Use of ABTHERA™ for an extensive abdominal wall defect caused by entrapment in a noodle stirring machine: a case report

An extensive abdominal wall defect is rare but severe trauma. Here, we have described the case of a male patient in his 20s who sustained extensive abdominal wall injury and intra-abdominal organ damage after being caught in a noodle stirring machine. We used ABTHERA as a substitute for a defective abdominal wall, achieved open abdominal management and temporary closure of a wide abdominal wall defect, and performed staged reconstruction surgery.


Introduction
After an abdominal injury, the open abdomen must be managed during damage control surgery and for abdominal compartment syndrome.In this report, we have described a case of severe abdominal trauma caused by a noodle stirring machine that resulted in an extensive abdominal wall defect.Open abdominal management (OAM) was achieved using an ABTHERA™ Dressing Kit, and abdominal wall reconstruction with skin flap surgery was performed.

Case presentation
A male in his 20s was injured when his abdomen became entangled in the shaft of a noodle stirrer while working at a noodle factory.The abdominal wall suffered an injury by the shaft of the agitator, and the intestinal tract had prolapsed, which made shaft removal difficult.A physician was sent to the location, where the agitator was disassembled and first aid was provided simultaneously.The patient was sent to the hospital with the shaft entangled in his abdomen.
Examination at the time of hospital admission revealed the following: Glasgow Coma Scale, E4V5M6; blood pressure, 145/102 mmHg; pulse, 128 beats/min; respiratory rate, 24 breaths/min; body temperature, 35.7 • C; and SpO 2 , 98 % (room air).The patient was slightly disturbed with marked cold sweats.Abdominal examination showed intestinal evacuation with an agitator shaft trapped in the abdomen (Fig. 1a, b).
The patient underwent surgery immediately upon arrival at the hospital, and the trapped clothing and shaft were removed from the abdomen.The abdominal wall was torn in a complex manner and was difficult to repair.However, the intra-abdominal organ damage was repaired, and the patient was admitted to the intensive care unit with OAM using ABTHERA™.On days 2, 4, and 7, the patient underwent the second, third, and fourth surgeries to clean the abdomen, replace the ABTHERA™, and resect the necrotic abdominal wall, respectively.On day 8, the patient's general condition was stable, and he was extubated and weaned from the ventilator.On day 10, the patient underwent left lateral femoral flap surgery by a plastic surgeon, and continuous negative pressure wet therapy (NPWT) * Corresponding author at: 1397-1, Yamane, Hidaka-City, Saitama-Pref, 350-1298, Japan.
Contents lists available at ScienceDirect  Even after 3 years of injury, the patient has a huge hernial gate on the right side of his abdomen; however, he is in good general condition and has returned to work as a driver in the transportation industry.

Intraoperative findings and surgeries
The abdominal wall was severely ruptured.The serosa of the small intestine was damaged and perforated 80 and 120 cm, respectively, from the ligament of traits, and the mesentery of the small intestine was damaged 130 cm from the ligament of traits.The right external iliac artery was ruptured.The abdominal wall, including the right rectus abdominis muscle, was severely damaged and was expected to be a source of infection due to a lack of blood flow.Partial resection and reconstruction of the injured small bowel were Y. Ooya and S. Takahira achieved using functional end-to-end anastomosis.After thrombectomy, an artificial graft was placed in the ruptured right external iliac artery.The abdominal wall was resected (10 × 10 cm), where necrosis was likely to occur because of severe damage.OAM was performed using ABTHERA™.
On the second day of hospitalization, another operation was performed to examine the abdomen.The small bowel anastomosis was clean, and no contamination or bleeding was detected in the abdominal cavity (Fig. 2).On the fourth day of hospitalization, the remaining abdominal wall tissue was debrided because of poor coloration.The torn skin was sutured as much as possible, and OAM with ABTHERA™ was continued.On the seventh day of hospitalization, the intestinal tract was covered with a large mesh and adhesions were observed.No infection or bleeding was detected (Fig. 3).OAM was continued with ABTHERA™.The abdominal cavity was in a good condition to allow wound closure.On the tenth day of hospitalization, a plastic surgeon created a 30 × 22-cm skin flap on the anterolateral side of the left thigh.Sternotomy was performed to reconstruct the abdominal wall.The skin defect was simultaneously treated with a segmental skin graft (Figs.4-5).The final diagnosis was extensive abdominal wall injury, right common iliac

Fig. 1 .
Fig. 1. a. Agitator shaft in the abdominal wall.b.Extensive abdominal wall defect and prolapsed intestine.

Fig. 3 .
Fig. 3. Covering of the intra-abdominal organs with biofilm during the fourth surgery.

Y 6 Fig. 5 .
Fig. 5. Postoperative skin valvuloplasty.NPWT was used to manage the skin flap extraction area and segmental skin graft area.