Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_785_Библиотеки_им_академика_М_И_Перельмана
.pdf
43 Abdominal Closure 469
(or should be), and that postoperatively they will acquire their normal tone; the
tissues in the wound will swell, and abdominal girth will increase. All of these
changes make the wound closure tighter; if it is tight when you put the sutures in,
then something must give way when these changes take place—the tissue tears. A
ratio of suture length to wound length of at least 4:1 will ensure a moderate but
secure tension of closure. The corners of the incision are the Achilles heels of closure, especially the corner that is closed last. Do not compromise complete closure
of the corner because you are afraid of injuring the underlying bowel; there are
good tricks to accomplish this endeavor—learn them from one of your mentors.
Do not harm the underlying bowel, which frequently bulges toward your
large needle. At the end of the operation, the anesthetist always swears to God
that the patient is “maximally relaxed”; the anesthetist lies. Make the anesthetist
relax the patient again—do not compromise. Protect the bowel by whichever
instrument is available; the best, in our experience, is the commercially available
rubber “fish” retractor. The assistant’s hand also may be useful for this purpose,
but with all the hepatitis and HIV around, we do not find many volunteers willing to offer a retracting hand.
We recommend the use of a “looped” number 1 PDS suture. It is a slowly
absorbable monofilament, usually long enough to provide a suture-to-wound ratio of 4:1. Threading the needle through the loop after the first bite replaces the
need for the initial knot. The final knot in our hands would be the “Aberdeen”
one. We cut it long—about 5 mm—and bury it in the subcutaneous space with
any thin absorbable suture.
The Subcutaneous Space
Now, when the fascia is closed, what do you do with the subcutis? Nothing.
There is no evidence that the so-called dead space reduction using subcutaneous
fat approximation reduces wound complications. On the contrary, subcutaneous
sutures act like a foreign body and strangulate viable fat while not producing a
more satisfactory wound. Subcutaneous drains increase the rate of infection and
are almost never indicated. Plain saline irrigation has been shown to be useless but
use of topical antibiotics (solution or powder) has been demonstrated to further
decrease wound infection rate in contaminated wounds in patients who have
already received systemic antibiotic prophylaxis.
“Delayed Primary” or “Secondary Closure”
What about the well-entrenched ritual of “delayed primary” or “secondary
closure” after contaminated or infected laparotomies?
470 Moshe Schein
We believe that these techniques are only rarely indicated. In spite of
surgeons’ obsession with tradition, lessons learned years ago under certain
circumstances are not necessarily true today. Thus, 20 years ago when antibiotic prophylaxis was given incorrectly, heavy silk sutures were buried in the
fat, and rubber drains were mushrooming through every wound, the infection
rate in primarily closed wounds was intolerable. Today, on the other hand,
with proper surgical technique and modern antibiotic prophylaxis, primary
suture of the wound can be undertaken uneventfully in the majority of emergency laparotomy cases. When a wound infection develops, it usually responds
to local measures. Thus, leaving all contaminated, potentially infected wounds
gaping open—awaiting spontaneous or secondary closure—produces unnecessary physical and financial morbidity. On the rare occasion we decide to
leave a wound open, usually in patients with gross established purulent or
fecal peritonitis, in patients planned for further reoperat ions, or in the relaparotomized abdomen. In the vast majority of patients, we irrigate the subcutaneous tissues with antibiotics (after fascial closure) and close the skin with
staples or interrupted sutures. Truly modern surgeons, however, are happy to
close most wounds with a subcuticular stitch of absorbable material. This obviates the discomfort and expense of arranging staple or suture removal and
gives a much neater scar. (This is the only part of your handiwork that the
family and the patient see, and you would be surprised to discover how much
this little thing matters to some patients.) An occasional wound infection is
not a disaster and is simple to treat (> Chap. 55).
The High-Risk Abdominal Closure
Regarding high-risk abdominal closure, classically, in patients with systemic
(e.g., cancer) or local (e.g., abdominal distension) factors predisposing to wound
dehiscence (> Chap. 53), “retention” sutures were and are still used by surgeons.
Those heavy “through-and-through,” interrupted sutures take bites of at least 2 cm
through all abdominal wall layers—including the skin—preventing evisceration
but not the occurrence of late hernia formation.
We do not find any use for the classical retention sutures, which cut through
the skin and produce parietal damage and ugly skin wounds and scars. Instead,
we suggest that in selected high-risk closures you place a few interrupted alllayers mass sutures (excluding the skin) to take the tension off the continuous
mass closure. Should the latter fail at any point, the interrupted sutures would
prevent separation of the fascial edges and evisceration.
1
Coeditor P.R. comments: there is no evidence supporting this. Moreover, if the mechanically sound
pulley mechanism of the mass suture fails, then these itty-bitty interrupted sutures cannot survive.
1
43 Abdominal Closure 471
The crucial consideration is, however, that the use of retention sutures
together with abdominal distension results in intra-abdominal hypertension.
Forceful closure under excessive tension may result in an abdominal compartment syndrome with its deleterious physiological consequences (> Chap. 40).
