Successful Re-Closure with Adjunctive Retention Sutures for Fascial Dehiscence after Mesh-Mediated Fascial Traction in Open Abdomen Management for Perforated Sigmoid Diverticulitis: A Case Report.

INTRODUCTION: Open abdomen management (OAM) is sometimes required in patients with severe peritonitis and septic shock when primary fascial closure is unsafe or impossible. Mesh-mediated fascial traction (MMFT) combined with negative pressure wound therapy (NPWT) is a useful strategy for delayed fascial closure. However, fascial dehiscence may still occur after definitive closure in patients with multiple risk factors for impaired wound healing. Reports describing retention sutures as a salvage adjunct for fascial dehiscence after MMFT are scarce. We report a high-risk case in which re-closure with adjunctive retention sutures maintained abdominal wall closure after fascial dehiscence following staged closure.

CASE PRESENTATION: A man in his 60s with obesity and ongoing corticosteroid therapy for interstitial pneumonia was transferred to our hospital with upper abdominal pain and profound septic shock. CT showed extraluminal gas predominantly in the upper abdomen and pelvic ascites, but the perforation site was unclear. Emergency exploratory laparotomy revealed perforated sigmoid diverticulitis. Because of severe hemodynamic instability, segmental sigmoid colectomy was performed, and OAM was initiated. After second-look surgery, primary fascial closure remained difficult because of marked bowel edema and obesity. MMFT combined with NPWT was therefore performed. The abdominal wall defect gradually decreased, and fascial closure was achieved on POD 13. However, fascial dehiscence occurred on POD 17, with the small intestine in direct contact with the fascial sutures. On POD 18, re-closure was performed using fascial re-suturing combined with 4 retention sutures. During closure, the fascia was gradually approximated toward the midline with manual lateral-to-medial compression of the trunk, and the skin was left open with continued NPWT. The patient was transferred for rehabilitation on POD 100. At 1-year follow-up, the wound was fully epithelialized, and no obvious incisional hernia was observed.

CONCLUSIONS: Fascial dehiscence may occur even after staged closure with MMFT and NPWT in high-risk patients. Adjunctive retention sutures may be a salvage option for re-closure when conventional fascial re-suturing alone is considered insufficient.