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_232_библиотеки_им_акад_М_И_Перельмана
.pdf
A
bdo
min
a
l W
ou
n
d
Cl
o
s
u
re
:
H
o
w t
o
A
void Com
p
lication
s
Patrick Hogsto
n
C
l
osing an a
bd
omina
l
incision is one o
f
t
h
e commonest an
d
simp
l
est proce-
d
ures per
f
orme
d
b
y gyneco
l
ogists an
d
o
b
stetricians. Most woun
d
s
h
ea
l
unevent
f
u
ll
y,
b
ut
f
ai
l
ures, particu
l
ar
l
y in t
h
e
f
ascia
l
l
ayer, cause
d
istress to t
h
e
patient, increase
l
engt
h
o
f
h
ospita
l
stay, an
d
can en
d
anger
l
i
f
e. C
l
osure o
f
t
h
e
a
bd
omina
l
woun
d
is not wi
d
e
l
y
d
iscusse
d
in t
h
e gyneco
l
ogica
l
l
iterature, an
d
t
h
is c
h
apter aims to provi
d
e up-to-
d
ate in
f
ormation
f
or t
h
e practicing c
l
ini
-
cian on
h
ow to minimize woun
d
f
ai
l
ure an
d
h
ow to
d
ea
l
wit
h
it w
h
en it
occu
r
s.
efiniti
o
n
a
n
d
Inci
d
ence
o
f W
ou
n
d
F
a
il
u
r
e
Most wound failures are superfi
cial separations and should be clearly dis-
tinguis
h
e
d
f
rom
f
ascia
l
b
rea
kd
own or woun
d
d
e
h
iscence. T
h
e
l
atter ma
y
present as a burst abdomen where the abdominal contents spill out through
both the fascial and skin defect and is associated with high rates of death and
comp
l
ications. A
l
ternative
l
y, t
h
e s
k
in may stay intact an
d
t
h
e c
l
inica
l
presenta
-
tion may be as a subsequent incisional hernia
.
Superfi
cial separation commonly follows a hematoma or wound infection.
Wit
h
a rising cesarean section rate an
d
most
h
ysterectomies sti
ll
b
eing per-
f
orme
d
b
y t
h
e a
bd
omina
l
route, t
h
ere are more t
h
an a mi
ll
ion
l
aparotomies
f
or o
b
stetric an
d
gyneco
l
ogic in
d
ications in t
h
e Unite
d
States eac
h
year an
d
at
least 200,000 in the United Kingdom. Superfi
cia
l
woun
d
separation can
b
e as
high as 20%, as this rate depends on the rate of infection. Using the classifi
ca-
tion o
f
woun
d
s in Ta
bl
e 5.1, emergency cesarean section a
f
ter pro
l
onge
d
l
a
b
or
with amnionitis will be class 3 or 4 and hence associated with a signifi
cant ris
k
of infection.
F
ascial dehiscence is the separation of the musculoaponeurotic layer and
generally occurs between 3 and 10 days after surgery. However, incisional
h
ernias may present years
l
ater. T
h
e inci
d
ence
h
as remaine
d
remar
k
a
bl
y sta
bl
e
over the past 50 years at a rate of 0.5% to 3%. This may refl
ect improve
d
tec
h
niques t
h
at
h
ave overcome t
h
e increase
d
comor
b
i
d
ities in patients w
h
o
wou
ld
not previous
l
y
h
ave
h
a
d
surgery per
f
orme
d
. However, t
h
e overw
h
e
l
m
-
ing evi
d
ence suggests t
h
at
f
ascia
l
d
e
h
iscence is near
l
y a
l
ways
d
ue to a tec
h
nica
l
e
rr
o
r
.
