Presentation on theme: "Specialists Without Borders"— Presentation transcript:
1Specialists Without Borders Seminar in SurgeryRwanda, September 2010Closing the AbdomenMary Theophilus
2Outline Factors influencing type of abdominal closure OutlineFactors influencing type of abdominal closurePost-operative wound dehiscencePrinciples of abdominal closureAbdominal Compartment SyndromeLaparostomy = temporary closureClosure post-laparostomy
3What type of closure? Factors influencing type of abdominal closure What type of closure? Factors influencing type of abdominal closurePatient factorsdiabetes, steroids, obesity, malnutrition etc…Operative factorsRisk of wound infection…contamination?Unable to close abdomenWeak or frayed fasciaPlanned re-operation(s)?
4Post-operative Wound Dehiscence Post-operative Wound DehiscenceSignsExcessive serous discharge from woundPalpable defect in fasciaBowel on view !A full thickness wound dehiscence involving bowel requires urgent closureherniated bowel will develop an overlying layer of granulation tissue (peritonealised) making future hernia repair impossible.
5Post-operative Wound Dehiscence Post-operative Wound Dehiscence2 weeks post-laparotomy for perforated appendicitisSmall 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.
6Principles of Abdominal Closure Principles of Abdominal ClosureNo tension !Single layer closureIncorporating fascia and no muscleJenkins’ Rule of 42cm by 2cmContinuous vs InterruptedIf high risk of wound infection - use interrupted
8If it will not close! Back to first principles – NO TENSION If it will not close!Back to first principles – NO TENSIONAbdominal Compartment Syndrome= Laparostomy with later primary or mesh closure
9Abdominal Compartment Syndrome Abdominal Compartment SyndromeOrgan dysfunction caused by intraabdominal hypertensionNormal pressure – 5-7mmHg , Hypertension - >12mmHgRespiratory, renal and GI tract impairmentIntravesical pressure measurementNG tube, empty gut, diuretics= Laparostomy with later primary or mesh closure
10Laparostomy - Temporary Closure Advantages Laparostomy - Temporary Closure AdvantagesProtects small bowel from fascial adhesionsAvoids fascial retraction and loss of domainAllows tissue oedema to settle and the abdomen to close without tensionUseful if further planned re-operation
11Laparostomy - Temporary Closure Disadvantages Laparostomy - Temporary Closure DisadvantagesFraying of the fascia (if sutured) compromising subsequent definitive closureLong term laparostomy can lead to shortening of the rectus abdominis musclesEspecially in the obeseMakes definitive closure difficultRelaxation incisions maybe required
12Good technique Rapid closure Protects intra-abdominal organs Good techniqueRapid closureProtects intra-abdominal organsPrevents peritoneal contaminationAddresses peritoneal fluidAllows reoperation with minimal tissue damageAllows timely and easy closure with low rate of ensuing wound complications
22ConclusionsPrimary 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
23ReferencesFinding the best Abdominal Closure: An evidence based review of the Literature, Ceydeli A, Rucinsk J, Wise L; Current Surgery 2005 vol 62:2,Temporary abdominal closure with the Vacuum pack technique, Ozguc H, Paksoy E,Ozturk E; Acta Chir Belg 2008, 108 ( )