Abdominal Wall Flashcards
Patient risk factors for abdominal wall suture complications
- Age>70
- Obesity
- Cigarette use/chronic obstructive pulmonary disease
- Steroid use
- Diabetes mellitus
- Malnutrition
- Ascites
- Previous laparotomies
Disease: surgical risk factors for abdominal wall suture complications.
- Abdominaltrauma
- Ruptured abdominal aortic aneurysm
- Retroperitoneal hematoma
- Pancreatitis
- Peritonitis/sepsis
- Bowel occlusion surgery with resection or suture
- Wound infection
- Wound Class III (contaminated) or Class IV (dirty)
- Presence of enterocutaneous fistula
- Synthetic mesh infection
- Necrotizing fasciitis
- Abdominal wall defect >10 cm width
What is the incidence of fascial dehiscence?
The incidence of fascial dehiscence has been reported in the literature to be between 3% and 3.5% after major abdominal surgery and is associated with significant morbidity and mortality.
What is the ideal suture material for abdominal wall closing?
The ideal suture material for abdominal wall closure is one that:
- resists infection
- provides adequate tensile strength to prevent abdominal wall disruption - minimizes tissue damage
- absorbable.
Most common underlying case of surgical dehiscence
- SSI
- intraabdominal abscess
Technical causes of acute fascial dehiscence
knot failure and fascial damage related to tension, ischemia, or suture material failure
Indications for temporary abdominal closure
- Damage control:
- Severe hemorrhage
- Hypothermia, acidosis, coagulopathy
- Delayed definitive operation secondary to patient’s physiologic state
- Intraabdominal hypertension or compartment syndrome
- Major abdominal and/or retroperitoneal tissue edema
- Questionable visceral viability
- Planned acute reoperation
- Severe intraabdominal sepsis
- Triage
when is the ideal time for devfenitive closing of abdominal wall?
ideally within the first 8 days, to mini- mize complications related to the open abdomen managemen
What can reduce seroma formation after abdominal wall reconstruction?
To reduce seroma formation, closed suction drains should be placed in the subcutaneous and/or retrorectus space. These drains should be stripped regularly during the early postoperative period and are typically removed when less than 25 to 30 mL in a 24-hour period has been recorded.
Treatment of skin necrosis ?
- Superficial skin necrosis can be treated locally with hydrating gels or enzymatic debriding agents. These products reduce the bacterial and necrotic tissue burden and maintain a moist environment for healing.
- Full-thickness wounds require skin and subcutaneous sharp debridement
preparation of patient before definitive abdominal wall reconstruction
- control diabetes and obtain a hemoglobin A1C less than 8
- optimize protein-calorie repletion and cardiopulmonary status.
- Mandatory cigarette smoking cessa- tion is required for at least 4 to 6 weeks before repair.
- In patients with a previous methicillin-resistant Staphylococcus aureus infec- tion, consideration should be given to decolonizing the patient or suppressing methicillin-resistant S. aureus carriers preoperatively and using vancomycin prophylaxis perioperatively.
2 ideal reconstruction technique of abdominal wall reconstruction
- Rives-Stoppa-Wantz
- Transversus Abdominis Release
Both techniques utilize a pos- terior component separation and the placement of lightweight macroporous synthetic mesh in the retrorectus space and outside of the peritoneal cavity.
Rives-Stoppa-Wantz is a retrorectus, less extensive technique often used for simpler hernia repairs.
TAR is a more complex, lateral extension technique used for large or recurrent hernias, providing a larger mesh placement and better tension management.
Ramirez technique for component separation
requires large subcutaneous flaps to gain access to the lateral abdominal wall and release the external oblique fascia.
Emergent Indications for bedside laparotomy
1- decompressive laparotomy for ACS
2 - control and packing for recurrent bleeding after a previous damage control laparotomy, and
3 - suspicion of intraabdominal infection in patients too critically ill to be transported to the OR
Semielective indications for bedside laparotomy
1 - pack removal after damage control laparotomy,
2 - irrigation and debridement of the open abdomen
3 - source control for sepsis resulting from intraabdominal pathology
4 - management of traumatic abdominal defects.
Indications for abdominal pressure monitoring
Routine monitoring of bladder pressures of patients requiring significant resuscitation after abdominal procedures and patients being resuscitated from a significant shock (base deficit >10) who receive 6 L or more of crystalloid or 6 units or more of packed red blood cells in a 6-hour period is indicated
The inguinal canal is bounded
superficially by the external oblique aponeurosis. The internal oblique and transversus abdominis musculoaponeuroses form the cephalad wall of the inguinal canal. The inferior wall of the inguinal canal is formed by the inguinal ligament and lacunar ligament. The posterior wall, or floor of the inguinal canal, is formed by the aponeurosis of the transversus abdominis muscle and transversalis fascia.
Hesselbach triangle
The inferior epigastric vessels serve as its superolateral border, the rectus sheath as the medial border, and the inguinal ligament and pectineal ligament as the inferior border.
Direct hernias occur within Hesselbach triangle, whereas indirect inguinal hernias arise lateral to the triangle.
The boundaries of the femoral canal
iliopubic tract a teriorly, Cooper ligament posteriorly, and femoral vein laterally. The pubic tubercle forms the apex of the femoral canal triangle.
iliopubic tract repair
transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures. The repair begins at the pubic tubercle and extends laterally past the internal inguinal ring
The Shouldice repair
the p terior wall of the inguinal canal is reconstructed by superimposing running suture lines progressing from deep to more superficial layers.
The initial suture line secures the transversus abdominis aponeurotic arch to the iliopubic tract. Next, the internal oblique and transversus abdominis muscles and aponeuroses are sutured to the inguinal ligament.
The Bassini repair
suturing the transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon (when present) to the inguinal ligamen
McVay repair
Interrupted nonabsorbable sutures are used to approximate the edge of the transversus abdominis aponeurosis to Cooper ligament. When the medial aspect of the femoral canal is reached, a transition suture is placed to incorporate Cooper ligament and the iliopubic tract. Lateral to this transition stitch, the transversus abdominis aponeurosis is secured to the iliopubic tract. An important principle of this repair is the need for a relaxing incision. This incision is made by reflecting the external oblique aponeurosis cephalad and medial to expose the anterior rectus sheath. An incision is then made in a curvilinear direction, beginning 1 cm above the pubic tubercle throughout the extent of the anterior sheath to near its lateral border.
Patient-related factors linked to v tral hernia formation
Patient-related factors linked to v tral hernia formation include obesity, older age, male gender, sleep apnea, emphysema, and prostatism.