Thus, when the fascia is destroyed, as is often the case after multiple abdominal
re-entries, or when closure may produce excessive intra-abdominal pressure,
we suggest that you do not close the abdomen but cover it with a temporary
abdominal closure device (TACD; “laparostomy”) (> Chaps. 40, 52.2, and 53).
Closing the Skin Only
Occasionally, when we wish to avoid fascial closure but do not want to condemn the patient to the not insignificant morbidity associated with laparostomy,
we leave the fascia unsutured but close the skin. Scenarios ideal for such an approach would be when you feel that no reoperation would be necessary but visceral “bulging” prevents fascial closure without excessive tension. Of course, all
surviving patients will develop a large incisional hernia; the very old and infirm
will live with the hernia for the rest of their lives. In others, an elective repair of the
hernia is associated with lower morbidity than the staged management of laparostomy. Regarding how to do it: always spread the omentum, if available, over the
viscera; the skin is closed with 2–0 nylon interrupted mattress sutures, taking bites
at least 1 cm from the skin edge. Do not let anyone remove these sutures until you
approve—usually not before 3 weeks. Remember: the patient’s own normal skin is
better than the VAC (Vacuum Assisted Closure) system or skin grafts.
In conclusion, remember: big continuous bites, with a monofilament, not
too tight—this is how to avoid dehiscence and herniation.
“Abdominal closure: if it looks all right, it’s too tight—if it looks too loose, it’s all
right.” (Matt Oliver)
Before Landing
Moshe Schein
“Pilots may have more incentive than surgeons to be perfect, right or wrong. When
they botch a landing, it’s usually their last. Fortunately, modern day aircraft are a
lot more predictable and reliable than any of our patients.” (Tim Eldridge
(USAF ret)).
Takeoffs are optional. Landings are mandatory.
Everyone knows that a “good landing” is one from which you can walk
away. But, very few know the definition of a “great landing.” It is one after which
you can use the airplane another time. Yes, we know that you are tired; you may
have worked all night, and this may be the last of many long cases. But, any landing must be perfect, and even this last operation has to succeed.
Before closing the abdomen, you must be absolutely happy with what you
did. You do not want to spend the next week in guilt and worry as your patient
fails to recover promptly. Prevent “guilt-worry.” Always ask yourself, “Am I totally satisfied with my procedure?” (> Fig. 44.1). Do not silence the little voice
within you that informs you that the anastomosis is somewhat dusky, or it needs
44
Fig. 44.1. “Am I satisfied?”
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_44, © Springer-Verlag Berlin Heidelberg 2010
473
474 Moshe Schein
another stitch. You must be absolutely convinced, at this stage, that you have
done the best that your patient deserves. If not, swallow your pride, summon the
last vestige of your patience, do it again or call for help. Hiding a potential problem will not solve it. And, you will go back to sleep so much better. However, bear
in mind that—to paraphrase Voltaire—better is the enemy of good. You must be
sure that any attempts to improve a less-than-perfect situation are justified.
(Remember the philosophy of the abbreviated laparotomy.)
You may want to go over a pre-closure checklist:
Hemostasis perfect? This does not mean that you have to run after each red
blood corpuscle.
Source control achieved?
Peritoneal “toilet” completed? All fluid sucked out?
Anastomosis: Viable? Not under tension, lying well?
Potential sites for internal herniation dealt with?
Small bowel comfortably arranged in place below the transverse colon?
Omentum placed between intestine and incision?
All additional fascial defects (e.g., trocar sites) closed?
Nasogastric tube in position (if needed)?
Drains (only if indicated) in place?
Need a feeding jejunostomy?
Should I close the abdomen at all? Or leave it open?
Do not compromise. Keep looking around; there is always something you
have missed. Remember: when the abdomen is open you control it; when closed,
it controls you!
There are old pilots, and there are bold pilots, but there are no old, bold pilots!
There are, however, old bold surgeons—but their patients do not live long…
After the Operation
C
Postoperative Care
Moshe Schein
“When is a surgeon … nervous? Not during operations. But basically a surgeon’s
nervousness begins after the operations, when for some reason the patient’s
temperature refuses to drop or a stomach remains bloated and one has to open
it not with a knife, but in one’s mind, to see what had happened, to understand
and put it right. When time is slipping away, you have to grab it by the
tail.” (Alexander Solzhenitsyn)
We repeat: “As long as the abdomen is open you control it. Once closed it controls you.”
The long operation is finished, leaving you to savor the sweet postoperative
“high” and elation. But very soon, when your serum levels of endorphins decline,
you start worrying about the outcome. And worry you must, for the cocksure,
macho attitude is a recipe for disaster. We do not intend to bring here a detailed
discussion of postoperative care or to write a new surgical intensive care manual.
We only wish to share with you some basic precepts, which may be forgotten,
drowned in a sea of fancy technology and gimmicks. The following are a few
practical commandments for postoperative care.
45
Know Your Patient
It is no joke! How often do we encounter a postoperative patient looked after
by someone who has no clue about the patient’s pre- and intraoperative details?
Mistakes in management are more commonly made by those who “temporarily
adopt” the case. Once you operate on a patient, he or she is yours. Shared respon-
sibility means that no one is responsible!
