A Case Series Describing Combined Negative Pressure Wound Therapy and Split-Thickness Skin Graft as a Method of Sterilizing and Closing Midline Laparotomy Wounds Near Ostomies

Negative pressure wound therapy (NPWT) was first developed in 1997 as a method to augment healing and regulate local inflammatory response.¹ By intermittently contracting the wound, negative pressure causes local hypoxia, which stimulates the release of pro-angiogenic factors and local vasodilation via nitric oxide.² This increased blood flow promotes bacterial load clearance, tissue granulation, and appropriate wound healing.²

Over the last 2 decades, studies have shown that NPWT decreases morbidity, hospitalization time, and health care costs.³ It has been incorporated into numerous surgical procedures. Due to the ability to sterilize the area and stimulate the development of new, healthy tissue, NPWT is a potential therapy to manage wounds near contaminated fields, including infected open abdominal lesions.^4-6

Using NPWT both preoperatively and postoperatively can also improve skin graft survival. Prior to skin grafting, NPWT can prepare the recipient site by promoting the creation of a clean, granulated base.^7-9 Postoperatively, NPWT devices stimulate imbibition, inosculation, and revascularization towards the graft.^10-11

The following case series of 3 patients describes the methodology and practice of successful skin grafting with NPWT to complex abdominal laparotomy wounds in close proximity to ostomies. The authors then provide insight into using NPWT for the effective preparation of previously contaminated and dirty laparotomy wounds, as well as evidence regarding the application of NPWT systems for successful skin graft take under these conditions. Lastly, future directions for research, such as controlled studies that analyze the benefits and challenges of using NPWT devices to improve skin graft survival in similar complex scenarios, are discussed.

Written and verbal informed consent was obtained from patients for the use of deidentified case information and photos in this study. Institutional review board approval is not required by Northwell Health for case series describing up to 3 patients. Information was obtained from Northwell Health inpatient and outpatient electronic medical records system and the attending physician’s knowledge of the case. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent was obtained for use of deidentified information and images.

After presentation, the patients’ wounds required several days of debridement with wet-to-dry (WTD) dressings, and antibiotics were used in cases of infection. After the wound was cleaned, debrided, and deemed not infected, NPWT with black granufoam was applied (3M V.A.C. Therapy), with negative continuous pressure at 125 mm Hg. The black granufoam was changed every 2 to 3 days. Cavilon barrier cream (3M) was applied to the edges of the skin to protect it prior to the application of the transparent drape of the NPWT. Wound edge maceration was not an issue in any of these cases after NPWT takedown. Several days later, a split-thickness skin graft from the thigh as the donor site was obtained with a dermatome kit (Integra). The graft was applied to the wound with staples around the edges to hold the graft in place. An NPWT device was applied on top of the graft and taken down on postoperative days 3 to 5.

Patient A

Patient A, a 75-year-old female with a history of rheumatoid arthritis treated with prednisone, coronary artery disease, and elective incisional hernia repair 2 years prior, presented with altered mental status, abdominal pain, and foul-smelling urine. Initial workup demonstrated fever, leukocytosis, hyponatremia, and acute kidney injury. The abdominal exam revealed tenderness over the left hemiabdomen without peritonitis. Imaging revealed sigmoid diverticulitis with associated small bowel inflammation and a small adjacent abscess, as well as a spigelian hernia. Patient A was treated nonoperatively with antibiotics, and a computed tomography (CT) cystogram was ordered to rule out a possible colovesical fistula. No fistula was found, but new onset pneumoperitoneum was noted, so the patient was taken emergently to the operating room for an exploratory laparotomy. The sigmoid colon was perforated with gross intraabdominal feculence (Hinchey IV diverticulitis), dense phlegmon, and abscessed cavity. An open resection of the sigmoid colon and transverse loop colostomy were performed.

The recovery was complicated by bleeding from the ostomy and uptrending leukocytosis despite antibiotics. On postoperative day 5, the patient returned to the operating room for an exploratory laparotomy with abdominal washout, lysis of adhesions, and spigelian hernia repair.  After closing the fascial defect, the 10-cm midline wound could not be closed primarily, and an NPWT device was used to facilitate healing. One month after the second surgery, the patient was transferred to the rehabilitative medicine service for 3 weeks of nutritional and functional rehabilitation.

