abdominal wall closure - suny downstate medical center€¦ · · 2015-03-26what is the optimal...

Abdominal Wall Closure David Radvinsky, PGY-4 Richmond University Medical Center March 26, 2015

WWW.DOWNSTATESURGERY.ORG

Presenter

Presentation Notes

Labs Ct references

First, a Case!

61 year old male ◦ 5 day history of diffuse abdominal pain ◦ Worsened the morning of presentation ◦ Nausea and nonbilious/nonbloody vomiting ◦ Denies fevers ◦ No obstructive symptoms ◦ Similar to prior episodes


Presentation PMHx: none PSHx: 4 prior instances of small bowel perforation s/p

ex-lap (2003, 2007, 2009, 2012) ◦ Ventral hernia repair with mesh during 2007 operation

SH: smokes 1 ppd x 43 yrs Allergies: NKDA Meds: omeprazole

Prior workup included CT scans, upper and lower

endoscopy, and capsule endoscopy.

Working Diagnosis: Small bowel vasculitis secondary to smoking


Exam Afebrile, HR 90’s BP 120’s/70’s Sp02 >95% Moderate distress Abdomen distended, peritoneal Previous midline laparotomy scar noted with

reducible ventral hernias

17 382 12.1 24.0

132 92 11 1.1 3.3 26 0.6

98

16.4 50.9


Presenter

Presentation Notes

Add labs

OR – after resuscitation of course

Exploratory Laparotomy Extensive lysis of adhesions Primary repair of jejunal perforation

2 layers

Pathology: none


Abdominal Wall Closure

Alternating interrupted figure of eight and simple #1 prolene sutures

Fascia supported with #2 nylon retention sutures


POD#1 Sedation weaned Evisceration of small bowel

To OR: ◦ Re-exploration ◦ Abdominal washout ◦ Strattice Mesh ◦ Sutures broke / pulled through fascia


Post-Op Course Extubated POD#2 Wound VAC Complicated by post-op ileus, AKI ◦ Metabolic alkalosis ◦ Short term TPN

POD#11- Return of bowel function POD# 14 - Restarted diet ◦ Downgraded to the floor

Nutrition – Prealbumin 5.9 -> 29 PT and Wound Care POD#21 Discharged


Questions?


Laparotomy Closure

Anatomy Primary closure ◦ Basics of elective closure ◦ Dehiscence ◦ Retention sutures

Relaparotomy ◦ Temporary abdominal closure ◦ Planned ventral hernia ◦ Abdominal wall reconstruction


Anatomy


Abdominal Wall Closure

What is the optimal technique for primary abdominal wall closure to prevent incisional hernia, dehiscence, and evisceration?

Incisional hernia incidence – 9-20% Dehiscence – 0.5-3.5%


Presenter

Presentation Notes

wound ruptures along surgical suture.

Case:

50 yo male with hx of recurrent diverticulitis.

Exploratory laparotomy, sigmoidectomy with primary anastomosis.

About to close abdomen….


What do you do?

Mass closure vs. layered? Type of suture? ◦ Absorbable vs. non-absorbable? ◦ Monofilament vs. Braided?

Running vs. Interrupted closure? Close the peritoneal layer? Size of the bites? Suture to wound length ratio?


Presenter

Presentation Notes

What size looped PDS

Mass closure vs. Layered technique Layered technique ◦ Anterior and Posterior aponeurotic sheaths separately

Mass closure technique ◦ Single-layer closure of all musculofascial layers ◦ +/- peritoneum ◦ No skin

No advantage of layered technique over mass closure


Presenter

Presentation Notes

Rates of sepsis and sinus formation in RCT do not depend on closure technique Increased risk of burst abdomen and incisional hernia with layered technique No advantage of layered technique over mass closure

Continuous vs. Interrupted Distribution of tension across the suture Adjust to strains of wound post-op Faster Single thread holding fascia together


Continuous > Interrupted


Elective vs. Emergency WWW.DOWNSTATESURGERY.ORG

Absorbable vs. Non-absorbable

Decreased rates of scar pain and suture sinus/fistula

Intrinsic loss of tensile strength Increased rates of hernia

Synthetic absorbable suture with delayed

degradation


Slowly absorbable vs. Non-absorbable

Incisional hernia and dehiscence rates equivalent

Lower rates of suture sinus formation and scar pain


Slowly vs. Rapidly absorbable


Monofilament vs. Braided

Lower rates of wound infection Lower rates of incisional hernia and

dehiscence


Closure of the Peritoneum

Closure vs. non-closure of peritoneum Dehiscence 2.5% vs. 3% Hernia – 4.3% vs. 4.3%