https://t.me/med1917
4
4 P. Ho
g
ston
isk F
a
ct
o
rs
S
ystemic
f
actors t
h
at may app
l
y to gyneco
l
ogy patients inc
l
u
d
e o
b
esity,
d
ia
b
etes, o
ld
er age, pu
l
monary
d
isease, ma
l
ignancy, an
d
steroi
d
use. Ensuring
c
orrect tec
h
nique in t
h
ese patients is particu
l
ar
l
y important, as t
h
e margin
f
or
error is small, and if the fascial wound stays intact, any superfi
cia
l
separation
an
e manage
muc
more easi
y
I
t is wi
d
e
l
y
b
e
l
ieve
d
t
h
at transverse incisions are associate
d
wit
h
a muc
h
l
ower inci
d
ence o
f
f
ascia
l
d
e
h
iscence t
h
an mi
dl
ine incisions. Greena
ll
et a
l
. [1]
sh
owe
d
a
l
ower inci
d
ence o
f
incisiona
l
h
ernia (2 vs 9) an
d
no
b
urst a
bd
omens
0 vs 2) in 579 patients ran
d
omize
d
to transverse or mi
dl
ine incisions
f
or
n
ongyneco
l
ogica
l
con
d
itions. However, t
h
ey state
d
t
h
at w
h
en contro
ll
e
d
f
or
i
n
f
ection, t
h
ere was no
d
i
ff
erence in woun
d
f
ai
l
ure, w
h
ic
h
occurre
d
in 2.24%
of
t
h
e patients. Hen
d
rix et a
l
. [2]
h
ave per
f
orme
d
a case contro
l
stu
d
y o
f
48
c
ases o
f
f
ascia
l
d
e
h
iscence comp
l
icating 17,995
l
aparotomies (8950 cesarean
s
ections an
d
9405 gyneco
l
ogic proce
d
ures)
d
uring a 6-year perio
d
. T
h
is
r
e presents an inci
d
ence o
f
0.3%. O
f
t
h
e 48 patients w
h
o un
d
erwent repair o
f
f
ascia
l
d
e
h
iscence, 27 were a
f
ter cesarean section (10 vertica
l
, 17 transverse)
a
n
d
21 a
f
ter gyneco
l
ogic surgery (12 vertica
l
, 9 transverse). T
h
e ris
k
f
or
d
e
h
is
-
c
ence wit
h
vertica
l
incisions was not increase
d
over t
h
at wit
h
transverse inci
-
s
ions
(
P
0.39). However, 47 o
f
t
h
e 48 cases
h
a
d
d
ocumente
d
woun
d
in
f
ections
c
ompare
d
wit
h
1 o
f
t
h
e 144 contro
l
s (
P
<
0.0001, o
dd
s ratio [OR] 37.8).
H
en
d
rix’s stu
d
y inc
l
u
d
e
d
on
l
y patients operate
d
on wit
h
in 6
d
ays o
f
t
h
e
i
nitia
l
surgery. T
h
is may exp
l
ain t
h
e sma
ll
num
b
er o
f
cases o
f
f
ascia
l
d
e
h
is
-
cence identifi
ed as compared to Greenall’s study. The rate of incisional hernia
a
t 6 mont
h
s in t
h
e open co
l
posuspension arm o
f
a ran
d
omize
d
contro
ll
e
d
tria
l
of
surgica
l
management o
f
stress incontinence is 10 times t
h
at reporte
d
b
y
H
en
d
rix, i.e., 3% at 6 mont
h
s [3].
L
uijen
d
ij
k
et a
l
. [4] suggest t
h
at
l
aparoscopy
f
o
ll
owe
d
b
y transverse
l
apa
-
r
otomy is associate
d
wit
h
a ris
k
o
f
incisiona
l
h
ernia just cau
d
a
l
to t
h
e um
b
i
l
i
-
c
us (3.5% o
f
169 cases vs 0 o
f
177 wit
h
out
l
aparoscopy). T
h
is may
b
e re
l
ate
d
Tab
le
5.
1
.
W
ou
n
d
Cl
a
ssific
a
ti
o
n
a
n
d
Risk
o
f Infecti
on
W
ou
n
d
C
lass Categor
y
Definition Infection Rate
Clean Ideal conditions. No entr
y
lumen of GI,
5
%
GU
tr
a
c
t
2
C
l
ean- Woun
d
inc
l
u
d
es entr
y
in GU tract 2%–10
%
c
o
nt
a
min
a
te
d
3
Contaminated O
p
en,
f
resh trauma. Incisions on 15%–20
%
nonpurulent in
f
ection, e.
g
., amnioniti
s
4
Dirt
y
Dela
y
ed trauma,
f
oreign bod
y
,
3
0
%
d
evit
al
ize
d
tiss
ue
GI, gastrointestinal tract; GU, urinary tract or vagina.
https://t.me/med1917
5. Abdominal Wound Closure: How to Avoid Com
p
lications 4
5
to t
h
e su
b
sequent
d
issection o
f
t
h
e musc
l
e awa
y
f
rom t
h
e s
h
eat
h
. However,
consi
d
eration s
h
ou
ld
b
e
g
iven to c
l
osin
g
t
h
e s
h
eat
h
o
f
t
h
e
l
aparoscop
y
woun
d
w
h
en a su
b
sequent transverse
l
aparotom
y
incision is ma
d
e.
Surgical Considerations
B
e
f
ore consi
d
ering c
l
osure o
f
t
h
e incision, it is pertinent to consi
d
er t
h
e
opening. T
h
ere are on
l
y 2 types o
f
incision use
d
b
y t
h
e gyneco
l
ogist, name
l
y,
vertica
l
an
d
transverse. T
h
ere are severa
l
variations wit
h
in t
h
is genera
l
ization,
h
owever, an
d
it is c
l
ear
l
y essentia
l
t
h
at exposure
b
e a
d
equate
f
or t
h
e proce
d
ure
to
b
e per
f
orme
d
. T
h
e type o
f
incision s
h
ou
ld
b
e
d
iscusse
d
wit
h
t
h
e patient
preoperative
l
y, as t
h
e woun
d
wi
ll
b
e t
h
e on
l
y part o
f
t
h
e proce
d
ure s
h
e wi
ll
see
an
d
cosmetic consi
d
erations are
l
i
k
e
l
y to
b
e important. Transverse incisions
are cosmetica
ll
y more accepta
bl
e to most patients
b
ut are a
l
so
l
ess pain
f
u
l
an
d
may
b
e
l
ess prone to
h
erniation, a
l
t
h
oug
h
t
h
is remains unc
l
ear (see a
b
ove).
