Compartment Syndrome of the Abdominal Cavity

Michael Sigman

Dietmar H. Wittmann

Fred A. Luchette

I. GENERAL PRINCIPLES

A. Overview.

1. The abdominal cavity is considered as single compartment enclosed by an aponeurotic envelope with limited compliance.

2. First coined by Kron et al. in 1984 when they described the pathophysiologic changes following a ruptured abdominal aortic aneurysm.

3. Elevated intra-abdominal pressure (IAP) can impair blood flow and organ function.

4. Once critical threshold volume is reached, small increments in tissue volume lead to exponential increases in intraperitoneal pressure. Elevated IAP may result in multiorgan failure and death if not reversed promptly.

B. Definitions.

1. Compartment syndrome: increased pressure in a confined anatomic space that adversely affects function and viability of tissue within the compartment.

2. Abdominal compartment syndrome (ACS): acutely increased and sustained pressure within the abdominal wall, pelvis, diaphragm, and retroperitoneum, adversely affecting function of organs and tissue within and adjacent to the abdominal cavity. Usually requires operative decompression of the peritoneal cavity.

3. Intra-abdominal hypertension (IAH): sustained (>6 hours) increase in IAP that may or may not require operative decompression.

4. On the basis of the consensus statement of the World Society of the Abdominal Compartment Syndrome, IAH was defined as IAP ≥ 12 mm Hg and ACS as a sustained IAP ≥ 20 (measured at the level of the mid-axillary line), which is associated with new organ dysfunction or failure. Note that there is no definitive IAP at which ACS occurs.

a. Normal abdominal pressure: 10 mm Hg.

b. Grade I: 12 to 15 mm Hg.

c. Grade II: 16 to 20 mm Hg.

d. Grade III: 21 to 25 mm Hg.

e. Grade IV: >25 mm Hg.

TABLE 102-1 Causes of Abdominal Hypertension

Peritonitis, trauma, burns	Retroperitoneal hematoma
Fluid overload: hemorrhage or septic shock	Peritoneal operative trauma
Bowel edema, reperfusion injury, acute pancreatitis	Ileus, bowel obstruction
Intra-abdominal mass	Abdominal closure under tension
Ascites, intra-abdominal fluid collection	Laparoscopic abdominal insufflation
	Weight lifting up to >200 mm Hg (physiologic abd. hypertension)

II. PATHOPHYSIOLOGY

A. Causes: Most IAH is caused by peritoneal, mesenteric, or retroperitoneal edema impinging on the fascial envelope of the abdominal compartment.

1. Total surface area of peritoneum is about 1.8 m², which is approximately equal to the entire surface area of skin. Theoretically, 1 mL of peritoneal thickening may contain 15 to 18 L of fluid.

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