Request PDF on ResearchGate | Primary Fascial Closure with Mesh patients ( mesh-reinforced and 27 bridged repairs) with a mean follow-up of The technique of fascial closure is highly variable among surgeons; however, the . Examples of such circumstances include the following. Incision and closure of the abdominal wall is one of the most frequently performed, yet least closure. Transversalis Fascia, Peritoneum, and Bladder Reflection.
Patient characteristics Overall, the majority of patients were men. This could partly be explained by the high percentage of male patients in the series with trauma patients [ 51838 ]. However, even the series without trauma patients showed high percentages of male patients [ 41852 ]. The authors did not find a reason for this difference in the current literature on peritonitis or pancreatitis.
Temporary abdominal closure Although the authors categorized the techniques in this review, the techniques were not standardized.
Therefore, an unknown amount of practice variation for each technique remains. Subdivision of the series per patient group and technique resulted in small numbers of patients and heterogeneous results and was omitted.
Fascial closure For the purpose of this study, the authors pooled the results per technique. The artificial burr, VAC, and dynamic retention sutures seemed to produce the highest rates of delayed primary fascial closure.
These techniques might simply have been superior to the other techniques.
Operations on the Abdominal Wall | GLOWM
However, little information was available on the severity of the underlying condition. Therefore, the higher closure rates might have been due to less severe disease inclusion bias. An indication for this could be the low mortality rates in these series; however, this remains speculation. As mentioned in Materials and methods, the authors calculated the delayed primary fascial closure rate for all included patients. This was done because the moment of death before or after closure often was not recorded.
However, it is likely that many patients died before closure [ 32 ]. Therefore, the delayed fascial closure rate of the survivors might have been higher than the rates reported above. This applies to all TAC techniques. Some techniques were used in hundreds of patients, whereas others were used in less than 20 patients. Although the authors considered this by weighing the rates of delayed fascial closure rate and mortality, the reliability of the weighted estimate of fascial closure per series differs.
Fistulae and abscesses Fistulae and abscesses were the most consistently reported complications. However, the reported rates may be underestimated because, in retrospective chart reviews, complications may be difficult to identify. Like the fascial closure, the fistulae and abscesses could have been the result of initial peritoneal contamination rather than a function of the TAC technique.
Furthermore, a higher likelihood of fistulae or abscesses might have influenced the choice of technique inclusion bias. Again, this remains speculation. Mortality All series reported a mortality rate. Despite the high overall mortality, two series reported no mortality. This is most likely the result of inclusion bias and the small number of patients in these series 8 and 11 patients.
The four techniques with the highest delayed fascial closure rates also showed the lowest mortality rates.
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Limitations This systematic review suffers from an unknown but presumably large amount of inclusion bias and lack of standardization of techniques. Therefore, it cannot be determined whether the fascial closure rate and mortality shown in this review are the result of the TAC technique, the severity of the underlying condition, or other factors not included in the retrospective studies.
These issues stress that, although this is the strongest evidence in this field of surgery, the conclusions that can be drawn from this systematic review are limited. Conclusions The results of this review may suggest that the artificial burr and the VAC are associated with the highest closure rates as well as the lowest mortality rates level IV evidence [ 56 ]. The lack of high-quality comparative data underlines the need for randomized, clinical trials in this field.
The anterior rectus sheath is approximated as closely as possible. In some instances, dissection between the hernial sac and the fascia may prove exceedingly difficult or impossible, in which case the Marlex mesh may be anchored to the anterior aspect of the rectus muscles and, again, the anterior rectus sheath would be approximated as closely as possible. This location of the dissection is not as satisfactory, however, in that the already increased risk of wound infection due to the presertce of the graft is further increased by its proximity to subcutaneous tissue and skin.
Postoperatively, predisposing conditions for wound failure should be addressed fastidiously, including control of nausea and vomiting, aggressive and early treatment of ileus and pulmonary complications, and attention to adequate nutrition. Clean incisions are defined as those initiated on prepared skin without entering a contaminated viscus or encountering infection.
Clean contaminated wounds are the same as clean incisions, but a contaminated viscus, such as the vagina that has been prepared, is entered without gross spillage. A wound is classified as contaminated if an infected genitourinary tract is entered or gross gastrointestinal spillage occurs. A dirty wound is one that occurs when pus from an abscess is spilled intraoperatively, or previously ruptured bowel is present.
