Plastics 2 Flashcards
What is a difficult about abdominal hernia
1. What is more significant than size?
- Complication?
- Presence or absence of components is more significant than size
- Damage to abdominal wall components compromises future repair efforts
- 36 (80%) had what?
- 11 (24%) had a what?
- 13 (29%) had a what?
- incisional hernias
- trauma history
- history of gynecologic surgery
Comorbid Conditions
for difficult hernia? 4
- Obese (>30% over ideal wt) 25 (56%)
- Cigarette smoking 15 (33%)
- Hypertension 12 (27%)
- Diabetes 11 (24%)
Complaints
for difficult hernia? 5
- Back pain
- Abdominal pain
- Gastrointestinal symptoms
- Inability to perform ADL or work
- Dissatisfaction with appearance
Preoperative Evaluation
3
- Physical Examination
- CT Scanning
- General Surgery Consultation
General Surgery Consultation
includes? 3
- Stoma takedown
- Extensive enterolysis
- Other conditions (diaphragmatic hernia)
Hernia Closure Strategy 4
Additonal manuevers? 2
- Reduction of hernia with lysis of adhesions
- Mobilization of skin and subcutaneous tissues to axillary line and costal margin
- Incision of of external oblique from costal margin to iliac spine
- Incision of rectus fascia along costal margin
Additional maneuvers
- Incise anterior rectus sheath bringing medial edges together in midline
- Incise transversalis fascia as needed
Repair Techniques for hernia?
- Most common?
- Other options? 4
- Components separation (89%)
- Rectus release 73%
- External oblique release 73%
- Both external and internal 58%
- Mesh augmentation (13%)
Hernia Postoperative Data
Complications?
4
Postop stay mean 11.5 days—range 2 to 60
- One death
- Wound infection 29%
- Sepsis 4%
- Dehiscence 4%
Hernia Postoperative Followup
- ranges from what to what?
- PE how often?
- Intervention for abdominal wall?
- When would we do a CT scan?
- Followup ranges from 8 to 52 months
- Monthly clinic appointments with physical examination
- Postoperative physical therapy for abdominal wall strengthening at 6-8 weeks
- CT scanning in cases of unclear clinical findings of recurrence
Management of Recurrences of hernias? 3
- Prosthetic mesh–absorbable
- Local flaps
- Primary closure
Presence of what is a much more significant factor than the size of a hernia?
abdominal wall components
- What is a major risk factor for recurrence?
2. _____ patients have significantly more problems
- Prior procedures, especially more than one prior procedure,
- Obese
Lower Extremity Soft Tissue Reconstruction
-The First Decisions?
6
1 Is this a salvageable limb?
- Nerve loss,
- vascular damage,
- extensive bone or
- soft tissue loss
- Look at patient–associated injuries and setting of injury
General Guidelines: Lower Extremity Soft Tissue Reconstruction?
5
- Two or more vessels out
- Need for fasciotomies
- Failed initial vascular repair
- Insensate plantar surface–posterior tibial nerve
- Extensive bone loss
Patient Variables that will affect healing? 5
- Look at nutritional numbers–prealbumin, transferrin
- Sugars need to be tightly controlled
- Oxygenation, acidosis, perfusion should be optimized
- Smokers do very poorly
- Control of infection
Skin Grafts:
- What do you need?
- What can work but may be unstable?
- Prepping wound bed with what can be useful?
- Need vascularized bed
- Paratenon, periosteum can work but may be unstable
- Prepping wound bed with VAC can be useful
Skin Graft Technique:
- Prep bed well
- 1.___________ for donor site
- Cover donor with 2.________then let dry out Mepilex border also OK
- 3.____ thousandths for depth
- VAC makes great dressing–leave on for 4. how long?
- Then dress with 5. ______
- Marcaine with epi
- xeroform–
- 16
- 5 days
- xeroform
Fasciocutaneous flaps
Advantages? 3
- Very durable, reliable
- No muscle donor (can have that as a backup if available)
- Quick dissection
Muscle Flaps
- Use what for proximal defects?
- What for the middle third?
- Distal third of lower extremity?
- Gastrocnemius for proximal defects
- Soleus for middle third
- Distal third of lower extremity may require free tissue transfer
MOA for V.A.C.
- Mechanical? 2
- Vascular? 3
- Chemical? 2
- Infection control? 2
- MECHANICAL
- Recruitment
- Increased Mitosis - VASCULAR
- Neovascularization
- Decreased Edema
- Decreased Afterload - CHEMICAL
- Removal of Inhibitory Factors
- Promotion of Growth Factors - INFECTION CONTROL
- Hostile Medium
- Increased Vascularity
Indications for VAC Therapy
12
- Pressure ulcers
- Dehisced incisions
- Traumatic wounds
- Meshed grafts: Expanded & 5. Non-expanded
- Flaps
- Arterial insufficiency ulcers
- Venous stasis ulcers
- Diabetic ulcers
- Radiation ulcers
- Burns
- Compromised flaps
Precautions for VAC therapy?
4
- Patients on anticoagulants
- Patients with difficult hemostasis after debridement
- Universal precautions should be observed
- Dressing should be removed if therapy is interrupted for more than 2 hours per day
Free Tissue Transfer
- Usually for what?
- Requires what?
- What are the typical donors?
- Need to be sure about what?
- Usually for large coverage problems more distally
- Requires vascular supply–need angiogram
- Donors typically rectus, latissimus, gracilis, lateral arm
- Need to pretty sure the limb will be worth the cost