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Closing the Abdomen

Closing the Abdomen

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Closing the Abdomen

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  1. Specialists Without Borders Seminar in Surgery Rwanda, September 2010 Closing the Abdomen Mary Theophilus

  2. Outline www.specialistswithoutborders.org Factors influencing type of abdominal closure Post-operative wound dehiscence Principles of abdominal closure Abdominal Compartment Syndrome Laparostomy = temporary closure Closure post-laparostomy

  3. www.specialistswithoutborders.org What type of closure?Factors influencing type of abdominal closure • Patient factors • diabetes, steroids, obesity, malnutrition etc… • Operative factors • Risk of wound infection…contamination? • Unable to close abdomen • Weak or frayed fascia • Planned re-operation(s)?

  4. www.specialistswithoutborders.org Post-operative Wound Dehiscence • Signs • Excessive serous discharge from wound • Palpable defect in fascia • Bowel on view ! • A full thickness wound dehiscence involving bowel requires urgent closure • herniated bowel will develop an overlying layer of granulation tissue (peritonealised) making future hernia repair impossible.

  5. Post-operative Wound Dehiscence www.specialistswithoutborders.org 2 weeks post-laparotomy for perforated appendicitis Small bowel in the base of the wound has been covered by granulation tissue, making primary closure of the wound impossible. The wound was treated with dressings.

  6. www.specialistswithoutborders.org Principles of Abdominal Closure • No tension ! • Single layer closure • Incorporating fascia and no muscle • Jenkins’ Rule of 4 • 2cm by 2cm • Continuous vs Interrupted • If high risk of wound infection - use interrupted

  7. Tension Sutures www.specialistswithoutborders.org

  8. www.specialistswithoutborders.org If it will not close! • Back to first principles – NO TENSION • Abdominal Compartment Syndrome • = Laparostomy with later primary or mesh closure

  9. www.specialistswithoutborders.org Abdominal Compartment Syndrome • Organ dysfunction caused by intraabdominal hypertension • Normal pressure – 5-7mmHg , Hypertension - >12mmHg • Respiratory, renal and GI tract impairment • Intravesical pressure measurement • NG tube, empty gut, diuretics • = Laparostomy with later primary or mesh closure

  10. www.specialistswithoutborders.org Laparostomy - Temporary ClosureAdvantages • Protects small bowel from fascial adhesions • Avoids fascial retraction and loss of domain • Allows tissue oedema to settle and the abdomen to close without tension • Useful if further planned re-operation

  11. Laparostomy - Temporary ClosureDisadvantages www.specialistswithoutborders.org • Fraying of the fascia (if sutured) compromising subsequent definitive closure • Long term laparostomy can lead to shortening of the rectus abdominis muscles • Especially in the obese • Makes definitive closure difficult • Relaxation incisions maybe required

  12. www.specialistswithoutborders.org Good technique • Rapid closure • Protects intra-abdominal organs • Prevents peritoneal contamination • Addresses peritoneal fluid • Allows reoperation with minimal tissue damage • Allows timely and easy closure with low rate of ensuing wound complications

  13. www.specialistswithoutborders.org Laparostomy Techniques • Bogota bag • Towel clip closure • Zip closure • Mesh (absorbable, non-absorbable, composite) • Vac dressing

  14. www.specialistswithoutborders.org Laparostomy Techniques • Bogota bag

  15. www.specialistswithoutborders.org Laparostomy Techniques • Towel clip closure

  16. www.specialistswithoutborders.org Laparostomy Techniques • Vac Dressing

  17. www.specialistswithoutborders.org Laparostomy Techniques • Suction dressing

  18. www.specialistswithoutborders.org Primary closure post laparostomy • Ideal • May be closed serially • May require other techniques to facilitate : Relaxing incisions in the fascia

  19. www.specialistswithoutborders.org Component Separation Technique

  20. www.specialistswithoutborders.org Mesh closure post Laparostomy • Non absorbable • Absorbable • Composite • Bilayer • Organic

  21. www.specialistswithoutborders.org Close skin if possible, else vac dressings, skin grafting, tissue flaps

  22. Conclusions www.specialistswithoutborders.org Primary closure best but only if NO TENSION Abdominal compartment syndrome should be avoided and treated with laparostomy Good laparostomy techniques enable early secondary closure and help avoid late wound complications

  23. www.specialistswithoutborders.org References • Finding the best Abdominal Closure: An evidence based review of the Literature, Ceydeli A, Rucinsk J, Wise L; Current Surgery 2005 vol 62:2, 220-225 • Temporary abdominal closure with the Vacuum pack technique, Ozguc H, PaksoyE,Ozturk E; ActaChir Belg 2008, 108 (414-419)

  24. www.specialistswithoutborders.org

  25. www.specialistswithoutborders.org Thank You!