Use of Negative Pressure Wound Therapy as an Occlusive Dressing on a Skin Graft in a Patient With Hostile Abdomen

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In hostile abdomen the abdominal cavity is exposed, with retracted edges compacted into a single block of fibrous tissue that does not allow adequate dissection or separation.¹ This condition is secondary to inflammation, sepsis, or chronic radiation, or as a sequela of intestinal leakage, a traumatic injury, or an adhesive process following surgery.^2-4 

One technique used to address hostile abdomen is open abdomen, which involves intentionally leaving the fascial edges of the abdomen without approximation, thus exposing the abdominal contents.⁵ After the inflammation is controlled, definitive closure of the abdomen can be attempted with techniques such as primary fascial closure, separation of fascial components, or a controlled ventral hernia (primary skin closure or skin graft).⁵

A skin graft is a fragment of skin tissue that is separated from its donor site and attached to a recipient site intended for spontaneous revascularization.⁶ An adequate recipient site without infection is needed for adequate integration of the graft.⁷ Several therapies are used to promote the granulation process, such as dressings, antiseptic solutions, and negative pressure wound therapy (NPWT).⁸ However, there is limited evidence on the use of these therapies in a hostile abdomen.⁵ 

The present study reports a patient with a hostile abdomen for which a split-thickness skin graft (STSG) and a full-thickness skin graft were used in conjunction with a lipidocolloidal dressing and NPWT for abdominal closure in a public tertiary care hospital. This case is reported in line with the Surgical CAse REport criteria.⁹

A 73-year-old male farmer with a body mass index of 29.1 (weight, 86 kg; height, 1.72 m) with incomplete primary education, and with no comorbidities, allergies, or drug addiction, walked into the emergency department with an intestinal obstruction that had started 48 hours prior. 

Clinical findings and diagnostic assessment

Physical examination and laboratory test results led to a diagnosis of acute abdomen, and exploratory laparotomy was performed. The surgeon found a rectosigmoid tumor with peripheral abscesses and performed the Hartmann procedure¹⁰ without apparent complications. The histopathology report described severe chronic colitis with ischemic-hemorrhagic infarcts and intestinal perforation. The main challenge to adherence to medical treatment was the patient’s illiteracy, resulting in his complete dependence on his daughter as a caregiver.

On the fourth day, the patient presented fever, tachycardia, and an elevated leukocyte count. Abdominal computed tomography revealed an intra-abdominal abscess in the left colic flexure (Clavien-Dindo grade IIb),¹¹ and laparotomy was performed. After 7 days, the patient was discharged. 

Seven months later, surgery for restoration of intestinal transit was performed, with intraoperative findings of multiple loose and firm loop-to-loop and loop-wall adhesions (Mazuji grade 3 and Clavien-Dindo grade III).¹¹ Cold cut adhesiolysis and the Deloyers procedure¹² were performed. The patient presented adequate clinical improvement and was discharged 5 days after this surgery on an antibiotic regimen (Ciprofloxacin and Metronidazole).

Seven days after surgery (48 hours after discharge), the patient returned to the emergency department with a dehiscent surgical wound (Figure, part A). Urgent exploratory laparotomy was performed, and the anastomosis was found to be dehiscent, with fecal matter in the abdominal cavity (Clavien-Dindo grade III).¹¹ The anastomosis was dismantled, and right hemicolectomy with terminal ileostomy was done; the cavity was cleaned, and the abdominal wall was closed; on the third day the surgical wound was dehiscent, with necrotic edges and with exposure to abdominal contents. 

Therapeutic intervention

Surgical cleaning with debridement was scheduled, with the intraoperative discovery of a hostile abdomen (Björck grade 3A and Clavien-Dindo grade III).¹¹ Surgical cleanings were initiated with surgical soap, saline solution, and a hypochlorous acid solution (Vashe; Urgo Medical North America) in conjunction with intra-
abdominal NPWT (AbThera; Solventum) at a constant pressure of −120 mm Hg. Surgical cleanings were scheduled on demand, based on the collection volume of the NPWT device. Seven surgical cleanings with NPWT dressing changes were performed in a 5-week period. Each surgical cleaning lasted approximately 40 minutes. 

Component separation was unsuccessfully attempted on 2 occasions (Figure, part B). Thus, it was decided to generate granulation tissue and apply an STSG. After 5 weeks of wound care, the intra-abdominal NPWT was changed to a suprafascial device (Renasys; Smith & Nephew). This change of NPWT device was made for administrative reasons. Wound cleaning was performed weekly for 4 weeks at bedside, using only hypochlorous acid solution. A sterile gauze was used to gently stimulate the granulation tissue, and then the NPWT device was placed. The patient did not experience significant pain, and anesthesia was not required.  

