Open abdomen (OA) with temporary abdominal closure (TAC) is a therapeutic strategy that surgeons are forced to use for the management of abdominal sepsis, damage control surgery and abdominal compartment syndrome (ACS) until the necessary conditions for a definitive closure are achieved. When early closure is not possible, the likelihood of performing primary fascial closure (PFC) decreases abruptly, hospital length of stay increases, and the incidence of complications associated with this method is higher¹.

Several static and dynamic TAC techniques have been described to protect the abdominal viscera and facilitate subsequent closure while providing easy access to the abdominal cavity. An ideal TAC technique should provide visceral coverage while maintaining a physiologic environment, prevent evisceration and adhesions between the viscera and the abdominal wall, and decrease retraction of the rectus abdominis muscles. It should also actively remove peritoneal fluids along with bacteria and debris, be easy to use and, because of all these mechanisms, preserve the integrity of the viscera and facilitate definitive abdominal closure².

Some older techniques, as the Bogota bag, do not allow adequate fluid control and have also failed in facilitating abdominal wall closure, resulting in longer hospital stay with formation of enteroatmospheric fistula, one of the most feared complications, and the unavoidable consequence of large incisional hernias with their associated complications. These techniques evolved with the advent of negative-pressure therapies. Nevertheless, PFC of the open abdomen, mainly in longer therapies using vacuum systems, was not satisfactory¹. In 2007, Petterson et al. described the dynamic closure (DC) technique of the abdominal wall, the vacuum-assisted wound closure with mesh mediated fascial traction, as a therapy for long-standing OA, facilitating PFC and reducing the complications associated with TAC of the OA³.

Since then, this technique has been used in many centers, and their experience and long-term results are still under consideration³. We report a case using this type of DC associated with the injection of botulinum toxin (BT) in the lateral muscles of the abdomen. This technique has already been used by Ibarra-Hurtado et al. in the preoperative management of giant incisional hernias, allowing the approximation of the rectus abdominis muscles to the midline and improving the compliance of the abdominal wall⁴.

A primary fascial closure of a 16-cm initial defect in a Björck grade 3 OA was achieved without mesh; there were no complications during a 6-month follow-up period. A 54-year-old male patient who was hospitalized for bilateral pneumonia due to COVID-19, presented an acute gastrointestinal perforation secondary to complicated diverticular disease with fecal peritonitis. The patient underwent Hartmann’s operation with OA and Bogota bag. Subsequently, the patients developed colonic ischemia and underwent total colectomy with end ileostomy. She was admitted to the intensive care unit and received treatment for different sources of sepsis (respiratory tract, abdomen, urinary tract and biliary tract). He required peritoneal lavage in 12 occasions and percutaneous cholecystostomy. The vacuum-assisted wound closure (VAWC) technique was used for 7 weeks and changed every week, leading to a Björck grade 3A OA. As the patient evolved with a favorable clinical course, we decided to perform mesh-mediated traction with the VAWC technique on day 70.

The patient was taken to the operating room 6 times to change the vacuum system, with section and gradual approximation of the mesh traction system (Fig. 1). Each procedure lasted about 20 minutes. All the procedures were performed in the operating room, under general anesthesia. On the third procedure, 30 days before the definitive closure, botulinum toxin was injected under ultrasound guidance in the plane between the transverse muscle and the inferior oblique muscle. A total of 100 IU of toxin were administered, distributed in 3 equidistant points on each side.

FIGURA 1 Dynamic closure with section and gradual approximation of the mesh traction system associated with vacuum-assisted wound closure. 

In each procedure, the mean gap between both edges decreased 2.6 cm, starting with a gap of 16 cm (Fig. 2).

FIGURA 2 Treatment over time. Computed tomography scan of the abdomen showing an initial gap of 16 cm, with retraction of the large muscles. On the right, the large muscles are relaxed (red box) after infiltration with BT and the rectus abdominis muscles are approximated to the midline. 

Definitive closure was achieved 6 weeks after therapy was initiated, performing a simple closure of the aponeurotic plane with PDS-0 in 6 tension-free sections. The patient remained in the general hospital ward and was discharged 48 hours later without associated complications and with a postoperative follow-up of 6 months. Open abdomen is an entity with high morbidity and mortality, not only because of the critical condition of the patient, but also because of the complications associated with the method. Enteroatamospheric fistula and complex incisional hernia with loss of abdominal domain are associated with the greatest morbidity. Primary fascial closure is the optimal strategy to prevent these complications⁵. Negative pressure associated with TAC should be the therapy of choice, as it has demonstrated better results compared with cases in which this technique has not been used or is not available¹. When early definitive closure (7-10 days) has not been performed and patients present Björck grade 1 or 2 OA, a DC technique is recommended, as they have shown benefits compared with static closure techniques⁶.

Prolonged OA is associated with retraction of the lateral muscles and increased risk of frozen abdomen (grade 3 OA) and enteroatmospheric fistula (grade 4 OA). In these cases, definitive closure is delayed between 6 and 12 months, resulting in a long period of high morbidity and with the risk of developing complex incisional hernias. Botulinum toxin has been used for delayed closure as treatment of large incisional hernias resulting from OA and in the acute management of OA to facilitate the definitive closure⁴. In our case, the use of a DC technique (fascial traction using mesh and VAWC) combined with infiltration of BT within a 5-week period allowed PFC of a Björck grade 3 OA.

A dynamic closure technique should involve VAWC with a large sheet separating the space between the viscera and the parietal peritoneum to avoid adhesion formation between these two planes so that the muscle wall can slide over the viscera. Botulinum toxin produces a temporary flaccid paralysis in the lateral muscles, favoring muscle elongation and the closure of the midline with the traction of the DC technique, thus achieving a tensionfree PFC.

The association of a DC technique and BT allowed definitive abdominal closure in a patient with OA with large muscular retraction (Björck grade 3). The use of BT had a favorable influence, since relaxation of the lateral muscles was evident in the operating room and in comparative CT scans, resulting in a tension-free definitive closure. Future studies with larger number of patients are necessary to obtain long-term results with the use of this technique.