However, the patient was readmitted 9 days after discharge with hypotension and fever due to a wound infection. Intravenous fluids, vasopressors, and broad-spectrum antibiotics were started. On physical exam, the abdominal wound had necrotic and friable tissue with foul-smelling drainage, but no abscess was indicated. The wound was treated with bedside debridement, daily dressing changes, and 14 days of antibiotic therapy. Per recommendations by the wound care team, dressings consisted of WTD fluffed gauze packing with dilute sodium hypochlorite solution (1/4 Dakin’s) twice a day along with surgical debridement. On hospital day 7, the patient underwent excisional debridement and pulsatile irrigation in the operating room. The abdominal wound was 20 cm × 10 cm with extensive fat and fascial necrosis, loose suture material, and granulation tissue at the level of the fascia. At the conclusion of the operation, an NPWT device was placed and irrigated with hypochlorous acid solution for 24 hours. During exchange of the NPWT sponge, the wound was pink and clean. The patient was discharged on postoperative day 58 with NPWT and antibiotics.

During outpatient follow-up, the full-thickness abdominal wound consisted of mostly granulated tissue with some yellow brown necrotic tissue at the right inferior aspect. The wound was malodorous with cultures positive for vancomycin-resistant Enterococcus faecalis, methicillin-resistant Staphylococcus aureus (MRSA), Citrobacter freundii, and Pseudomonas aeruginosa. Blood cultures were drawn and also had positive results, leading to a third admission 3 months after Patient A’s original discharge. Infectious disease was consulted and recommended starting cefepime. On hospital day 5, the wound appeared much improved without gross signs of infection. The patient underwent debridement in the operating room with abdominal split-thickness skin grafting using the right thigh as the donor site. An NPWT device was applied (Figures 1 and 2). The patient’s ostomy was 11 cm from the grafted wound. The NPWT system was first removed on postoperative day 5, showing a pink, clean, and adherent skin graft without hematoma or seroma (Figure 3). The NPWT system was replaced, and during exchange on postoperative day 7, the wound showed continued healing. No purulent drainage, malodor, or bleeding were observed. The right thigh donor site was also pink and moist without active bleeding. The patient was discharged and followed for the next 4 months for local wound care, including dressing change and debridement. The graft tissue was viable without necrosis or signs of infection.

Patient B

Patient B, an 84-year-old female with past medical history of hypertension, heart failure with preserved ejection fraction, dementia, and a left ovarian mass, was transferred from an outside hospital for management of an abdominal wound. The patient had been admitted for 55 days at the outside hospital, during which time she underwent an exploratory laparotomy, lysis of adhesions, rectosigmoidectomy, enterotomy repair, colovesical fistula takedown with bladder repair, pelvic mass unroofing, end colostomy creation, and hernia repair with component separation and biological mesh. The patient also underwent subsequent abdominal wound debridement, partial closure of the incision, and NPWT placement (Figure 4) after breakdown of the wound during that same hospitalization.

The patient arrived for wound care with a functional colostomy and a 12 cm × 10 cm abdominal wound with a pink, moist surface and scattered areas of yellow necrotic tissue in the center (Figure 5A and 5B). The wound was irrigated with hypochlorous acid solution (Vashe) and packed with WTD fluffed gauze. The patient was started on ampicillin/sulbactam with ciprofloxacin. The wound was cleaned with dilute sodium hypochlorite solution and packed with WTD fluffed gauze twice a day. Infectious disease changed antibiotic therapy to piperacillin/tazobactam based on culture results of P. aeruginosa and Enterobacter cloacae. On hospital day 5, the patient underwent debridement and split-thickness skin grafting with the right thigh as the donor site. An NPWT device was applied in close proximity to the patient’s ostomy.