The rate of infection varies not only according to increasing severity, but also according to patient socioeconomic status, surgical technique, operating time, obesity, age, and sex. Infection is often initiated by direct inoculum of bacteria into the wound from the patient's or surgeon's skin and is potentiated by the presence of necrotic tissue.
Proper preparation of both is necessary to ensure the lowest possible rate of infection. If hair removal is required, clipping immediately before surgery is preferable to shaving, and either is preferable to shaving the evening before, which has been associated with higher rates of wound infection.
After adequate skin antisepsis, multiple intraoperative factors come to bear. Since devitalized tissue offers increased opportunity for poor wound healing and infection, every effort should be made to minimize infection's presence, including meticulous incisional technique with a stainless steel scalpel and precise hemostasis with cautery or fine, nonreactive suture.
These same considerations hold true while operating i. Mass closure of the abdominal wall with continuous mortoff-lament suture would seem preferable in theory, although clinical studies have not yet supported this view other considerations, such as decreased risk of dehiscence, may suggest this combination.
Even in clean wounds, however, irrigation removes fragments of free tissue and fat globules from separated adipose cells that will prolong inflammation and delay repair. Drains may be placed in the subcutaneous tissue when diffuse oozing resistant to hemostatic efforts is present. Soft drains, such as the Penrose, have been replaced by closed suction drains brought out through a separate stab wound with improved results i.
A trial of closed, subcutaneous drains alternately placed in suction and irrigated every 8 hours for 3 days with an antibiotic solution showed possible benefit in grossly infected wounds, but probably are not justified in clean contaminated wounds.
With delayed primary closure, Verrier and colleagues showed a decrease in infection rates in contaminated wounds from A delayed primary closure is one in which the subcutaneous tissue and skin are not closed at the time of initial surgery, but covered by a: Sutures can be placed during the original operation and left to be tied later, or the wound can be sutured under local anesthesia in the patient's room. During this time, the body's immune response has had a chance to clean the wound, and microscopic capillary formation has begun, creating excellent oxygenation of the wound edge.
Closure of the wound on the fourth day greatly decreases the chance of infection, allowing patients to avoid the potentially serious problem of sepsis associated with wound infection. This approach is most helpful during treatment of pelvic infection, especially in patients with poor healing characteristics. In these patients, delayed primary closure has resulted in an extremely low complication rate.
Wound infections may present in several ways, depending on the extent of the infection, host resistance, and the etiologic microorganisms. Early, mild infections may be associated with only scant exudate from the incision and, upon exploration of the wound, poor healing. Hemolytic streptococcal organisms may cause erysipelas, an infection marked by a rapidly extending erythematous cutaneous border. Deeper infections may be found during the process of evaluation for postoperative fever and may additionally be associated with erythema, induration of skin and subcutaneous tissues or, possibly, fluctuation.
One must be alert for the rare but devastating signs of necrotizing infections, including brawny edema, cutaneous sensory loss, and obvious necrosis. Patients with necrotizing fasciitis need prompt and aggressive debridement under general anesthesia to avoid death. In cases of contaminated and infected wounds, consideration should be given to delayed primary or secondary closure.
In these situations characteristics of each case should be taken into account, such as the amount of infected tissue left behind, nutritional status of the patient, presence of diabetes, malignancy, or obesity--factors associated with poor wound-healing. When the decision is made to proceed with delayed closure, retention sutures may be placed. Permanent, monofilament suture would be the best choice.
Cultures, of course, should be obtained. Postoperatively, the incision can be left covered until the fourth day, at which time the attending physician assesses whether the wound is clean enough to close. If there is any infected or necrotic tissue, then regular dressing changes and debridement can be commenced postoperatively until the wound is ready to close. Delayed primary closure may be done using one of several techniques: In the high-risk patient, when coaptation of the wound is difficult, or if the wound does not appear clean in a reasonable period of time, the wound may be allowed to heal by secondary intention.
Perhaps surprisingly, the cosmetic result in such a case is equal to that of delayed primary closure. Careful instruction prior to discharge and follow-up by a visiting nurse will be very helpful to the patient and her family. Treatment for superficial and minor infections may consist only of application of moist heat. Erysipelas usually responds rapidly to such local treatment with the addition of penicillin.
When discharge from the wound is prominent, or fluctuation is thought to be present, the wound should be explored and all areas presenting little resistance to separation opened fully.