Suture length to wound length

Reduction of incidence of incisional hernia

Ratio > 4:1


Small vs. Large bites

5-8 mm bites every 5 mm 10 mm bites every 10 mm


Presenter

Presentation Notes

2009

Primary elective closure

Running technique Slowly absorbable, monofilament suture Small bites, 5-8 mm every 5mm Mass closure Suture length: wound length ◦ 4:1 or greater


Technique

Start at the apices Looped suture Not too tight


Dehiscence Approximate wound edges Don’t strangulate! Ischemic tissue becomes necrotic Avoid tension Retention

sutures


Retention sutures? Fascial evisceration - 15-20% mortality High-risk patients No difference: ◦ Wound infection ◦ Incisional hernia

Decreased incidence of dehiscence and evisceration


High risk for dehiscence Poor nutritional status Intra-abdominal infection Malignancy Corticosteroids > 3 mo. COPD Jaundice DM Uremia Age > 60


Technique

Large non-absorbable Placed every 2-5 cm along the incision 3-5 cm bites Exclude peritoneum Bridge



Presenter

Presentation Notes

careful attention to technical detail during fascial closure, such as proper spacing of the suture, adequate depth of bite of the fascia, relaxation of the patient during closure, and achieving a tension-free closure.

Now What?

Back to the OR for relaparotomy

Etiology? ◦ Dehiscence or Evisceration Technical vs. patient-related

◦ Secondary peritonitis ◦ Trauma ◦ Hemorrhage


Presenter

Presentation Notes

Once the patient has undergone adequate decompression, an immediate plan for the eventual closure must begin to be formulated. A variety of temporary closure techniques have been advocated over time. Some simply contain the abdominal viscera and protect them from further injury. Other techniques have the advantage of preserving abdominal domain while still allowing room for expansion if required. Finally, some techniques allow for the recruitment of domain as the patient's physiology allows. The authors use the abdominal vacuum dressing for that very reason. Not only does it protect the viscera, but as the edema resolves, the vacuum can shrink to continually recover lost abdominal domain. Other dressings (Whitman's patch, Bogata bag) can also be adjusted to regain domain but necessitate physician intervention on a regular basis. Abdominal washout to resolve any septic source Look at technique – suture / fascia

Relaparotomy Closure Tension free repair Primary Facial closure? Open abdomen ◦ Mortality rates of >30% ◦ Temporary abdominal closure ◦ Closure within 8 days 12% vs. 52% Fistula formation Abscess formation Wound infection


Presenter

Presentation Notes

Patients should undergo assessment at the time of each abdominal exploration, with the goal of working toward expedited primary facial closure. Miller and associates were able to show a marked increase in the risk of associated complications if the abdomen was unable to be closed within 8 days.

Temporary abdominal closure

Protection of bowel Minimization of fascial injury Protection against abdominal

compartment syndrome Minimization of loss of domain


VAC closure ◦ Tension on fascial edges ◦ Collects excessive abdominal fluid ◦ Resolves edema

Whittmann patch ◦ Velcro sheets ◦ Stepwise re-approximation of fascial edges

Bogota bag ◦ Sutured to fascial edges ◦ Reduced in size to

reapproximate fascial edges Skin approximation ◦ Towel clips ◦ Running suture

Temporary abdominal closure WWW.DOWNSTATESURGERY.ORG

Planned Ventral Hernia

Open abdomen for > 8 days Abdominal visceral coverage ◦ Skin Graft ◦ Acute component separation ◦ Bridge closure Biologic Absorbable


Abdominal Wall Reconstruction Delayed 6-12 months for nutritional

optimization Component separation Complex abdominal wall closure ◦ Free tensor fasciae latae (TFL) flap utilizing a

saphenous vein arteriovenous loop


References Zhamak Khorgami, Saeed Shoar, Bardia Laghaie, Ali Aminian, Negin Hosseini Araghi,

and Ahmadreza Soroush. Prophylactic retention sutures in midline laparotomy in high-risk patients for wound dehiscence: A randomized controlled trial. Journal of surgical research. (2012)

O. Abbasoglu, T. Nursal. Surgical Technique for Closure of Difficult Abdomen. Acta chir belg, 2003, 103, 340-341.

Markus K. Diener, Sabine Voss, Katrin Jensen, Markus W. Buchler, and Christoph M. Seiler. Elective Midline Laparotomy Closure. The INLINE Systematic Review and Meta-Analysis. Ann Surg 2010;251: 843–856.

F. E. Muysoms et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia (2015) 19:1–24

Richard H. Turnage and Brian Badgwell. Abdominal Wall, Umbilicus, Peritoneum, Mesenteries, Omentum, and Retroperitoneum. Sabiston Textbook of Surgery, Chapter 45, 1088-1113.

Jordan A. Weinberg and Timothy C. Fabian. The Abdomen That Will not Close. Current Surgical Therapy, 1104-1109.


abdominal wall closure - suny downstate medical center€¦ · · 2015-03-26what is the optimal...

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