On postoperative day 3, the NPWT device was removed to reveal a well-healing wound with graft take (Figure 6A). The NPWT device was replaced. On postoperative day 5, the patient’s condition had not changed except for a few areas of pale graft that bordered the wound (Figure 6B). Later, during the hospitalization, a portion of the skin graft appeared nonviable at the edge of the wound. This devitalized graft was excised at bedside. The donor site healed properly. The patient was ultimately discharged with continued local wound care (Figure 6C). Sharp excisional debridement was required once in follow-up, and no signs of infection were observed.

Patient C

Patient C, a 75-year-old female with past medical history of hypertension, type 2 diabetes, chronic obstructive pulmonary disease, myasthenia gravis, and stage 3 chronic kidney disease, presented with complicated diverticulitis with intraabdominal collections in the perisigmoid area and right lower quadrant (RLQ). Interventional radiology placed a drain to treat the abdominal collections, and the patient was discharged with antibiotics. Two weeks after discharge, Patient C presented with feculent output around the drain. The patient had mild RLQ and suprapubic pain without peritonitis. A CT scan of the abdomen and pelvis revealed a persistent abscess abutting the sigmoid colon and bladder with a fistulous tract extending towards the RLQ, which had larger collections extending into the subcutaneous tissue. A contrast injection demonstrated a large fistula directed to the sigmoid colon. The patient was started on broad-spectrum antibiotics and surgery was consulted.

Patient C underwent an exploratory laparotomy with abdominal washout, sigmoidectomy, and end colosotomy creation followed by open drainage of the abdominal wall collections. The fascia was closed using retention sutures, and the wound was packed with WTD dressings. The patient tolerated the procedure and was transferred to the Surgical Intensive Care Unit for postoperative monitoring. The patient recovered well, was downgraded to the surgical floor on postoperative day 6, and was ultimately discharged that day with WTD dressings.

During outpatient follow-up, feculent drainage and mild erythema were noted in the midline wound. Antibiotics were started, and the patient was readmitted for abdominal wound management. Cultures were positive for E. faecium and Candida lusitaniae. The burn and wound care team was consulted and performed a dressing change with betadine-soaked gauze and abdominal (ABD) pads. The wound was 12 cm × 8 cm × 3.5 cm with a bed of dry, marbleized subcutaneous tissue and tan-brown devitalized tissue. There was no active drainage, odor, induration, or warmth. The colostomy was well-appearing and in close proximity to the midline wound. During hospitalization, the wound beds were cleansed with normal saline, and an undermined area of the wound was packed with saline-moistened fluffed gauze dressing, covered with ABD pads, and secured with foam tape. The dressing was changed to collagenase Santyl ointment (Smith+Nephew) for enzymatic debridement, followed by an NPWT device on hospital day 5. On postoperative day 18 (hospitalization day 7), midline and RLQ necrotic and fibrinous tissue were debrided. The patient recovered well and was discharged with NPWT wound care.

Sixteen days after discharge, Patient C presented again to the emergency department with rectal pain and difficulty caring for the colostomy. The midline wound appeared irregular with copious green pus and a large eschar in the inferior right corner of the wound. The RLQ circular wound also had green pus and an eschar that tracked to the midline wound. An abdominal CT revealed a 3.1-cm fluid collection adjacent to the right kidney for which antibiotics were initiated. On hospital day 2, the area of necrotic tissue was debrided and irrigated at bedside. Cultures taken from the wound were positive for extended spectrum beta-lactamase Klebsiella pneumoniae, Proteus mirabilis, and P. aeruginosas. WTD daily dressing changes were continued. A necrotic area of 5 cm × 5 cm inferolateral to the wound was excised at bedside.

By hospital day 5, this patient required operative debridement and a new NPWT device. Extensive fat necrosis was found during surgery. On postoperative day 2, the patient underwent further debridement and split-thickness skin grafting (donor site from the right thigh) with NPWT placement. Infectious disease recommended starting meropenem. The NPWT device was removed on postoperative day 3, showing an adherent pink graft with minimal oozing and without purulence, hematoma, or seroma. The NPWT device was replaced and again removed on postoperative day 5, showing good graft take with a pink, adherent, and clean appearance (Figure 7A-7C). The right thigh donor site healed properly.

