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

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Presentation on theme: "Closing the Abdomen Mary Theophilus Specialists Without Borders Seminar in Surgery Rwanda, September 2010."— Presentation transcript:

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

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

3 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 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. Post-operative Wound Dehiscence

5 Post-operative Wound Dehiscence 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. 2 weeks post-laparotomy for perforated appendicitis

6 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 Principles of Abdominal Closure

7 Tension Sutures

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

9 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 Abdominal Compartment Syndrome

10 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 Laparostomy - Temporary Closure Advantages

11 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 Laparostomy - Temporary Closure Disadvantages

12 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 Good technique

13 Bogota bag Towel clip closure Zip closure Mesh (absorbable, non-absorbable, composite) Vac dressing Laparostomy Techniques

14 Bogota bag Laparostomy Techniques

15 Towel clip closure Laparostomy Techniques

16 Vac Dressing Laparostomy Techniques

17 Suction dressing Laparostomy Techniques

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

19 Component Separation Technique

20 Non absorbable Absorbable Composite Bilayer Organic Mesh closure post Laparostomy

21 Close skin if possible, else vac dressings, skin grafting, tissue flaps

22 Conclusions 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 Finding 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 ( ) References

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25 Thank You!


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