Cultures should be obtained, appropriate antibiotics should be started and the wound should be debrided and packed. Secondary closure may be desirable and possible if the wound reveals healthy granulation tissue 3 to 5 days after opening.
Again, the patient may be sent home with follow-up by a visiting nurse.
Nerve Injury Nerve injury associated with abdominal incision can pose a distressing, and often unexpected ending to an otherwise successful operation. Two types of injury occur. First, the incision and closure may transect or damage the nerves of the abdominal wall.
Second, a retractor used during the operation can cause injury to nerves on the posterior body wall. The most serious nerve damage is that to the fiemoral nerve, because of the loss of innervation to the quadriceps muscle in the leg and loss of the ability to extent the leg at the knee joint. This damage is usually caused by the blades of a self-retaining retractor. The lateral blades of these instruments can press upon the nerve as it emerges from the lateral border of the psoas muscle before passing under the inguinal ligament Fig.
Damage to the nerve should be suspected with loss of sensation in the anteromedial thigh, diminished knee jerk, and weakness of extension of the knee, which creates a specific problem climbing stairs. Retractor inductor nerve injury. Fernoral nerve impairment subsequent to hysterectomy. Am J Obstet Gynecol Although this situation creates no motor abnormality, the loss of sensation in the upper medial thigh and labium majus can be quite distressing.
The risk of these complications is higher in thin individuals and when retractors with deep blades have been used. Simply placing a laparotomy pack over the retractor blades will not diminish the amount of force that impinges on the nerve, and a space between the blade and nerve should always be confirmed, remembering that some downward pressure will unavoidably be placed on the retractor during surgery. Although the nerve itself can not readily be palpated in the operating room, the psoas muscle can be.
It lies lateral to the external iliac artery, and identification of the vessel by its pulse will lead the examining finger laterally to the muscle. An additional type of injury that can occur is entrapment of the iliohypogastric or ilioinguinal nerves in the lateral closure of a transverse incision Fig. These nerves lie medial to the anterior superior iliac spine, first, between the layers of the transversus abdominus and internal oblique muscles, and then, more medially, come to lie between the internal oblique and external oblique.
Although most surgeons fail to notice them during the lateral extension of a transverse incision, they are sometimes visible in the lateral aspects of the wound and should be looked for and avoided when seen. Location of the iliohypogastric and ilioinguinal nerves that can be injured during transverse abdominal incisions, as well as incisions in the groin.
Anatomical Complications in General Surgery. New York, McGraw-Hill, Minor sensory abnormalities can arise when the nerve that innervates the abdominal skin and that accompanies the blood vessels that run between the rectus muscle and its sheath to reach the skin is transected during elevation of the fascia off of the muscle in a Pfannenstiel incision.
Because of the extensive overlap of dermatomes here, this transection is usually not a problem, but can cause troublesome loss of sensation above the incision. The rectus abdominus muscle and the epigastric arteries. Surg Gynecol Obstet An Atlas of Human Anatomy, p Fundamentals of Wound Management.
Contamination versus surgical technique. The epidemiology of wound infection: A year prospective study of 62, wounds. Surg Clin North Am Damage to tissue defenses by vasoconstrictors. J Am Coil Emerg Phys 4: Technical factors in wound management. Fundamentals of Wound Management, pp — Careful surgical technique can reduce infectious morbidity after cesarean section.Abdominal Wall Closure BBraun
Relationship between morbidity and surgical technique. Current use of skin and wound cleansers and antiseptics. Am J Surg Studies in themanagement of the contaminated wound. Resistance to infection of surgical wounds made by knife, electrosur-gery and laser. Studies in the management of the contaminated wound. Resistance to infection of surgical wounds made by knife, electrosurgery and laser. Historical and current perspectives on surgical drainage. Potentiation of wound infection by surgical drains.
Modifications of celiotomy techniques to decrease morbidity in obese gynecology patients. Am J Ob-stet Gynecol A five-year prospective study of 23, surgical wounds. A modified transverse incision for low abdominal operations.
Transverse periumbilical incision in the massively obese patient. Anatomical Complications in General Surgery, p Circumumbilical versus transumbilical abdominal incision.
Br J Surg Disruption of abdominal wounds. Pressure necrosis is the primary cause of wound dehiscence. Can J Surg Principles of abdominal wound closure: The chemical dimensions of a healing incision. Tissue strength of structures involved in musculo-aponeurotic layer sutures in laparotomy incisions. Acta Chit Scand Abdominal midline incision closure: