Simple adaptation for dynamic Bogota bag

Introduction

The use of the Bogota bag has been a great advance in the management of abdominal wounds which cannot be immediately closed after laparotomy. ¹ The problem arises in several scenarios where there is loss of abdominal fascia and skin from an infected abdominal wound, excessive tension in closing which may result in abdominal compartment syndrome or the need for an early second look relaparotomy. After resolution of the abdominal problems, the treatment of patients is variable. The Bogota bag may be removed and primary closure of fascia accomplished. Sometimes the bag is removed and the residual defect is skin grafted. A significant ventral hernia requiring subsequent operation may or may not arise. So there is need to continue to reflect on improving the closure plan because this is done for patients who have a significant mortality risk from the initial disease or the development of multi-organ system failure.

Many of the local abdominal complications which occur in these patients are attributable to the underlying disease. Sometimes there is an accumulation of residual sero-purulent drainage and possibly intra-abdominal abscess. There are concerns about the development of intestinal fistula but very few reports of this problem. In our experience there was a problem of serious haemorrhage when the Bogota bag was removed at day 21. Adhesions form between the abdominal wall and bowel and may result in complications during an effort to free them. This happens in patients who may have multiple problems precluding an early return to theatre as in this case and in others in whom oedema of the bowel is slow to resolve such that the abdominal wall cannot be closed for some time. This led to reconsideration of the technical aspects of applying the bag and development of some adaptations.

There are differences in application of the Bogota bag: some surgeons suture the bag to skin, some to the fascia. And there are significant differences in the timing of Bogota bag change, attempts at final closure. More recently there have been efforts to gradually coapt the fascial edges facilitated by elastic strips. ² Vacuum-assisted devices have been used to assist in abdominal wound closure. ³ Several studies make a kind of ‘sandwich’ of gauze within the plastic sheeting which comes just to the wound edges. ⁴ A retrospective study has shown improvement of closure rates and mortality using a VAC system. ⁵ The timing of application of all these various devices is quite variable but several authors have observed that as closure or closure systems are delayed, the problem of visceral adhesion and fascial retraction becomes greater. A study by Cheatham et al. ⁶ compares two methods that differ partly in the size and placement of the subfascial sheet. This larger than usual internal sheet may prevent visceral adherence and allow gradual coaptation of the fascial edges more easily ‘sliding’ over the viscera as oedema resolves.

In low resource settings, many of these advances can seem quite daunting and out of reach. Therefore we are happy to share a limited experience. A variety of materials are actually readily available for the Bogota bag method in most centres (sterile soft i.v. fluid bags, urine collection bags and even an Esmarch elastic bandage). We have taken the insights about improved closure by the dynamic techniques and the VAC methods so that a sufficiently large bag is fashioned that can reach under the fascial layer to both colon gutters (sometimes this requires two i.v. fluid bags sewn together). Then strips of an elastic Esmarch bandage are cut (approximately 1 cm wide). These are introduced bluntly with small artery forceps through the fascia at a distance of about 2 cm from the edge of the wound (not including the skin), about 3 cm apart. They are then tied under gentle tension, just enough to engage the elasticity of the strips while maintaining a soft abdominal wall. Although it was not done in this series, a check of abdominal pressure can be done by measuring urinary bladder pressure with a manometer. The system allows for a subsequent laparotomy if necessary. At that time the strips are easily removed and new strips can be applied at the end of the laparotomy. Over the subsequent weeks of observation as the primary abdominal problem improves and oedema resolves, the wound defect gradually gets narrower. Sometimes the strips can be retied especially if the defect width had been very large and the strips become loose as oedema resolves. Eventually the fascial defect is quite narrow. Then the Bogota bag is removed at the bedside under mild sedation and the strips removed. Sometimes one trip to theatre is made for secondary closure or for adjunctive skin grafting but multiple trips to theatre for changing of the Bogota bag are avoided. In this programme of management the dynamic closure system for the Bogota bag is applied at the very laparotomy when it is decided that the abdominal fascia cannot be primarily closed (whether the first laparotomy or the subsequent laparotomy for septic complications).

We can already recommend this improved adapted technique. The key features are the use of a large Bogota bag under the fascial layer and the use of elastic strips which can be adjusted as need arises. The advantages of these improvements are a substantial decrease in number of required subsequent operations and a much narrower subsequent wound defect and a trend towards shorter hospital stay. We are investigating the comparative improvement that might happen with a sandwiched negative pressure device in addition to this dynamic technique. The combination of negative pressure and drainage may aid in resolution of oedema and control the unwanted accumulation of discharge at the bag interface allowing faster closure and lower incidence of residual wound for graft closure and subsequent hernia formation. ⁷ This is a subject for our future study. OPEN IN VIEWER

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Figure 2.

Bogota bag inside, strips laid through fascia.

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Figure 3.

Removal of bag under mild sedation after healing.

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Table 1.

Septic abdomen, fascial edges unable to be coapted without tension.

Cases (n)	Fascial defect	Deaths (multisystem organ failure)	Subsequent closure operations
9	2–5 cm	4	– 1 secondary fascial closure after dynamic system had reduced size of defect (2 weeks) – 1 skin graft after dynamic system reduced size of defect (3 weeks) – 3 satisfactory closures, Bogota bag removed with sedation only (3 weeks)