necrosis y derrames laminares en páncreas. Se realizó manejo en Unidad de Cuidados Intensivos Adulto. Se realizó laparotomía exploratoria y descomprensión abdominal por síndrome compartimental con el fin de efectuar lavado peritoneal terapéutico y necrosectomía. Se colocó bolsa de Bogotá durante el manejo. Por aplicación de criterios, se inició cierre por segunda intención con utilización del método de curación avanzada con productos de alta tecnología, un tratamiento complejo que mostró un resultado favorable en la recuperación del paciente.

Abstract A 27-year-old male is presented with a complex open abdominal wound, diagnosis of severe abdominal sepsis and multisystem organ failure associated to recurrent acute pancreatitis. Other signs and symptoms were acute abdominal pain and distension, obesity, tachypnea, xanthomas and signs of fluid sequestration. Triglycerides 3450mg / dL, amylase 1212 U / L were some lab results. Abdominal tomography showed a pancreatic inflammatory process with severity index E (4 points), necrosis and laminar effusions in the pancreas. Management in the Adult Intensive Care Unit (ICU) was necessary. Exploratory laparotomy and abdominal decompression were performed due to compartment syndrome, in order to do therapeutic peritoneal lavage and necrosectomy . A Bogota bag was installed during management. Using criteria, the surgical wound closure was initiated by secondary intention using advanced wound care treatment. It showed favorable results in patient recovery.

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OBJECTIVE: To evaluate the outcome of abdominal wall integrity of both techniques. METHODS: a retrospective study was carried out at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, identifying the patients undergoing temporary abdominal closure (TAC) from January 2005 to December 2011. Data were collected through the review of clinical charts. Inclusion criteria were indication of TAC and survival to definitive abdominal closure. In the post-operative period only a group of three surgeons followed all patients and performed the reoperations. RESULTS: Twenty eightpatients were included. The difference in primary closure rates and mean time for fascial closure did not reach statistical significance (p=0.98 and p=0.23, respectively). CONCLUSION: VAC and Bogota Bag do not differ significantly regarding the outcome of abdominal wall integrity, due to the monitoring of a specific team and the adoption of progressive closure.

OBJETIVO: Avaliar o resultado da integridade da parede abdominal após utilização do fechamento assistido a vácuo e da bolsa de Bogotá. MÉTODOS: um estudo retrospectivo foi realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), identificando os pacientes submetidos à técnica de fechamento abdominal temporário (FAT) entre janeiro de 2005 e dezembro de 2011. Os dados foram coletados por meio de revisão de prontuários. Os critérios de inclusão foram indicação de FAT e sobrevivência até o fechamento definitivo da parede abdominal. No período pós-operatório, apenas um grupo de três cirurgiões, seguiu todos os pacientes e realizou as reoperações. Além disso, independente da técnica de FAT utilizada, foi aplicada a tática de fechamento fascial progressivo durante as reoperações. RESULTADOS: Vinte e oito pacientes foram incluídos. Não houve diferença estatística nas taxas de fechamento primário e tempo médio de fechamento fascial. CONCLUSÃO: O fechamento assistido a vácuo e a bolsa de Bogotá não diferem significativamente em relação ao resultado da integridade da parede abdominal após as reoperações. Isso se deve ao acompanhamento de uma equipe específica e a adoção de técnica de fechamento fascial progressivo.

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OBJECTIVE: To verify the effectiveness of the rubber elastic band in the treatment of large wounds of the body wall of rabbits by means of traction of its edges. METHODS: we studied 30 New Zealand rabbits, divided into three groups (n=10): Group 1- healing by secondary intention; Group 2- removal and eutopic repositioning of skin as full thickness skin graft; Group 3- Approximation of wound edges with elastic rubber band. In all animals, we removed a segment of the back skin and subcutaneous tissue down to the fascia, in accordance with an acrylic mold of 8cm long by 12cm wide. All animals were observed for 21 days. RESULTS: two animals of groups 1 and 2 had wound abscess. In Group 2, there was partial or total graft loss in 90% of animals. The complete closure of the wounds was observed in four animals of Group 1, six of Group 2 and eight of Group 3. There was no difference between the scar resistance values of groups 2 and 3, which were higher than those in Group 1. The scars of the three groups were characterized by the presence of mature connective tissue mixed with blood vessels and inflammatory infiltration, predominantly polymorphonuclear. CONCLUSION: the tensile strength of the wound edges with rubber elastic band is as efficient as the skin graft to treat rabbits' large body wounds.

