Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.
Despite an open abdomen being accompanied with substantial morbidity and mortality, there are surgical conditions which warrant it as a temporary measure to manage surgical pathologies as life-saving measures [
The Bogota bag is a simple plastic material bag which is applied over an anterior abdominal incisional wound and sutured over the skin or fascia edges [
A 29-year-old male was referred to our center with clinical features suggestive of intestinal obstruction. He had three prior histories of abdominal surgeries two years prior current complaints. On examination, he was ill-looking, in distress, pale, dehydrated, and conscious with the Glasgow coma scale score of 15. His vitals were blood pressure 110/75 mmHg, pulse rate 135 beats/minute, temperature 36.7°C, and oxygen saturation was 94% on room air with random blood glucose of 6.7 mmol/L. His hemoglobin level was 15 g/dL.
He was scheduled for emergency explorative laparotomy. Intraoperative findings were a constriction band 10 cm from the ileocaecal junction with grossly dilated viable small bowels from ligament of Treitz to the obstruction point. Adhesion band was released, and bowel patency was established. Abdominal fascia was closed with vicryl number 1 and skin nylon number 2-0. Postoperatively, the patient progressed well initially. His postoperative albumin level was 16.09 g/L.
However, he developed incisional anterior abdominal wall wound dehiscence day seven postoperatively. He was scheduled for a second emergency explorative laparotomy. Preoperative hemoglobin was 11.9 g/dL. Intraoperative findings were a gapped abdominal fascia, grossly dilated and edematous bowels, and immature adhesions, and small amount of intraperitoneal pus was noted. Appendectomy was done, and thorough abdominal lavage with copius Normal saline infusion, refreshing of abdominal fascia and skin edges, one abdominal drain left in situ, and tension sutures were applied. Postoperatively, he developed generalized body edema, abdomen was distended, and bowel sounds were reduced with limited bowel movement. Serous fluid discharge per incision site was noted. Postoperative serum albumin was 13.12 g/L and total protein 32.8 g/L.
On the seventh day posttension sutures, he developed a second incisional anterior abdominal wall wound dehiscence. He was scheduled for a third emergency explorative laparotomy. Intraoperative findings were remnants of broken-down tension sutures, gross dilation, and edematous bowels from gastrium to ileum together with the large colon up to the sigmoid colon with immature adhesions.
Abdomen lavage was done, gentle decompression of bowels through the rectum done. Multiple attempts of reduction of bowels into the peritoneal cavity were attempted with approximation of abdominal fascia in the midline without success. A clinical decision was made to abort attempts to forcefully reduce the grossly dilated edematous bowels into the peritoneal cavity in fear of abdominal compartment syndrome and respiratory failure due to cephalad displacement of diaphragm. Resection and primary anastomosis of a segment of ileum to reduce the volume of intraabdominal contents was not an option due to his low serum albumin and total proteins levels. A standard empty sterile double-layered polyvinyl urinary collection bag was applied over the open anterior abdominal wall incisional wound (Figures
Standard urine collection bag sutured over anterior abdominal wall incisional wound exposing oedematous bowels with abdominal drain in situ.
The urine bag was cutand trimmed to fit the open abdominal wall incisional defect. It was stitched to anterior abdominal wall skin edges using interrupted prolene 0 stitches at an interval of 2 cm apart. An intraabdominal drainage tube was placed in situ for drainage of peritoneal fluid.
Postoperatively, the patient edematous bowels could be visible from the urinary bag. His generalized edema subsided and was scheduled for elective tension suture application 7th day post urinary bag application. Intraoperatively, abdominal fascia was slit bilaterally and mobilized, and horizontal mattress sutures were applied with nylon number 1. The skin was closed with horizontal mattress tension sutures. He was discharged and reviewed 5 weeks later. He had on and off episodes of relative constipation which resolved on conservative management. No anterior abdominal wall ventral hernia was noted.
There are a number of techniques from authors for open abdomen/temporary abdominal closure methods; however, there is no documentation of a proven superior technique [
In these challenging clinical scenarios, prosthetic materials are used to temporarily close the abdominal wall as forceful primary abdominal fascia closure could produce undue tension on fascia [
It should however be noted that the material of the Bogotà bag used for temporary initial abdominal closure should preferably be durable enough to preserve its integrity and protect intraperitoneal contents, flexible to avoid inflicting trauma to intraperitoneal viscera organs, thus leading to enteroatmospheric fistula, noncarcinogenic, biologically inert not to provoke an inflammatory response cascade and relatively cheap and easily available [
The Bogota bag is the relatively inexpensive temporary abdominal closure method that is currently available with primary closure rates ranging from 12 to 82% and enteroatmospheric fistula development rate ranging from 0 to 14.4% [
With regards to time frame on eventual abdominal closure with respect to the Bogota bag, a retrospective analysis by Hu et al. [
In a systematic literature review, Ribeiro et al. [
A comparative study on the Bogota bag versus vacuum-assisted closure in Brazil by Rodrigues et al. [
In a prospective observational cohort study by Coccolini et al., with data from the International Register of Open Abdomen (IROA) on techniques of open abdomen closure, the Bogota bag and skin closure techniques seemed to improve results in trauma cases [
Setbacks of the Bogota bag include inability to reapproximate the abdominal fascia in the midline for closure due to fascia retraction posttemporary abdominal closure leading to large ventral hernias and loss of the abdominal domain [
In our case, the clinical settings faced by the attending surgeon were as follows: the surgery was an emergency procedure, it was not anticipated that a temporary abdominal closure technique would need to be employed, and there was no available standard used temporary closure materials such as vacuum-assisted closure techniques, meshes, or the Wittmann patch. The attending surgeon used his own ingenuity to use a urine collection bag as the only available alternative to the Bogota Bag. This was done as a temporary closure method of the anterior abdominal wall incisional wound after multiple failed attempts to approximate the abdominal fascia to the midline due to grossly dilated edematous bowels. This clinical setting created a surgical dilemma on the way forward in an austere situation. Forceful midline approximation of the abdominal fascia would put the patient at risk of development of abdominal compartment syndrome, or sustain yet another abdominal wall incisional wound dehiscence status.
The standard urine collection bags can be safely used as alternatives to the Bogotà bag. In limited resource settings and in emergency open abdominal closure methods, urine collection bags are effective, relatively cheap, and useful materials.
All data and materials pertaining to this case report can be made available on request.
Approval to publish was obtained from relevant authorities.
Written informed consent was obtained from the patient for writing of this case report; additionally, accompanying images have been censored to ensure that the patient cannot be identified. A copy of the consent is available on record.
The authors declare they have no competing interests. All authors of the manuscript have read and agreed to its contents.
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave the final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.
The authors would like to thank the patient for the permission to share their medical history for educational purposes and publication.