Touch Examine Your Patient
Touch examine your patient—do not examine only from the foot of the
bed. Examining the chart or the intensive care unit (ICU) monitor is not enough.
Look at the patient, smell and palpate the patient at least twice a day. Wouldn’t it
be embarrassing to load your patient with intravenous antibiotics or CT scan the
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_45, © Springer-Verlag Berlin Heidelberg 2010
477
478 Moshe Schein
patient’s abdomen while an unsuspected abscess is cooking under the wound
dressing, begging simply to be drained at the bedside?
Leo Tolstoy wrote in War and Peace: “When he came to himself the splintered portions of his thigh bone had been extracted, the torn flesh cut away and
the wound bandaged. Water was being sprinkled on his face. As soon as Prince
Andrei opened his eyes the doctor bent down, kissed him on the lips with not a
word and hurried away.” We do not ask you to kiss your patients—just touch
them! And, you may hug their wives or husbands.
Treat the Pain
You know the different drugs and their modes of administration. Sure, you
always prescribe postoperative analgesia, but ordering is not nearly enough. Most
randomly questioned postoperative patients complain that they are undertreated
for pain. Nurses tend to be stingy with analgesia. You are the person on the spot;
consider pain as the “fifth vital sign” and see that your patient does not suffer
unnecessarily.
Do Not “Crucify” Your Patient in the Horizontal Position
Typically, the “modern” patient is “crucified” horizontally, tethered by a spaghetti of monitoring cables, nasogastric (NG) tubes, venous lines, drains, leg
pumps, and urinary catheters. Free the patient from these paraphernalia as soon
as possible; the nurses will not do it without your order. The earlier your patient is
out of bed, sitting or walking about, the faster the patient will be going home.
Conversely, keeping the patient in the supine position increases the incidence of
atelectasis/pneumonia, deep vein thrombosis (DVT), and decubitus ulcers and
prolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS (systemic
inflammatory response syndrome). Have your patient out of bed as soon as pos-
sible (ASAP), and this means commonly a few hours after the operation. If the
nurses are reluctant or lazy, lift the patient out of bed by yourself—always provide
the example.
Decrease the Plastic and Rubber Load
Monitoring functions as an early warning system to detect physiological
disturbances so that prompt corrective therapy can be instituted. The invasiveness of monitoring employed in the individual patient should be proportionate to
the severity of disease: The sicker the patient, the greater number of monitoring
tubes used, the less likely is survival.
45 Postoperative Care 479
Complete discussion of the continuously growing number of monitoring
methods available today is beyond the scope of this chapter. However, please note:
To be able to respond to monitoring-generated warning signs, you must
fully understand the technology employed. You should be able to distinguish
between real acute physiological changes and electrical or mechanical artifacts
of observation.
Understand that all methods of monitoring are liable to myriad potential
errors specific to the technique or caused by patient-related variables. Alertness
and sound clinical judgment are paramount.
Because of improving technology, monitoring is becoming more and more so-
phisticated (and expensive). Furthermore, monitoring techniques are responsible for
a significant number of iatrogenic complications in the surgical ICU. Use monitoring
discriminatingly and do not succumb to the Everest syndrome: “I climb it because it
is there.” Before embarking on invasive monitoring ask yourself: “Does this patient
really need it?” Remember there are safer and cheaper alternatives to invasive monitoring; for example, in a stable patient, remove the arterial line as the blood pressure
can be measured with a conventional sphygmomanometer, PO2 determined transcutaneously, and blood tests drawn by phlebotomy. Each time you see your patient, ask
yourself which of the following can be removed: NG tube, Swan-Ganz catheter, central venous line, arterial line, peripheral venous line, Foley catheter.
NG tubes Prolonged postoperative NG decompression to combat gastric
and intestinal ileus is a common ritual. The concept that the NG tube “protects”
distally placed bowel anastomosis is ridiculous as liters of juices are secreted
each day below the decompressed stomach. Nasogastric tubes are extremely irritating to the patient, interfere with breathing, cause esophageal erosions, and
promote gastroesophageal reflux. Traditionally, surgeons keep the tube until the
daily output drops below a certain volume (e.g., 400 ml); such a policy often results in unnecessary torture. It has been repeatedly demonstrated that most
postlaparotomy patients do not need nasogastric decompression—not even following upper gastrointestinal procedures—or need it for a day or two at most.
In fully conscious patients, who are able to protect their airway from aspiration,
NG tubes can be safely omitted in most patients. Following an emergency abdominal operation, nasogastric decompression is compulsory in mechanically
ventilated patients, in obtunded patients, and after operations for intestinal obstruction. In all other cases, consider removing the NG tube on the morning
after surgery. If in doubt, you may want to cap or clamp the tube for 12 hrs before
removing it and observe how this is tolerated by the patient. A small percentage
of patients will need the tube to be reinserted because of early postoperative
small bowel obstruction or persistent ileus (> Chap. 48).
Drains Despite the widely publicized dictum that it is impossible to drain
the free peritoneal cavity effectively, drains are still commonly used and misused
Соседние файлы в папке Библиотека им академика М.И. Перельмана