T
h
e variations on t
h
is type o
f
incision inc
l
u
d
e P
f
annenstie
l
, Joe
l
-Co
h
en, May
-
l
ar
d
’s musc
l
e-cutting incision, C
h
erney’s, an
d
Turner-Warwic
k
incisions [5],
and hence the gynecologic surgeon should be familiar with these modifi
cat
i
ons
so as to realize that large masses, complex fi
stula surgery, as well as radical
h
ysterectomy can
b
e per
f
orme
d
wit
h
a
d
equate access wit
h
out resorting to a
vertica
l
incision. Vertica
l
incisions can
b
e mi
dl
ine or parame
d
ian, wit
h
t
h
e
l
atter
b
eing more
l
i
k
e
l
y to
d
amage t
h
e nerve supp
l
y to t
h
e musc
l
e. A mi
dl
ine
is easier an
d
quic
k
er an
d
superior
f
or t
h
e gyneco
l
ogist. It is particu
l
ar
l
y use
f
u
l
in ovarian cancer surgery, w
h
ere access to t
h
e upper a
bd
omen may
b
e
require
d
.
Many of the risk factors are diffi
cult to infl
uence. It is important, however,
to use proper antisepsis an
d
antimicro
b
ia
l
prop
h
y
l
axis
f
or a
ll
a
bd
omina
l
pro
-
ce
d
ures. Simi
l
ar
l
y, t
h
e avoi
d
ance o
f
h
ypot
h
ermia may re
d
uce woun
d
in
f
ection
rates. T
h
ere is a tren
d
to use e
l
ectrocautery to open t
h
e a
bd
omen. It is impor
-
tant to use cutting current, as t
h
is causes vaporization, w
h
ereas coagu
l
ation
current causes
d
esiccation an
d
a wi
d
er pat
h
o
f
t
h
erma
l
injury. T
h
ere is c
l
ear
evi
d
ence
f
rom anima
l
stu
d
ies t
h
at coagu
l
ation current
d
ecreases t
h
e a
bd
omi-
na
l
wa
ll
b
ursting strengt
h
[6]
.
C
losin
g
the Abdominal Wound
P
er
i
toneum
Traditionally the fi
rst layer to be closed is the peritoneum. This is no longer
recommended. The presumed benefi
ts (e.g., restoring anatomy, preventing
adhesions, preventin
g
herniation, reducin
g
infection) have not been proved in
randomized trials. Furthermore, animal studies have shown that the exact
opposite may be the case, with increased adhesion formation and infection
https://t.me/med1917
4
6 P. Ho
g
ston
due to ischemia and necrosis as well as infl
ammatory reactions to the sutures
th
emse
l
ves. T
h
e peritoneum wi
ll
h
ea
l
spontaneous
ly
wit
h
in 6
d
a
y
s. T
h
e Ro
y
a
l
C
o
ll
e
g
e o
f
O
b
stetricians an
d
G
y
naeco
l
o
g
ists in t
h
e Unite
d
Kin
gd
om
h
as pro
-
d
uce
d
c
l
ear recommen
d
ations
b
ase
d
on review o
f
t
h
e
l
iterature
b
y a pane
l
o
f
e
x
p
erts [7]. Nonc
l
osure o
f
t
h
e
p
eritoneum is
q
uic
k
er an
d
is associate
d
wit
h
l
ower postoperative
f
e
b
ri
l
e mor
b
i
d
it
y
,
l
ower requirements
f
or ana
lg
esia,
q
uic
k
er return o
f
b
owe
l
activity, an
d
a s
h
orter
h
ospita
l
stay. Peritoneum
cl
osure is a
l
so not cost-e
ff
ective; costs may
b
e $330 per case. T
h
is is especia
lly
i
mportant in
d
eve
l
opin
g
countries, w
h
ere resources are particu
l
ar
ly
scarce.
Th
ere is simi
l
ar evi
d
ence to s
h
ow t
h
at peritonea
l
c
l
osure is not recom-
m
en
d
e
d
f
or simp
l
e or ra
d
ica
l
h
ysterectomy,
b
e it per
f
orme
d
vagina
ll
y or
abd
omina
ll
y
.
Fa
sci
a
W
ound Heal
i
ng
S
ur
g
ical wounds are entirel
y
dependent on suture support in the earl
y
p
ostsur
g
er
y
da
y
s, as wound stren
g
th takes time to develop. Fascial wounds
t
ake 3 months to re
g
ain 70% of their preoperative stren
g
th and probabl
y
never
r
e
g
ain full stren
g
th. It is therefore imperative that the suture retain its stren
g
th
f
or 3 months. The skin
,
in the absence of infection or hematoma
,
heals much
m
ore quickl
y
, particularl
y
with transverse incisions. In the latter circumstance,
s
utures can be removed after 3 or 4 da
y
s.
