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

2. Outline Factors influencing type of abdominal closure
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
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. Post-operative Wound Dehiscence
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
Post-operative Wound Dehiscence
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. Principles of Abdominal Closure
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

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

9. Abdominal Compartment Syndrome
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. Laparostomy - Temporary Closure Advantages
Laparostomy - Temporary Closure Advantages
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 Closure Disadvantages
Laparostomy - Temporary Closure Disadvantages
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. Good technique Rapid closure Protects intra-abdominal organs
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. Laparostomy Techniques
Laparostomy Techniques
Bogota bag
Towel clip closure
Zip closure
Mesh (absorbable, non-absorbable, composite)
Vac dressing

14. Laparostomy Techniques
Laparostomy Techniques
Bogota bag

15. Laparostomy Techniques
Laparostomy Techniques
Towel clip closure

16. Laparostomy Techniques
Laparostomy Techniques
Vac Dressing

17. Laparostomy Techniques
Laparostomy Techniques
Suction dressing

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

19. Component Separation Technique
Component Separation Technique

20. Mesh closure post Laparostomy
Mesh closure post Laparostomy
Non absorbable
Absorbable
Composite
Bilayer
Organic

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.
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,
Temporary abdominal closure with the Vacuum pack technique, Ozguc H, Paksoy E,Ozturk E; Acta Chir Belg 2008, 108 ( )

25.
Thank You!