The time to achieve adequate granulation tissue with NPWT was 9 weeks (5 weeks intra-abdominal and 4 weeks suprafascial) (Figure, part C). At week 10, the plastic surgeon (ERA) harvested an STSG from the left thigh using an electric dermatome (Padgett Model B; Integra Life Sciences) (Figure, part D). Incisions were made in the graft, and it was sutured with 5-0 nylon. A lipidocolloidal dressing (UrgoTul; Urgo Medical North America) was placed as an interface dressing (Figure, parts E and F). The NPWT was used as an occlusive dressing (over the graft) with a continuous pressure of −90 mm Hg for 5 days. To reduce the risk of contamination of the STSG due to the proximity of the ileostomy outlet, which lay 3 cm from the STSG, a hydrocolloid was used as a barrier method. It was not possible to place the ileostomy at a greater distance. When the site was uncovered 5 days later, total graft loss at the lower vertex due to contamination of the wound was observed, as were areas of hypergranulation and biofilm formation throughout the wound periphery. At the upper vertex, the graft was accepted only in the center and was translucent (Figure, part G). After 24 hours, the graft resembled normal skin (Figure, parts H and I). 

To promote granulation tissue suitable for a new skin graft, NPWT was applied at a continuous pressure of −120 mm Hg for 4 weeks, with weekly bedside wound cleanings (Figure, part J). On 2 occasions, the patient reported a slight increase in pain; thus, the pressure was reduced to −90 mm Hg for 1 week. However, the graft became pale and showed no evidence of expansion, which prompted a return to the original pressure of −120 mm Hg with adequate tolerance by the patient.

Wound surface area and skin graft expansions were determined using photo planimetry with the WoundGenius application (imito AG). Four weeks later, the skin graft had expanded 71% (Figure, part K) and was identical to the peripheral skin. At that time, a full-thickness skin graft was harvested (because for administrative reasons an STSG could not be harvested) from the left inguinal region (Figure, part L) and then was applied to the lower vertex and sutured. By the 19th week, 89% epithelialization of the total wound surface was observed (Figure, part M). The remaining defect, which measured approximately 2 cm², was covered with an antimicrobial hydrofiber dressing with silver and EDTA (Aquacel Ag+ Extra; ConvaTec) and plastic film; these were changed every 2 days. 

Follow-up and outcomes

The patient and his family were instructed on dressing changes as well as on ileostomy, skin, and wound care, and the patient was subsequently discharged home with follow-up in the outpatient clinic (Figure, part N). The hospital length of stay to close the abdominal breach was 20 weeks.

The patient’s daughter later reported, “Our dad experienced episodes of sadness at various times during his hospitalization, but thanks to the psychological services and the doctors’ care, he was able to overcome these difficulties. Today he is in our house doing most of his daily activities by himself.” In a telephone interview, the patient emotionally commented, “I thank you [the doctors] for taking care of me when I was in the hospital. I am very grateful.” His speech was interrupted by a “lump in his throat” and a cracking voice that conveyed the sincerity of his words.

Open abdomen is a strategy to prevent and treat compartment syndrome in patients with abdominal trauma or abdominal wall tissue loss.¹³ However, it is also associated with early, mid-term, and late complications. Early complications (<1 week) include fluid balance, temperature loss, electrolyte abnormalities, visceral injury, and abdominal compartment syndrome.¹⁴ Some mid-term complications (2 weeks-3 weeks) include loss of domain, visceral injury, anastomotic leaks, intra-abdominal abscess, and hospital-acquired infections. Late complications (>3 weeks) include enteroatmospheric fistula, planned ventral hernia, intestinal ileus, and nutritional losses, which may make medical treatment more challenging.¹⁴ 

Although various methods of abdominal coverage have been described, there is scant evidence of methods for abdominal closure.^5,15 The patient in the current report required damage control surgery and was subsequently managed as an open abdomen.¹⁶ In open abdomen, 2 problems coexist: the wound and the abdominal defect.¹⁷ Taking all these factors into account, 2-phase treatment was planned for the patient in the current report, with the first phase consisting of wound management and preparation of the receptor site for STSG, and the second phase focusing on closing the abdominal gap with STSG.

By generating mechanical stress, NPWT increases blood supply, promotes cell reproduction and angiogenesis, and reduces exudate and bacterial colonization.^5,18-20 Argenta and Morykwas²¹ obtained granulation tissue in wounds using continuous pressure of −125 mm Hg and applied a skin graft at a pressure of −50 mm Hg to −75 mm Hg. NPWT is an effective option for temporary closure of the open abdomen, because it adequately drains fluids and improves wound contraction.^22,23

The pH changes in the different phases of a wound; when infection is present or debridement is performed, an acidic environment predominates.²⁴ To promote an adequate microenvironment for tissue repair in the patient in the current report, hypochlorous acid solution was used at each wound cleaning. Hypochlorous acid also serves as an antimicrobial adjuvant, aids in odor control, and reduces pain.^25,26 For the current case, the solution was used for 60 seconds, which is the average time required to decrease the bacterial load and prevent biofilm formation.²⁷ Dressing changes should occur every 48 hours to 72 hours.²¹ However, in the current case, due to the decrease in exudate collected in the system, this frequency was reduced in order to minimize trauma and the risk of fistula formation.