Su
t
u
re M
a
teri
a
l
F
rom t
h
e a
b
ove
d
iscussion it wi
ll
b
e c
l
ear t
h
at rapi
dl
y a
b
sor
b
a
bl
e sutures
a
re not suita
bl
e
f
or
f
ascia
l
c
l
osure o
f
vertica
l
woun
d
s. Experimenta
l
anima
l
studies have confi
rmed that the use of monofi
lament nylon signifi
cantly
re
d
uces t
h
e rate o
f
woun
d
f
ai
l
ure as compare
d
to
b
rai
d
e
d
sutures. Bacteria
pro
l
i
f
erate in t
h
e interstices o
f
b
rai
d
e
d
sutures,
b
ut t
h
is cannot
h
appen wit
h
monofi
laments. Permanent sutures do have the problem of sinus formation,
w
h
ic
h
is not present wit
h
d
e
l
aye
d
a
b
sor
b
a
bl
e materia
l
s.
Techn
i
que
A
t the end of the nineteenth centur
y
, mass-closure techniques were aban
-
doned in favor of la
y
ered closure. Mass-closure techniques were reintroduced
in the 1940s and have now clearl
y
been shown to be associated with lower rates
of wound failure [8]. Hod
g
son et al. have searched for the ideal method of
abdominal fascial closure usin
g
MEDLINE and Cochrane Librar
y
databases
[9]. The
y
did not look onl
y
at randomized controlled trials but included com
-
parative studies, provided certain qualit
y
criteria were met. The primar
y
outcome was postoperative incisional hernia, and the primar
y
comparisons
w
e
r
e
bet
w
ee
n n
o
n
abso
r
bab
l
e
a
n
d
abso
r
bab
l
e
sutu
r
es
a
n
d
co
n
t
in
uous
v
e
r
sus
interrupted techniques. When comparin
g
nonabsorbable with absorbable
https://t.me/med1917
5. Abdominal Wound Closure: How to Avoid Com
p
lications 4
7
sutures, the odds of an incisional hernia were signifi
cantly lower with nonab-
sorbable sutures (OR 0.68, confi
dence interval [CI] 0.52–0.87), although wound
pain and suture sinuses were signifi
cantly more common (OR 2.18, CI 1.48–
3
.22, an
d
OR 2.05, CI 1.52–2.77, respective
ly
). T
h
e su
bg
roup ana
ly
sis s
h
owe
d
t
h
at po
lyd
ioxanone (PDS)
d
i
d
not
h
ave an increase
d
ris
k
o
f
incisiona
l
h
ernia
compared with pol
y
prop
y
lene (OR 1.53, CI 0.50–4.72).
A
ran
d
omize
d
stu
dy
o
f
225 patients s
h
owe
d
no more
f
ai
l
ures wit
h
d
e
l
a
y
e
d
a
b
sor
b
a
bl
e po
lygly
conate (Maxon) as compare
d
to n
yl
on at 2
y
ears [10], an
d
man
y
sur
g
eons
f
avor
d
e
l
a
y
e
d
a
b
sor
b
a
bl
e sutures, as in
l
ow- an
d
me
d
ium-ris
k
patients t
h
e
y
appear as e
ff
ective as non-a
b
sor
b
a
bl
es an
d
d
o not cause t
h
e
pro
bl
ems o
f
woun
d
sinus an
d
pain. However, metaana
ly
sis o
f
more t
h
an
cantly lower
woun
d
d
isruption. In gyneco
l
ogica
l
surgery using mi
dl
ine incisions, an ana
l
y-
s
is o
f
ris
k
f
actors s
h
ou
ld
b
e ma
d
e. Sur
g
eons s
h
ou
ld
consi
d
er permanent
s
utures in
h
i
gh
-ris
k
patients,
b
ut ot
h
erwise
d
e
l
a
y
e
d
a
b
sor
b
a
bl
e sutures appear
to
b
e an acce
p
ta
bl
e a
l
ternative
.
S
utures s
h
ou
ld
b
e p
l
ace
d
at
l
east 1 cm
f
rom t
h
e woun
d
e
dg
e an
d
l
ess t
h
an
1 cm apart. Un
d
ue tension s
h
ou
ld
b
e avoi
d
e
d
, an
d
suture
l
en
g
t
h
s
h
ou
ld
b
e 4
times t
h
e woun
d
l
en
g
t
h
. VanGe
ld
ere [11] s
h
owe
d
t
h
at wit
h
correct attention
to tec
h
nique, t
h
e inci
d
ence o
f
woun
d
d
isruption was 0.6% in 2488 cases. Inves
-
tigation o
f
t
h
ese 15
f
ai
l
ures revea
l
e
d
a suture
l
engt
h
o
f
just over 3 : 1 rat
h
er
t
h
an t
h
e recommen
d
e
d
ratio o
f
4 : 1. T
h
e ot
h
er scenario res
p
onsi
bl
e
f
or woun
d
d
isruption is running out o
f
suture an
d
managing
b
y using sma
ll
er
b
ites an
d
s
trugg
l
ing wit
h
an unsatis
f
actory
k
not
.