In these 3 complicated cases, midline surgical wounds were successfully treated and closed with the combination of NPWT and split-thickness skin grafts (Table). It has been established that NPWT effectively promotes wound healing.^1-3 However, the benefit of NPWT in the preparation of wound beds for delayed primary closure and local flap or skin graft placement is still underexplored.^12,13

NPWT works through 4 major mechanisms of action. First, macrodeformation reduces the wound size by approximately 80%.¹⁴ Second, increased tissue pressure reduces intravascular hydrostatic pressure through the Bernoulli and Venturi principles, preventing edema formation and improving cell oxygenation.^1-2,14 Third, it stabilizes the wound environment and reduces the frequency of dressing changes. Finally, it promotes microdeformation, which contributes to angiogenesis, cellular proliferation through mechanotransduction, and ultimately the generation of granulation tissue.¹⁰ Interestingly, the local immunoregulatory effects of negative pressure are essential for the correct development of these processes. For instance, by decreasing the distance between the capillaries and the healing cells, nutrients, oxygen, and white blood cells can transport freely.¹⁵ Furthermore, negative pressure is responsible for removing wound healing inhibitors such as metalloproteinases and other mediators, namely neutrophil gelatinase associated lipocalin, interleukin-8, tumor necrosis factor-α, and transforming growth factor-β.^15,16 Additional tissue proliferates in response to mechanical stress, which is encouraged by the cell membrane microstrain and the consequent disruption of integrins from the external forces of NPWT.^1,2,14 This releases growth factors, creates granulation tissue, and fully re-epithelializes the wound.^1,2

Argenta et al¹⁷ conducted a randomized study showing that NPWT healed wounds by secondary intention more rapidly than WTD dressings (P < .038). Eginton et al¹⁸and McCallon et al¹⁹ reported similar results. Condé-Green et al²⁰ conducted a retrospective study from 2008 to 2011 to compare abdominal wall reconstructions with NPWT to those using dry gauze. They showed a significantly lower rate of complications with NPWT, including dehiscence, infection, necrosis, and hernia recurrence.²⁰ The evidence for NPWT devices sterilizing previously infected wounds is still limited. Ford et al ²¹ presented a non-statistically significant result in microscopic wound healing after NPWT placement; favorable histologic changes and control of underlying infections in high-risk wounds that included osteomyelitis-related scenarios were observed. In this context, NPWT effectiveness in diabetic foot ulcers and pressure ulcers has also been widely discussed among literature.²²

In general surgery, the application of NPWT for temporarily closed abdominal wounds revolutionized treatment by minimizing bowel injury, fistula, and loss of heat.^4,23,24 However, the effect of NPWT devices on contaminated abdominal wounds is controversial. Lozano-Balderas et al²⁵ compared infection rates after primary closure, delayed primary closure, or NPWT placement in 81 laparotomized patients with either class 3 or 4 surgical wounds. Compared to other interventions, patients undergoing NPWT presented no surgical site infection.²⁵ Jannasch et al²⁶ compared the effects of NPWT and relaparotomy on demand on severity of disease, intraperitoneal bacterial load, and inflammatory response. There was no difference in mortality. However, the authors noted a tendency towards more severe findings, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and longer hospitalization time in the NPWT group.²⁶ Nevertheless, these findings might have been secondary to a biased selection of severe peritonitis in the NPWT group.²⁶

This article presents 3 scenarios in which the treatment of previously infected abdominal wounds with an NPWT device promoted the sterilization of the wound bed and successful skin grafting implantation. The combination of NPWT closure devices and split-thickness skin graft under contaminated fields is not clearly presented in the literature, especially regarding general surgery patients with ostomies. Zhang et al²⁷ demonstrated the effectiveness of combining NPWT, artificial dermis, and autologous epidermis skin grafting in the management of refractory wounds. Webster et al²⁸ conducted a systematic review that focused on the effects of NPWT for acute surgical wounds in orthopedic surgery, skin grafts, and general surgery. Other studies showed a similar wound infection rate compared to standard dressings and suggested a significant benefit from NPWT for skin graft survival.^29,30 The authors concluded that it was still unclear whether NPWT reduced surgical site infection or wound dehiscence, but NPWT lowered graft loss rates.²⁸ In addition, Maruccia et al³¹ proposed that the combination of NPWT and skin graft immobilized the matrix, moisturized the wound bed, removed debris, prevented the accumulation of collections, and reduced bacterial colonization, which ultimately improved graft take. The authors discussed the management of chronic vascular wounds and posttraumatic ulcers in 23 patients, and they reported a significant reduction of wound exudation, edema, and perilesional margins after NPWT.³¹

