Safe and Early Primary Closure of Open Abdomen in Pediatric Liver Transplantation Using a Doppler-Guided Tension Relief Strategy and Enhanced Wound Environment.

Abstract

Pediatric liver transplantation (LT) with large-for-size (LFS) grafts frequently necessitates open abdomen (OA) management due to donor-recipient graft size mismatch, increasing the risk of delayed closure and frequently requires the use of permanent prosthetic materials, together compounding the risk of postoperative infection. This study evaluates the safety and effectiveness of the Topaz-Gurevich Doppler-guided controlled-closure technique (DGCT) in facilitating early primary abdominal closure without graft size reduction or the use of permanent prosthetic implants. A retrospective review was conducted at Schneider Children's Medical Center (2016-2024), including 21 pediatric LT recipients requiring OA management, primarily due to LFS grafts. DGCT integrates a tension relief system (TRS) for gradual abdominal wall approximation, guided by real-time Doppler ultrasound to monitor perfusion and modulate closure tension, and is complemented by regulated, oxygen-enriched irrigation and negative pressure-assisted wound therapy to optimize the local wound environment. All patients achieved primary abdominal closure within a median of 8 days (range, 2-23); only the first three cases required the temporary use of prosthetic materials. The median PICU and hospital stays were 17 and 35 days, respectively. No cases of graft failure, retransplantation, or mortality occurred. One patient developed sepsis related to a bowel leak and fully recovered. DGCT proved safe and effective in managing OA in pediatric LT, avoiding permanent prosthetic implantation, and enabling early closure while maintaining graft perfusion. Its combined approach of mechanical tension control and enhanced local wound conditions reduces the need for graft size reduction, minimizes infection risk, and may broaden the donor pool. Based on high-risk cases involving immunosuppressed children with significant graft-recipient mismatch, these findings support DGCT as a valuable strategy for pediatric transplantation. Moreover, the principles demonstrated here may be extrapolated to the closure of complex OA scenarios across broader pediatric and adult surgical populations.