Alternat
i
ve Techn
iq
ue
N
iggebrugge et al. [12] described a new technique using a continuous
double-loo
p
closure (CDLC). Its use in an animal model a
pp
eared su
p
erior to
other techniques and resisted high intraabdominal pressure without strangu
-
lation. However, when Niggebrugge et al. performed a randomized controlled
trial in 390 patients, they found a signifi
cant risk of adverse events including
death, so this technique should not be used. The authors postulate that the
lessened compliance of the abdominal wall raised the intraabdominal pressure
and increased the risk of pulmonar
y
complications and death.
S
u
p
erf
i
c
i
al Fasc
ia
H
ematomas and seromas that form in the dead s
p
ace of the subcutaneous
layer can lead to infection and wound breakdown. Del Valle et al. [13] con
-
ducted a randomized controlled trial of closure versus nonclosure of Cam
p
er’s
fascia with 3-0 plain cat
g
ut. Althou
g
h the
y
found less wound disruption in the
closure
g
roup (2.7% vs 7.4%,
0.03), the
y
did not control for depth of the
s
ubcutaneous la
y
er. When patients with a subcutaneous la
y
er of
2
c
m
a
r
e
studied, both closure of the superfi
cial fascia [14,15] and suction drainage [16]
h
ave been shown to reduce the risk of wound disru
p
tion
.
https://t.me/med1917
4
8 P. Ho
g
ston
S
k
i
n
Th
ere are man
y
options
f
or c
l
osin
g
t
h
e s
k
in, an
d
cosmetic resu
l
ts are
i
mportant in
gy
neco
l
o
g
ica
l
sur
g
er
y
. Transverse incisions
h
ea
l
we
ll
d
ue to
l
ac
k
o
f tension, and most sur
g
eons use either a subcuticular runnin
g
stitch or
skin staples. Polybutester (Novafi
l) leaves a better scar than polypropylene or
nylon when assessed at 18 months [17,18]. The only benefi
t o
f
sta
pl
es
sh
own in ran
d
omize
d
stu
d
ies was s
p
ee
d
, as t
h
ere is more woun
d
p
ain an
d
a
w
orse cosmetic resu
l
t com
p
are
d
wit
h
su
b
cuticu
l
ar stitc
h
es [19,20]. More
r
ecentl
y
, skin adhesive (2-oct
y
l c
y
anoacr
y
late) has become available to close
w
ounds and is marketed as “an ideal skin closure” for
gy
necolo
g
ical sur
g
er
y
,
d
es
p
ite the lack of clinical studies in this area. It
p
roduces a
pp
ro
p
riate wound
s
tren
g
th in minutes, avoids needlestick in
j
ur
y
(as do staples) and is claimed
t
o be particularl
y
useful for children. However, a prospective stud
y
in children
a
nd adolescents su
gg
ested a worse cosmetic result [21]. A lar
g
e multicenter
randomized trial of 924 wounds confi
rmed that octyl cyanoacrylate was faster
h
ealin
g
than sutures but cosmetic results were the same [22]. For laparoscop
y
,
a
dhesive papertape ma
y
be faster and more cost-effective than oct
y
l c
y
anoac
-
ryl
ate or sutures [23].
anagement of Acute Wound Fa
i
lure
Dehiscence of both the fascial and superfi
cial components of abdominal
w
ound with extrusion of bowel is a
gy
necolo
g
ical emer
g
enc
y
. The patient is
l
aid su
p
ine, and saline-soaked towels are laid over the abdominal contents.
T
he patient will be distressed and often in pain and will require anal
g
esia. In
m
ost cases, preparation for an ur
g
ent return to the operatin
g
theater should
b
e made. The bowel should be ins
p
ected for trauma and the fascia and skin
f
or viabilit
y
. Necrotic or infected tissue will need debridement back to health
y
b
leedin
g
ed
g
es. Primar
y
repair can then be performed in most cases usin
g
a
c
ontinuous mass-closure techni
q
ue with a nonabsorbable suture as described
a
bove. Clib
y
[24] has ar
g
ued for interrupted sutures in this scenario, but a
s
ub
g
roup anal
y
sis b
y
Hod
g
son [9] has shown that incisional hernia is hi
g
her
w
ith interru
p
ted sutures. There is no need to use dee
p
-tension sutures or
p
lastic brid
g
es
.
T
he bi
gg
est problem occurs when closure without undue tension cannot
b
e accomplished [24]. G
y
necolo
g
ists would be advised to call for advice from
a
g
eneral sur
g
eon, who is likel
y
to have more experience with this problem. It
m
a
y
be necessar
y
to use an absorbable mesh such as pol
yg
lactin or a nonab
-
s
orbable material such as pol
y
prop
y
lene. While the latter is widel
y
used in
e
lective hernia re
p
air, there is less ex
p
erience with acute wound failure. There
is a high complication rate due to infection but a risk of enteric fi
stula of 23
%
.
