1. “How to Close a
Laparostomy”
Nigel Suggett
Queen Elizabeth Hospital, Birmingham

2. 3 Questions
• How do you make a laparostomy
• When do you close a laparostomy?
• How do you close a laparostomy?

3. Aims of a laparostomy
• Reduce intra-abdominal pressure
• Facilitate further access
• Manage exudate
• Reduce oedema
• Maintain abdominal domain
• Protect bowel
• Reduce adhesions from bowel to abdominal wall

4. Options
• Skin Closure
• Pack / Op-site
• Bogota Bag
• Topical Negative Pressure

5. Proprietary

6. D.I.Y
Skin
approximation
skin
muscle
interface
bowel

8. D.I.Y
Skin suction
Adhesive approximation
dressing
skin
muscle
interface
bowel

9. TNP and open abdomen
• Know what you are doing!
• Protect and separate the bowel
• Check 48-72h
• Risk of fistulas?

10. When to Close?

11. When to close
• Ideally <5 days
• Before granulation/ adhesion
• Try to avoid fascial retraction

12. Primary Fascial Closure?

13. How to Close?
• 2o intention
• Skin graft
• Bridging
• Gradual / Staged Closure
• Direct Suture +/- Mesh
• Component Separation +/- Mesh

14. Component Separation (Ramirez 1990)
Bleichrodt et al.

15. Case
• 51y M - LUQ Stabbing
• Left renal vein, stomach and splenic hilum damaged
• 24U Blood, 20U FFP , 4U plt
• Pack + TNP
• Re-look d1 - Colonic ischaemia – stapled off – TNP
• Re-look d4 – Re-anastomosis – TNP – unable to close
• Relook d9 – Unable to close

17. Component Separation
1-2cm

18. Component Separation

19. Component Separation
3-5cm upper abdo
7-10cm waist
1-3cm lower abdo

21. Component Separation

22. Component Separation
2-4cm

24. Component Separation

26. Mesh
• Biologic (in this setting)
• Intra-peritoneal
• (Extra-peritoneal)
• On-lay

30. Caution!
• Returned to ward 5/7 later
• Witnessed VF arrest ? cause
• Aspirin, clopidogrel, therapeutic enoxaparin
• Bleeding!!!!

31. So……
• Evacuation of haematoma and re-application of TNP
– Tracheostomy
– Fascia intact
• Skin re-closed 4 days later
• Discharged (after ICD)

32. Component Separation
Pros Cons
• A useful technique • Time consuming
• Allows primary fascial • Potential morbidity
closure
• Gets you out of trouble • Can only be done once!

33. 3 Questions
• How do you make a laparostomy
– Depends on your knowledge and skills
– Carefully and thoughtfully
• When do you close a laparostomy?
– As soon as it is safe to do so
– Or not at all
• How do you close a laparostomy?
– Primary suture
– Component Separation + Mesh
– Or not at all