Finally, Yeung et al³² performed a retrospective study from 2010 to 2016 to assess the application of NPWT in 34 patients who underwent abdominal wall closure with synthetic mesh after controlling intraabdominal contamination. Among the recorded complications, the development of fistula, hernia, and sinus tracts were observed. Mortality rate was not attributed to mesh-related complication, inferring that using NPWT may actually prevent complications by decreasing infection rate, increasing granulation tissue formation, and removing dead tissue.³² Holmdahl et al³³ reduced symptomatic parastomal hernias in 4 patients with autologous full-thickness skin graft as intraperitoneal reinforcement. There were no major technical complications, such as infection, seroma, hematoma, stoma complication, or need for reoperation.³³ The present case report also recounts the successful placement of actual autologous skin grafts on controlled abdominal wounds using an NPWT device with no major complications. On final inspection, all skin grafts showed a pink, adherent, and clean surface with no active bleeding, purulence, hematoma, or seroma development.

This study should be interpreted under the limitations inherent to its design. While it presents 3 successful cases combining skin graft and NPWT, the lack of control groups, and thereby its susceptibility to bias, challenges generalizability of the findings. Despite the authors’ efforts, the possibility of selection or information bias secondary to the reliance on retrospective data available in the electronic medical record cannot be ruled out. Finally, there are inherent methodological constraints due to the independent treatment performed on each patient and the lack of homogeneity between their baseline conditions. Nonetheless, this study serves as a valuable catalyst for discussion and hypothesis generation, urging the need for controlled, expansive studies in this realm to validate these initial observations.

Skin grafting is a complex procedure that consists of transferring cutaneous tissue to a specific area to promote faster and, at times, more cosmetically acceptable wound healing. Proper skin graft selection should consider graft take, contracture, donor and recipient site morbidity, aesthetic background, and durability. Split-thickness skin grafts were chosen for these patients because they left enough dermal appendages in the donor site to regenerate new skin and prevented the accumulation of potential fluid, blood, or seroma after implantation through meshing, which was augmented by NPWT. NPWT facilitated the creation of well-vascularized wound beds for the skin grafts of these patients, disinfecting the area and stimulating the development of new healthy tissue.

NPWT promotes the creation of a clean base, which is particularly important for ensuring appropriate skin graft take and improving the success rate of these and similar procedures by strengthening the bond between the graft and recipient area. Nevertheless, evidence in this area is still mixed among current literature. Future studies should compare the use of NPWT and split-thickness skin grafts with NPWT or WTD alone for sterilizing and closing previously infected abdominal wounds in proximity to ostomies.

Authors: Maria Cardenas Sanchez, MD^1,2; Stalin Cañizares, MD³; Russell Hollis, MD, MBA^1,2; Jaclyn Yamada, MD^1,2; and Michael Cooper, MD^1,2

Author contributions: C.S. and C.M. gathered the information, wrote the case, and performed the literature review. H.R. and Y.J. analyzed the information and reviewed the draft. C.M. directed the project, reviewed the discussion, and wrote the final conclusions.

Affiliations: ¹Northwell Health, New Hyde Park, New York; ²Department of Surgery at Zucker School of Medicine, Uniondale, New York; ³Universidad San Francisco de Quito, Quito, Ecuador

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Disclosure: The authors have no financial or other conflicts of interest to disclose.

Correspondence: Maria Cardenas, Northwell Health, 430 Lakeville Road, New Hyde Park, NY 11042; mcardenas4@northwell.edu

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