Biochemical assessments were completed twice weekly for the first 5 weeks and weekly thereafter. This assessment included complete blood count, blood chemistry, serum electrolytes, lipid profile, liver function tests, procalcitonin, and C-reactive protein. Nutrition plays a key role in recovery in patients with hostile abdomen and chronic wounds.²⁸ For the current case, the Controlling Nutritional status scale²⁹ was used to assess and monitor nutrition status. Initially, the patient was moderately malnourished, and as a result, he was evaluated by a clinical nutritionist who prescribed a high-calorie and high-protein diet supplemented with glutamine, ferrous sulfate, and B complex.²⁸ 

For the ileostomy assessment and to both avoid electrolytic imbalance and protect the peristomal skin in the current patient, serum electrolyte levels were monitored, as was the daily 24-hour ileostomy output.³⁰ Hemoglobin, procalcitonin, and C-reactive protein levels, as well as the quick sequential (sepsis-related) organ failure assessment  scale,^31-33 were used as markers of inflammation and sepsis in the current patient.

In the fifth week of treatment for the current patient, the abdominal gap was reduced and the NPWT modality was changed from intra-abdominal to suprafascial.³⁴ This eased the NPWT changes at bedside, which saved time, personnel, and materials costs.³⁵ The patient in the current report required multidisciplinary management involving nursing, general surgery, plastic surgery, nutrition, rehabilitation, and psychology personnel. Constant communication with the patient, his relatives (caregivers), and health care personnel had a positive effect on the patient’s recovery. Applying the Enhanced Recovery After Surgery protocol,^5,36 ambulation, basic hygiene activities, oral feeding, and withdrawal of intravenous solutions and medications were achieved in the present patient.

The lipidocolloidal dressing over the STSG serves as an interface between the graft and the NPWT dressing, allowing moisture to pass through, preventing traumatic removal, protecting the graft, and stimulating fibroblast proliferation in vitro and granulation tissue formation.^37,38 Chou et al³⁹ evaluated the vacuum-assisted closure system with a silicone-based dressing over the conventional tie-over bolster technique in skin graft fixation and found that the combination of NPWT with silicone dressing in skin grafts was more effective for graft integration compared with a conventional method, using a pressure of −50 mm Hg and removing it on the fourth day. However, that study did not include patients with open abdomen. 

Suzuki et al⁴⁰ used STSG to cover the abdominal contents and NPWT at a continuous pressure of −120 mm Hg as an occlusive dressing. They achieved successful epithelialization in a patient with an enteroatmospheric fistula, but unfortunately, the patient died. In a patient with open abdomen, Kim et al⁴¹ achieved abdominal closure using an acellular dermal matrix underneath an STSG placed over the abdominal gap that had been previously prepared with NPWT at a continuous pressure of −120 mm Hg. Cases similar to the one in the present report are scarce (Table).^40-42  

The Consensus Guidelines on Negative Pressure Wound Therapy for Wound Repair (2025 version) do not include recommendations for NPWT in patients with open abdomen.⁴³ However, despite the presence of open abdomen in both trauma and nontrauma patients, the World Society of Emergency Surgery guidelines state that NPWT can be used in combination with biologic mesh to facilitate granulation and skin closure; a detailed protocol for pressure settings is not described.⁵ In this challenging clinical scenario, there are currently no comprehensive clinical guidelines regarding the choice of pressure settings in NPWT; thus, the level of suction is based on individual assessment of the wound and patient tolerance.^5,43,44 

Although there are successful reports using different closure methods, the process for creating an adequate receptor site over the abdominal gap, as well as the use of an intermediate dressing, are not detailed. The present case provides valuable insights into the use of a lipidocolloidal dressing when applying a skin graft in conjunction with NPWT to achieve closure of the abdominal gap in a hostile abdomen. 

An important limitation of the present case is that a controlled hernia was created, which requires daily use of a girdle, weight control, avoidance of straining, and additional surgical interventions. The main limitation of this report is the lack of generalizability of the methods for achieving epithelialization of incisional wounds in other conditions that generate a hostile abdomen, such as traumatic injuries, abdominal compartment syndrome, and massive intra-abdominal bleeding, which are managed as an open abdomen; these other clinical scenarios should be validated in further studies. Furthermore, the methods described require a multidisciplinary approach, and use of the technique described herein would be difficult at institutions with a limited number of health care providers and limited economic resources. Finally, the method described requires healthy skin to cover the wound with STSG.

A multidisciplinary approach is needed to treat patients with a hostile abdomen. The application of NPWT, combined with a hypochlorous acid solution may improve the condition of the abdomen for receiving a skin graft. A lipidocolloidal dressing can be used as an interface between the graft and NPWT dressing. Effective and continuous communication among medical staff, the patient, and the patient’s family and caregivers contributes to improved outcomes.