laparostomy
TRANSCRIPT
“How to Close a Laparostomy”
Nigel Suggett
Queen Elizabeth Hospital, Birmingham
3 Questions
• How do you make a laparostomy
• When do you close a laparostomy?
• How do you close a laparostomy?
Aims of a laparostomy
• Reduce intra-abdominal pressure• Facilitate further access• Manage exudate• Reduce oedema• Maintain abdominal domain• Protect bowel• Reduce adhesions from bowel to abdominal wall
Options
• Skin Closure• Pack / Op-site• Bogota Bag• Topical Negative Pressure
Proprietary
D.I.Y
bowel
interface
muscle
skin
Skin approximation
D.I.Y
bowel
interface
muscle
skin
suctionAdhesive dressing
Skin approximation
TNP and open abdomen
• Know what you are doing!
• Protect and separate the bowel
• Check 48-72h
• Risk of fistulas?
When to Close?
When to close
• Ideally <5 days• Before granulation/ adhesion• Try to avoid fascial retraction
Primary Fascial Closure?
How to Close?
• 2o intention• Skin graft
• Bridging
• Gradual / Staged Closure
• Direct Suture +/- Mesh
• Component Separation +/- Mesh
Component Separation (Ramirez 1990)
Bleichrodt et al.
Case
• 51y M - LUQ Stabbing• Left renal vein, stomach and splenic hilum damaged• 24U Blood, 20U FFP , 4U plt• Pack + TNP
• Re-look d1 - Colonic ischaemia – stapled off – TNP
• Re-look d4 – Re-anastomosis – TNP – unable to close
• Relook d9 – Unable to close
Component Separation
1-2cm
Component Separation
Component Separation
3-5cm upper abdo7-10cm waist1-3cm lower abdo
Component Separation
Component Separation
2-4cm
Component Separation
Mesh
• Biologic (in this setting)
• Intra-peritoneal• (Extra-peritoneal)• On-lay
Caution!
• Returned to ward 5/7 later• Witnessed VF arrest ? cause• Aspirin, clopidogrel, therapeutic enoxaparin• Bleeding!!!!
So……
• Evacuation of haematoma and re-application of TNP– Tracheostomy– Fascia intact
• Skin re-closed 4 days later• Discharged (after ICD)
Component Separation
Pros
• A useful technique
• Allows primary fascial closure
• Gets you out of trouble
Cons
• Time consuming
• Potential morbidity
• Can only be done once!
3 Questions
• How do you make a laparostomy– Depends on your knowledge and skills– Carefully and thoughtfully
• When do you close a laparostomy?– As soon as it is safe to do so– Or not at all
• How do you close a laparostomy?– Primary suture– Component Separation + Mesh– Or not at all