D
ela
y
ed absorbable mesh is probabl
y
preferable, which can be attached to the
c
ircumference of the defect. The wound should then be
p
acked and not
c
l
osed.
https://t.me/med1917
5. Abdominal Wound Closure: How to Avoid Com
p
lications 4
9
Superf
i
c
i
al Wound Breakdow
n
The mainstay of treatment of superfi
cia
l
woun
d
b
rea
kd
own is a
d
e
q
uate
d
raina
g
e an
d
t
h
en care to promote
g
ranu
l
ation. Hea
l
in
g
can ta
k
e severa
l
wee
k
s
or months, and consideration can be
g
iven to dela
y
ed reclosure. Necrotic and
infected tissue must fi
rst be removed and the presence of healthy granulation
tissue o
b
serve
d
. Severa
l
stu
d
ies
h
ave s
h
own t
h
at secon
d
ar
y
c
l
osure re
d
uces
h
ea
l
in
g
time
f
rom a
b
out 70 to 16
d
a
y
s [25,26]. I
f
t
h
e woun
d
is
d
eep, an en
bl
oc
closure incorporating the deep and superfi
c
i
al
t
i
ssues
has
bee
n
desc
ri
bed
wi
th
a 94% success rate [26]. Closure can be
p
erformed under local anesthesia, and
antibiotics are not required. In cases with lar
g
e skin loss due to necrosis, it has
been shown that wounds heal faster under ne
g
ative suction pressure, and
sp
ecial
p
um
p
s are available that can be used in the
p
atient’s home [27]. The
assistance of a wound-care specialist nurse is particularl
y
helpful.
ana
g
ement of Late Wound Failur
e
It is important to realize that even follow-up at 1 year does not refl
ect
t
h
e
true incidence of incisional hernia. Mud
g
e and Hu
g
hes [28] followed a cohort
for 10
y
ears and showed that 35% of incisional hernias occurred after 3
y
ears.
Repair of incisional hernias in the United Kin
g
dom would usuall
y
be done b
y
a
g
eneral sur
g
eon rather than a
gy
necolo
g
ist, if required. Often there is a need
to use a mesh material
,
as closure of the fascia would be under too much
tension and further failure likel
y.
S
ummar
y
W
oun
d
d
isru
p
tion continues to
b
e a common
p
ro
bl
em
f
or t
h
e o
b
stetric or
gyneco
l
ogica
l
patient. Evi
d
ence is avai
l
a
bl
e
f
or t
h
e surgeon to re
d
uce t
h
is
mor
b
i
d
ity. A
d
equate training in a
bd
omina
l
c
l
osure, particu
l
ar
l
y o
f
vertica
l
incisions, is important. Correct suture c
h
oice
f
or
f
ascia an
d
s
k
in can a
l
so
b
e
evidence based. Management of the superfi
cial layer in obese patients could
inc
l
u
d
e c
l
osure o
f
Camper’s
f
ascia or t
h
e use o
f
a suction
d
rain. Furt
h
er stu
d
ies
sh
ou
ld
b
e rea
d
i
ly
possi
bl
e to c
l
ari
fy
t
h
e issues o
f
s
k
in c
l
osure an
d
d
raina
g
e, as
d
isruption o
f
t
h
is
l
ayer is associate
d
wit
h
muc
h
me
d
ica
l
an
d
nursing time as
we
ll
as
d
istress an
d
d
e
l
ay in returning to norma
l
activities
f
or t
h
e patient.
e
f
erences
1. Greena
ll
MJ, Evans M, Po
ll
oc
k
AV. Mi
dl
ine or transverse
l
aparotomy? A ran
d
omise
d
controlled clinical trial. Part 1: infl
uence on healing.
Br J
S
urg.
980
;
67:188–196
.
https://t.me/med1917
5
0 P. Ho
g
ston
2. Hendrix SL, Schimp V, Jo
y
M, et al. The le
g
endar
y
superior stren
g
th of the Pfan-
nenstie
l
incision: a m
y
t
h
?
A
m J O
b
stet G
y
neco
l
. 2000;182:1446–1451.
3. War
d
KL, Hi
l
ton P. Prospective mu
l
ticentre ran
d
omise
d
tria
l
o
f
tension-
f
ree va
g
ina
l
t
ape an
d
co
l
posuspension as primary treatment
f
or stress incontinence.
BMJ
.
2002;
325:
6
7–75
.
4. Luijen
d
ij
k
RW, Jee
k
e
l
J, Remmert KS, et a
l
. T
h
e
l
ow transverse p
f
annenstie
l
incision
and the
p
revalence of incisional hernia and nerve entra
p
ment.
A
nn
S
urg.
7
;22
5:
3
6
5–3
6
9.
5. Nichols DH. Incisions. In: Nichols DH, ed.
ynecologic and Obstetric Surgery.
S
t
L
ouis: Mosb
y
; 1993:165–196.
6. Rappaport WD, Hunter GC, Allen R, et al. The effect of electrocauter
y
on wound
healin
g
in midline laparotom
y
incisions. Am J Sur
g
. 1990;160:618–620.