OBJETIVOS: Verificar a eficácia da fita elástica de borracha no tratamento de grandes feridas de parede corpórea de coelhos por meio da tração de suas bordas. MÉTODOS: foram estudados 30 coelhos da raça Nova Zelândia, distribuídos em três grupos (n=10): Grupo 1. Cicatrização por segunda intenção. Grupo 2. Retirada e reposicionamento eutópico da pele como enxerto de pele total. Grupo 3. Aproximação das bordas da ferida com fita elástica de borracha. Em todos os animais, foi retirado segmento de pele e tecido subcutâneo até a fáscia musculoaponeurótica do dorso, de acordo com um molde de acrílico, com 12cm de comprimento por 8cm de largura. Todos os animais foram acompanhados durante 21 dias. RESULTADOS: dois animais dos grupos 1 e 2 apresentaram abscesso na ferida. No Grupo 2, houve perda parcial ou total do enxerto em 90% dos animais. O fechamento completo das feridas foi observado em quatro animais do Grupo 1, seis do Grupo 2 e oito do Grupo 3. Não houve diferença entre os valores de resistência cicatricial dos grupos 2 e 3, que foram maiores do que os do Grupo 1. As cicatrizes dos três grupos caracterizaram-se pela presença de tecido conjuntivo maduro entremeado por vasos sanguíneos e infiltrado inflamatório, predominantemente polimorfonuclear. CONCLUSÃO: a tração das bordas da ferida com fita elástica de borracha constitui método tão eficaz quanto o enxerto de pele para tratar grandes feridas de parede corpórea de coelhos.

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Introducción. La separación clásica de componentes crea un colgajo compuesto, el cual se moviliza para reparar primariamente hernias ventrales sin tensión. La extensa disección requerida produce muchas complicaciones e incapacidad. El abordaje mínimamente invasivo ofrece una alternativa menos mórbida. Se describe en detalle nuestra modificación técnica de la separación de componentes con abordaje endoscópico subcutáneo y los resultados iniciales y a corto plazo de una pequeña serie de pacientes. Métodos. Se hace una descripción detallada de la técnica con énfasis en la marcación preoperatoria de la línea semilunar bajo guía ecográfica y se evalúan los resultados de su aplicación en una serie piloto de seis casos de hernias ventrales grandes, intervenidos entre octubre de 2012 y febrero de 2013. Todos los pacientes han sido evaluados clínicamente entre los cuatro y los ocho meses después de la cirugía y, mediante una tomografía computadorizada de abdomen, a los tres meses. Resultados. Un paciente presentó un gran hematoma subcutáneo. No se presentaron otras complicaciones, como infección, problemas relacionados con la malla o seromas. No ha habido recurrencias durante el seguimiento clínico. El control tomográfico a los tres meses de la cirugía demostró una pared abdominal íntegra excepto por un pequeño defecto de 1 cm, bien reforzado por la malla, en uno de los pacientes. Discusión. La modificación descrita de la separación de componentes por abordaje endoscópico subcutáneo es factible, reproducible, ergonómica y de baja morbilidad en el corto plazo. Es necesario hacer un seguimiento más largo para evaluar la tasa de recurrencia.

Traditional component separation (CS) creates a compound flap that can be advanced for tension-free closure of ventral hernias. Wound complications are common because of the extensive dissection that is necessary with the traditional approach. Endoscopic CS offers an alternative with lower morbidity. We describe our initial experience with endoscopic subcutaneous CS and early postoperative results in a pilot series of six patients with large ventral central hernias. This study shows that endoscopic subcutaneous CS is feasible, reproducible, ergonomic, and can result in minimal postoperative complications. Long-term follow-up is necessary to evaluate recurrence rate outcomes.

