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

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Closing the Abdomen

Mary Theophilus

Specialists Without BordersSeminar in Surgery

Rwanda, September 2010

www.specialistswithoutborders.org

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

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)?

• 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

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

• 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

Tension Sutures

• Back to first principles – NO TENSION• Abdominal Compartment Syndrome

• = Laparostomy with later primary or mesh closure

If it will not close!

• 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

• 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 ClosureAdvantages

• 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 ClosureDisadvantages

• 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

• Bogota bag• Towel clip closure• Zip closure• Mesh (absorbable, non-absorbable,

composite)• Vac dressing

Laparostomy Techniques

• Bogota bag

• Towel clip closure

• Vac Dressing

• Suction dressing

• Ideal• May be closed serially• May require other techniques to facilitate :Relaxing incisions in the fascia

Primary closure post laparostomy

Component Separation Technique

• Non absorbable• Absorbable• Composite• Bilayer• Organic

Mesh closure post Laparostomy

Close skin if possible, else vac dressings, skin

grafting, tissue flaps

ConclusionsPrimary 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

• Finding the best Abdominal Closure: An evidence based review of the Literature, Ceydeli A, Rucinsk J, Wise L; Current Surgery 2005 vol 62:2, 220-225

• Temporary abdominal closure with the Vacuum pack technique, Ozguc H, Paksoy E,Ozturk E; Acta Chir Belg 2008, 108 (414-419)

References

Thank You!

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

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