7. Ro
y
a
l
Co
ll
e
g
e o
f
O
b
stetricians an
d
G
y
naeco
l
o
g
ists.
P
eritonea
l
Cl
osure.
G
reen
T
op
G
ui
d
e
l
ine No. 15. Ju
ly
2002.
8. Wei
l
an
d
DE, Bay C, De
l
Sor
d
i S. C
h
oosing t
h
e
b
est a
bd
omina
l
c
l
osure
b
y meta-
ana
l
ysis.
A
m J
S
urg.
998
;
17
6
:
666
–
6
70
.
9. Ho
d
gson NCF, Ma
l
t
h
aner RA, Ost
b
ye T. T
h
e searc
h
f
or an i
d
ea
l
met
h
o
d
o
f
a
bd
omi-
n
a
l f
asc
i
a
l w
ou
n
d
c
l
osu
r
e.
A
nn
S
urg.
2
000
;
231:43
6
–442.
10. Carlson MA, Condon RE. Polyglyconate (Maxon) versus nylon suture in midline
abdominal incision closure: a
p
ros
p
ective randomised trial. Am Sur
g.
1995;61:980–
9
83
.
11. VanGe
ld
ere D. One
h
un
d
re
d
y
ears o
f
a
bd
omina
l
woun
d
d
e
h
iscence an
d
not
h
in
g
h
as
ch
an
g
e
d
. Hern
i
a
.
2000
;4;
302
–
30
4
.
uence o
f
a
bd
omina
l
-woun
d
cl
osure tec
h
nique on comp
l
ications a
f
ter surgery: a ran
d
omise
d
stu
d
y.
L
ancet
.
1999
;
353:15
6
3–15
6
7
.
13. Del Valle GO, Combs P, Qualls C, et al. Does closure of Cam
p
er fascia reduce the
incidence of post-Cesarean superfi
cial wound dehiscence?
Obstet Gynecol.
:
1
0
1
3
–1
0
1
6.
cial wound dehiscence after Cesarean delivery: effect of the
depth and closure of the superfi
c
i
a
l
t
i
ssue.
Int J G
y
necol Obstet.
997;57:17–21.
15. Allaire AD, Fisch
J
, McMahon M
J
. Subcutaneous drain versus suture in obese
w
omen un
d
er
g
oin
g
Cesarean
d
e
l
iver
y
.
J
Re
p
ro
d
Me
d
.
2000
;45:
32
7–
331
.
16. Kore S, V
y
ava
h
ar
k
ar M, A
k
o
l
e
k
ar R, et a
l
. Comparison o
f
c
l
osure o
f
su
b
cutaneous
tissue versus non-c
l
osure in re
l
ation to woun
d
d
isruption a
f
ter a
bd
omina
l
h
yster-
e
ctomy in o
b
ese women. J Postgra
d
Me
d.
2000
;
4
6
:2
6
–28.
17. Trim
b
os
J
B, Smeets M, Ver
d
e
l
M, Hermans
J
. Cosmetic resu
l
ts o
f
l
ower mi
dl
ine
l
aparotomy wounds: polybutester and nylon skin suture in a randomised control
trial.
bstet Gynecol
.
1993;82
:
390
–
393.
18. Bang RL, Mustafa MD. Comparative study of skin wound closure with polybutester
l) and polypropylene.
J R Coll Surg Edinb. 1989;34:295–297.
19. Ranabaldo CJ, Rowe-Jones DC. Closure of laparotom
y
wounds: skin staples versus
sutu
r
es.
B
r J Sur
g
.
1992;79:1172–1173
.
https://t.me/med1917
5. Abdominal Wound Closure: How to Avoid Com
p
lications 5
1
2
0. Frishman GN, Schwartz T, Ho
g
an JW. Closure of Pfannenstiel skin incisions. Staples
v
s su
b
cuticu
l
ar suture. J Re
p
ro
d
Me
d
. 1997;42:627–630
.
2
1. Bernar
d
L, Do
yl
e J, Frie
dl
an
d
er SF, et a
l
. A prospective comparison o
f
oct
yl
c
y
ano
-
acry
l
ate tissue a
dh
esive (
d
erma
b
on
d
) an
d
suture
f
or t
h
e c
l
osure o
f
excision o
f
w
oun
d
s in c
h
i
ld
ren an
d
a
d
o
l
escents. Arc
h
Dermato
l
.
2001;13
7:
11
77–
1180.
2
2. Singer AJ, Quinn JV, C
l
ar
k
e RE, et a
l
. C
l
osure o
f
l
acerations an
d
incisions wit
h
o
ctylcyanoacrylate multicenter randomised controlled trial.
J
Fam Pract.
2002;
5
1:
2
70–27
6
.
2
3. Maartense S, Bemelman WA, Dunker MS, et al. Randomised stud
y
of the effective
-
n
ess of closin
g
laparoscop
y
trocar wounds with oct
y
lc
y
anoacr
y
late, adhesive pap-
e
rtape or poli
g
lecaprone.
B
r J Sur
g
.
