operative surgery notes by d. maseko
TRANSCRIPT
OPERATIVE SURGERY NOTESABDOMINAL DEHISCENCE
DALITSO MASEKO (Mr.)
BARCHELOR OF CLINICAL SCIENCE STUDENT (2014-2016)
CAVENDISH UNIVERSITY ZAMBIA
31-Jan-16
INTRODUCTION
Definition:
Burst Abdomen or Abdominal Dehiscence is disruption of a laparotomy wound occurring usually 5th and 8th postoperative day.
Usually occurs at sutures opposing the deep layers, i.e. peritoneum and rectus sheath tear through, causing burst abdomen.
2/19/2016 2:22 [email protected]
FACTORS RELATED TO BURST ABDOMEN
Abdomen is likely to burst if:
PATIENT FACTORS
1. Poor general condition of the patient- extremes of age (old and very young), malnutrition, immunopathology, anaemia, jaundice, hypoproteinaemia, obesity.
2. Severe cough, vomiting and distension in post-operative period.
3. Abdomen is swollen for any reason, such as ileus, intestinal obstruction, or a large tumour.
4. Has severe abdominal sepsis, such as an infected caesarean section, typhoid peritonitis, or a perforation of large gut.
5. Has carcinomatosis, uraemia, or obstructive jaundice.
2/19/2016 2:22 [email protected]
FACTORS RELATED TO BURST ABDOMEN
SURGICAL FACTORS
1. Choice of suture materials used. Absorbable material poor choice.
2. Method of closure: continuous closure is more likely to disrupt than interrupted sutures. Layers taking bites of tissues that are too small. (shouldn’t be too tight and take wide bites of tissue)
3. Upper midline and vertical wounds are more likely to disruption.
4. Surgical wounds of peritonitis, acute abdomen, and major surgeries like pancreatic, hepatic, gastric, surgeries for malignancies have high incidence of disruption.
2/19/2016 2:22 AM [email protected]
CLINICAL FEATURES
A sudden feeling of giving way from the wound on 5th to 8th post op day often precipitated by bouts of severe cough.
Pinkish serosanguinous discharge from the wound.
Often omentum or coils of intestines are forced out of the wound.
Clinically burst abdomen can be diagnosed without fail. Treat before it bursts.
2/19/2016 2:22 AM [email protected]
MANAGEMENT
1. Nasogastric aspiration
2. IV fluids
3. Pain management
4. Emergency surgery
2/19/2016 2:22 AM [email protected]
SURGICAL MANAGEMENT
Prepare for theatre/laparotomy.
If the abdomen has burst give general anaesthesia. Only repair under local anaesthesia if very unfit for GA.
Remove the skin sutures in the area where you suspect the burst.
Remove the dressings and gently explore the depths of the wound with a sterile gloved finger. Open it down its whole length by removing all the skin sutures. You will soon find out what has happened.
If you confirm a burst abdomen, remove all sutures from the fascial layers.
2/19/2016 2:22 [email protected]
SURGICAL MANAGEMENT
Try to insert your finger between the parietal peritoneum and underlying gut and omentum. In this way you should be able to mobilize enough of the abdominal wall to take some more sutures.
Re-suture the abdominal wall with interrupted steel or monofilament sutures, either intermittent or continuous. Suture from within outwards through the peritoneum, posterior rectus sheath, rectus muscle, and anterior rectus sheath (but not through the skin).
Hold all the sutures out on haemostats until you have placed the last one.
Some surgeons also insert tension sutures (consider that this is the only indication for them).
If indicated insert a peritoneal drain for 14 days.
If his skin is already infected, use delayed closure, and graft it later if necessary2/19/2016 2:22 AM [email protected]
POST OPERATIVE CARE
Wound cleaning
IV fluids
Antibiotics
Nursing care
Nutritional care
Psychological care
2/19/2016 2:22 AM [email protected]
CONCLUSION
Wound dehiscence is a surgical complication, that caries a 30% mortality, in which a wound ruptures along a surgical incision.
Most of the risk factors are either preventable or modifiable. It is imperative to manage it before it clinically occurs.
2/19/2016 2:22 AM [email protected]
REFERENCES
1. Rusiani L. and Robbins P. (2008). Textbook of dermatologic surgery. PICCIN.
2. Sriram Bhat M. (2005). SRB’S Manual of Surgery, 2nd edition. Jaypee Brothers Medical Publishers (P) Ltd. India
3. Wound Dehiscence (Surgical Wound Dehiscence; Operative Wound Dehiscence). EBSCO Industries. 2010-09-01. Retrieved 2011-06-24
2/19/2016 2:22 AM [email protected]
2/19/2016 2:22 [email protected]