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Dentre os desafios das esofagectomias, a fístula da anastomose cervical persiste desafiadora por suas consequências, sendo a principal, a estenose da anastomose. Os autores apresentam uma técnica de anastomose esofagogástrica cervical látero-lateral mecânica à Orringer, que reduz o índice de fístulas e de estenose.

Among the challenges of esophagectomies, the cervical anastomosis remains challenging for its consequences, the main being the anastomotic stricture. The authors present a technique for an Orringer-fashion mechanical cervical laterolateral esophagogastric anastomosis, which reduces the rate of fistula and stenosis.

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PURPOSE: To investigate if tests used in the preoperative period of upper abdominal or thoracic surgeries are able to differentiate the patients that presented cardiopulmonary postoperative complications. METHODS: Seventy eight patients, 30 submitted to upper abdominal surgery and 48 to thoracic surgery were evaluated. Spirometry, respirometry, manovacuometry, six-minute walk test and stair-climbing test were performed. Complications from immediate postoperative to discharge from hospital were registered. RESULTS: The postoperative complications rate was 17% in upper abdominal surgery and 10% in thoracic surgery. In the univariate regression, the only variable that kept the correlation with postoperative complications in the upper abdominal surgery was maximal expiratory pressure. In thoracic surgery, the maximal voluntary ventilation, six-minute walk test and time in stair-climbing test presented correlation with postoperative complications. After multiple regression only stair-climbing test continued as an important risk predictor in thoracic surgery. CONCLUSION: The respiratory pressure could differentiate patients with complications in upper abdominal surgery, whereas in thoracic surgery, only spirometric values and exercise tests could differentiate them.

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PURPOSE: To investigate if tests used in the preoperative period of upper abdominal or thoracic surgeries are able to differentiate the patients that presented cardiopulmonary postoperative complications. METHODS: Seventy eight patients, 30 submitted to upper abdominal surgery and 48 to thoracic surgery were evaluated. Spirometry, respirometry, manovacuometry, six-minute walk test and stair-climbing test were performed. Complications from immediate postoperative to discharge from hospital were registered. RESULTS: The postoperative complications rate was 17% in upper abdominal surgery and 10% in thoracic surgery. In the univariate regression, the only variable that kept the correlation with postoperative complications in the upper abdominal surgery was maximal expiratory pressure. In thoracic surgery, the maximal voluntary ventilation, six-minute walk test and time in stair-climbing test presented correlation with postoperative complications. After multiple regression only stair-climbing test continued as an important risk predictor in thoracic surgery. CONCLUSION: The respiratory pressure could differentiate patients with complications in upper abdominal surgery, whereas in thoracic surgery, only spirometric values and exercise tests could differentiate them.(AU)

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M-plastia pós-ajustada pode ser usada em qualquer defeito cirúrgico passível de fechamento por aproximação direta das bordas, evitando formação de protrusões apicais. É realizada sem planejamento prévio, sendo retirado tecido somente quando houver protrusão percebida pelo cirurgião no ato cirúrgico. Possui as vantagens de poupar tecido sadio, adaptar as incisões às linhas de força, rugas e unidades de junção cosmética de cada paciente, além da possível utilização do pedículo do M como pequeno retalho de avanço. Neste trabalho, é relatado o passo a passo desse procedimento cirúrgico, evidenciando suas diferenças e vantagens quando comparado à M-plastia tradicional.

Post-adjusted M-plasty can be used in any surgical defect that can be closed by direct approximation of the borders to avoid the formation of apical protrusions. It is performedwithout prior planning; the tissue is removed only if the surgeon detects a protrusion during surgery. This method offers the advantage of sparing healthy tissue by adjusting the incisions to each patient?s skin?s tension lines, wrinkles and junctions of cosmetic units, in addition to the possible use of the ?M?s pedicle as a small advancement flap. This study describes the procedure step by step, highlighting the differences and advantages compared to traditional M-plasty.