2
002;89:1370–1375
.
2
4. Clib
y
W. Abdominal incision wound breakdown.
lin Obstet G
y
necol. 2002;45:507–
5
1
7
.
2
5. Do
d
son MK, Ma
g
ann EF, Mee
k
s GR. A ran
d
omise
d
comparison o
f
secon
d
ar
y
closure and secondary intention in patients with superfi
cia
l
woun
d
d
e
h
iscence.
stet G
y
neco
l
.
:
321
–
32
4
.
2
6. Do
d
son MK, Magann EF, Su
ll
ivan DL, et a
l
. Extra
f
ascia
l
woun
d
d
e
h
iscence:
d
eep en
bloc closure versus superfi
c
i
a
l
s
kin
c
l
osu
r
e.
Obstet Gynecol. 1994
;
83:142–145.
2
7. Chua Patel CT, Kinsey GC, Koperski-Moen KJ, et al. Vacuum-assisted wound
c
l
osu
r
e.
A
m
J
Nurs.
2
000;10:45–48
.
2
8. Mud
g
e M, Hu
g
hes LE. Incisional hernia: a 10
y
ear prospective stud
y
of incidence
a
n
d
attitu
d
es. Br J Sur
g
.
5;7
2
:7
0
–7
1
.
https://t.me/med1917
Recent A
d
v
a
nces in
Ad
hesi
o
n Preventi
on
ere S. diZerega
Matthias
K
orell
U
se o
f
a
dh
esion prevention a
d
juvants
h
as
b
ecome t
h
e stan
d
ar
d
o
f
practice
f
o
ll
owing gyneco
l
ogic as we
ll
as genera
l
surgery [1–3]. T
h
e
f
requent occur
-
r
ence o
f
a
dh
esions a
f
ter peritonea
l
cavity surgery an
d
c
l
inica
l
consequences
of
a
dh
esions, inc
l
u
d
ing increase
d
rates o
f
reoperation, postoperative
b
owe
l
ob
struction, in
f
erti
l
ity, an
d
c
h
ronic pe
l
vic pain, w
h
ic
h
mar
k
e
dl
y increase
h
ea
l
t
h
care costs, ma
k
e prevention o
f
a
dh
esions a major contri
b
utor to suc
-
c
ess
f
u
l
postoperative outcome. Devices t
h
at re
d
uce postsurgica
l
a
dh
esion
f
or-
mation are a great benefi
t in reducing postoperative morbidity and failed
s
urgica
l
t
h
erapy
.
Adh
esion prevention a
d
juvants
b
ecame avai
l
a
bl
e to practicing surgeons in
990 wit
h
t
h
e intro
d
uction o
f
Intercee
d
A
b
sor
b
a
bl
e A
dh
esion Barrier (Gynec-
are, Somerville, NJ). Other site-specifi
c barriers soon followed, including Pre-
clude (Gore-Tex, Flagstaff, Ariz) and Seprafi
l
m Bioa
b
sor
b
a
bl
e Mem
b
rane
Genzyme, Cam
b
ri
d
ge, Mass). In 1996 an experts’ con
f
erence was
h
e
ld
as part
of
t
h
e Internationa
l
Fe
d
eration o
f
Ferti
l
ity an
d
Steri
l
ity to eva
l
uate t
h
e
d
ata
s
upporting t
h
e use o
f
b
arriers an
d
to ma
k
e recommen
d
ations
f
or t
h
eir app
l
ica-
t
ion [4]. In genera
l
, t
h
e gui
d
e
l
ines supporte
d
prop
h
y
l
actic use o
f
a
dh
esion
b
arriers
f
o
ll
owing a
d
nexa
l
surgery or myomectomy, proce
d
ures we
ll
k
nown
to create adhesions with clinical signifi
cance. A recognized limitation of these
site-specifi
c barriers was the requirement on the part of the surgeon to predict
wh
ere a
dh
esions wou
ld
most
l
i
k
e
l
y
f
orm an
d
w
h
ic
h
wou
ld
cause c
l
inica
l
pro
b
-
l
ems. T
h
is
l
imitation was overcome wit
h
t
h
e avai
l
a
b
i
l
ity o
f
intraperitonea
l
s
o
l
utions an
d
ge
l
s.
C
rystalloid
Th
e most popu
l
ar
d
evice use
d
f
or a
dh
esion prevention is t
h
e insti
ll
ation
of
sa
l
t-containing so
l
utions into t
h
e peritonea
l
cavity at t
h
e en
d
o
f
surgery in
suffi
cient volume (300–500 mL) to allow for “fl
otation” o
f
t
h
e a
d
nexa
l
struc
-
tures [5]. However, in a metaanalysis of 23 clinical trials, hydrofl
otation wit
h
c
rysta
ll
oi
d
s was s
h
own not to re
d
uce
f
ormation o
f
postsurgica
l
a
dh
esions [6].
Th
ese so
l
utions are a
b
sor
b
e
d
f
rom t
h
e peritonea
l
cavity at t
h
e rate o
f
30–60 mL
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана