Bogota bag - Forum

[Dottore]

This 47 year old Indian Patient presented with severe abdominal pain and
distension. A plain xray of abdomen showed dilated s.intestinal loops. He
had an upper midline scar,the surgery was performed 10 years ago for
stones in the abdomen!.Diagnosed as acute intestinal obstruction he had
an exploratory laparotomy, this showed intensely congested burgundy
coloured dilated small intestine from the DJ to caecum. the small
intestine had rotated around a Roux en Y going through the transverse
mesocolon to form a Puestow Pancreaticojejenostomy for Tropical
Pancreatitis. This is a pancreatitis only seen in the Kerela province of
India caused by obstruction of the pancreatic duct by calculi.Untwisted
the bowel only gangrenous part was the limb of the Roux en ,this was
resected, the bowel remained deep red and dilated. Decided to construct
the bogota bag( large plastic bag) sutures to linea alba. This was 6 days
ago, at present the bowel looks fine but still dilated
Questions
1.As the patient is still on Respirator with multiple organ failure, how
long can we safely keep the bowel in the plastic bag?
2.Would it be better to remove bag and use a vicyl mesh to close the
abdomen without creating a compartment syndrome?

[Surgeon]

>1.
As long as necessary- bowel will be happy within the moist environment of
Bogota bag.

>2.
Not "better" but an option. Once you decide that the bowel is less
distended you may wish to diminish the eventual abdominal wall defect by
reducing it's size; among the many options an absorbable mesh sutured to the
defect's edges is reasonable.

While decreasing the defect you may want to measure IAP in order not to pull
it too tight. I wouldn't want to have it above 15-20 cm water.

If you wait long enough -you may be able to close the abdomen although itis
a rare possibility in my experience.

[Marcel]

1. First you need to be able to reexamine the viscera until you are satisfied
that nothing else bad is going on.
2. If you leave a prosthetic material in contact w/ the intestine you will be
at risk for developing fistulae, which will be extremely difficult to treat
with an open abdomen.
3. You need to get the rectus muscles back together as quickly as possible,
before they become fixed in position and immovable.
4. I like to use polypropylene mesh sewn to the fascial edges, with a zipper
in the center. I put a folded rubber sheet under the mesh to keep it from
adhering to the bowel.
5. Each time I go back to the OR I reef up the mesh and gradually put tension
on the
rectus muscles/fascia. When I have just a small amount of mesh/zipper left in
place
I go back a final time and do a separation of components repair.
6. By separation of components, I mean take out all the prosthetic, make large
relaxing incisions in the anterior rectus sheaths bilaterally, pull the linea
alba together, and then irrigate and cover over the whole thing with a fresh
piece of polypropylene mesh. By now the bowel is protected by the patients own
tissue (rectus muscle and fascia) and the skin will usually be able to come
together and cover this.
7. This is a lot of work, and it uses a lot of resources, but it leaves the
patient with a nice closure and minimizes the chance of bowel erosion,
fistula, etc. I have found it helpful for really terrible risk patients e.g.
perforated diverticulum in renal failure pts. etc.

[forceps]

By now you will find the gut is well stuck to itself and you may remove the bag with impunity (we take it usually about 7 - 10 days). If you can't close the abdomen (which in your case you can't) then allow the wound to granulate and then put a split skin graft over it. The patient can be discharged and return later (6m - 1yr) for his hernia repair, amazingly the bowel seems to separate itself off from the abdominal wall by this time and the closure is usually not too difficult. My old boss in Durban has a series of about 150 of these which he's collected over the past 8 years or so. The mortality approaches 50%, a fair proportion could be closed whilst in hospital, but many needed delayed closure.

[John Dissector]

6. By separation of components, I mean take out all the prosthetic, make large
relaxing incisions in the anterior rectus sheaths bilaterally, pull the linea
alba together, and then irrigate and cover over the whole thing with a fresh
piece of polypropylene mesh. By now the bowel is protected by the patients own
tissue (rectus muscle and fascia) and the skin will usually be able to come
together and cover this.

I agree with all you said except this--and this is such a common practice
which represents the classic case of the doctor treating himself--there isn't
the slightest bit of evidence that covering a primarily-closed wound with a
prosthetic mesh has any benefit at all--are you really that insecure that you
feel you need to do something beyond your primary repair? I have chopped thru
enough of these abdominal walls with a layer of "security blanket" mesh
overlying a primary repair to know how horrendous a problem you thereby create
for the patient. I have also seen these closures dehisce and return with
ventral hernia despite the added mesh. Not only is this stuff expenseve (and
its so nice of you to add this useless cost to the patient's bill!), but it
can significantly increase the risk of complications--needlessly

[Sweden surgeon]

I would appreciate information regarding the procurement of vicryl meshes.

[Alalo]

I would appreciate information regarding the procurement of vicryl meshes.

Ethicon which is a division of Johnson and Johnson, makes the Vicryl mesh, I think.

[Dottore]

I am very insecure about these repairs. Most of these patients are very
sick, usually debilitated or malnourished to start with, and their rectus
muscles are often very weak and/or attentuated. That needs some additional
tensile strength.
Sometimes I have just used a diamond shaped piece of mesh to cover the muscle
exposed bu the relaxing incision. This allows a midline which is the patients
native
linea alba only (with suture material) and avoids having to chop through mesh.
I have also gone though mesh many times and often it is quite easy, and
actually
for a quite nice closure at the end of the case. The problem results in those
5-6% of cases where there is dense adhesion of bowel and erosion, fistula
formation, etc.
I am just not secure closing these patients without some additional
reinforcement.
What do you do?

[John Dissector]

My point is this practice does not ADD any security or tensile strength to
your repair--just like people throwing antibiotics at a wound at high risk
even tho it doe4s nothing--it sounds good to you, but since you are imposing
this risk and expense, it is your burden to prove it is justified with
evidence--do you have any? This is not a benign procedure to be doing with no
proven benefit

[Dottore]

As usual, you are right, I don't have any evidence, however I am trying to get
a tensiometer so I can test this concept in the lab. I do know the following:
1.there aren't any prospective studies about this either way.
2.the failure rate for abdominal wall closure under these circumstances is
high.
3.many abdominal wall closures(and hernia repairs as well) fail because of
creep in the suture materials used.
4.we don't know much about the biomechanics of prosthetic materials in
abdominal wall closure and failure of same. To my knowlege engineering
principles such as
analysis of stress in the abdominal wall of the living organism have not been
studied-
I think this is a potentially fruitful line of inquiry.