Scientific paper Endoscopic components separation for abdominal compartment syndrome Miranda Voss, M.D. a, *, Jose Pinheiro, M.D. a , James Reynolds, Ph.D. b , Rebecca Greene a , Mark Dewhirst, Ph.D., D.V.M. c , Steven N. Vaslef, M.D., Ph.D. a , Erik Clary, D.V.M. a , W. Steve Eubanks, M.D. a a Division of Surgery, Box 3479, Duke University Medical Center, Durham, NC 27707, USA b Division of Anesthesiology, Duke University Medical Center, Durham, NC, USA c Division of Radiation Oncology, Duke University Medical Center, Durham, NC, USA Manuscript received July 15, 2002; revised manuscript November 16, 2002 Abstract Background: Sustained intraabdominal pressures of 14 to 20 mm Hg have significant pathophysiological consequences, but there is currently no satisfactory low-morbidity procedure appropriate for intervention early in the disease process of abdominal compartment syndrome (ACS). The anatomical principles of abdominal wall components separation were used to develop a percutaneous procedure that increased abdominal capacity and decreased abdominal pressure. Methods: Using a porcine model, we determined abdominal capacity changes by helium insufflation. Corn oil was then used to create an episode of sustained intraabdominal hypertension and changes in intraabdominal pressure and intestinal mucosal oxygenation were determined. Results: Endoscopic abdominal wall components separation (EACS) increased abdominal capacity by 1 L (from 0.89  0.39 L to 1.95  0.48 L; P 0.001). During intraabdominal hypertension, EACS decreased abdominal pressure by 31.6% (from 15.9  2.1 to 11.0  1.5 mm Hg; P 0.001). Intestinal PO 2 was increased by 61% (18.8  11.4 to 30.3  11.7; P = 0.012) Conclusions: A minimally invasive procedure (EACS) is feasible and has demonstrated effectiveness in a porcine model of ACS. © 2003 Excerpta Medica, Inc. All rights reserved. The importance of abdominal compartment syndrome (ACS) as a major pathological event in the critically ill patient is being increasingly recognized. Initiated by a sus- tained increase in intraabdominal pressure (IAP), ACS may follow massive fluid resuscitation, burns, or abdominal trauma. Hypoperfusion of intraabdominal organs with im- paired cardiovascular, pulmonary, and renal function results [1–5]. Treatment for ACS involves decompression to reduce IAP. This is usually performed when an abdominal pressure greater than 20 to 25 mm Hg is associated with renal, cardiovascular, or pulmonary deterioration [1,3,6]. The ab- domen is opened and a pressure free closure is achieved by suturing a synthetic sheet to the fascia. The most popular current closure utilizes a sterile 3 L urological bag, the “Bogota bag”. This will successfully reverse the organ fail- ure that precipitated the decompression in more than 90%, but mortality from multiple organ failure is still 30% to 40% [1,6,7]. For survivors, this approach is associated with consider- able medium term morbidity. The abdomen cannot usually be formally closed on the same admission and, typically, the exposed viscera are covered with a split-thickness skin graft. The large hernial defect is then closed after approxi- mately 6 months. This means that most clinicians are un- derstandably reluctant to intervene at pressures less than 20 mm Hg. There is, however, good experimental evidence that more modest elevations in abdominal pressure have signif- icant physiological consequences. A significant drop in in- testinal mucosal perfusion has been demonstrated at pres- sures of 14 to 20 mm Hg in several animal models and is associated with impairment of the gut mucosal barrier [1,8 – 10]. Translocation of bacteria and endotoxin from the gut is * Corresponding author. Tel.: +1-919-681-3442; fax: +1-919-681- 7934. E-mail address: mvoss@duke.edu The American Journal of Surgery 186 (2003) 158 –163 0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00171-5