physical activity can result in a hernia, and thus patients are advised to avoid heavy lifting for one month following sur-gery. Depending on the clinical scenario, most incisional hernias should be repaired due to the risk of incarceration and strangulation.
In the setting of trauma or sepsis, massive fluid resuscita-tion is sometimes required and can lead to extreme bowel edema. Forcibly closing the abdominal fascia over such edem-atous bowel causes elevated intra-abdominal pressures, known as compartment syndrome . These high pressures decrease perfusion to the kidneys, leading to oliguria and rising creati-nine. In addition, intubated patients will demonstrate high peak airway pressures caused by the intra-abdominal organs compressing the diaphragms and limiting pulmonary capacity.
The intra-abdominal pressure can be measured using a foley catheter equipped with a pressure transducer. If compartment syndrome is diagnosed, the abdominal fascia should be imme-diately opened to relieve the pressure.
Classic Case
A surgical consultation is requested on a 76-year-old diabetic, obese woman who presents with peritonitis. Evaluation with an upright chest X-ray reveals that she has free air under the diaphragm. Immediate operative exploration is performed through a vertical midline incision and reveals perforated diver-ticulitis with gross fecal contamination of the abdomen. A Hartmann’s procedure is performed, where the proximal colon is exteriorized with a colostomy and a rectal stump is left in the pelvis. Antibiotics were administered prior to inci-sion and are re-dosed appropriately throughout the opera-tion. Upon completion of the operation, the fascia is closed with a running suture from either direction and the skin is only loosely approximated with staples.
The patient initially does well, but on the third postopera-tive day she develops a fever to 38.8 °C. Examination of the wound reveals blanching erythema of the skin with extension
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laterally across the abdominal wall. The staples at the site of greatest erythema are removed and probing of the wound is performed. The fascia is intact but some necrotic debris is present. Systemic antibiotics are initiated with some reces-sion of the erythema and local wound care with twice-daily wet to dry dressing changes are initiated.
Two days later the surgical team is paged STAT by the nurse. While coughing, the patient suddenly felt a gush of fluid from her wound. On examination, the skin is open and small bowel is visible in the wound. The patient is urgently taken to the operating room. Inspection of the wound reveals poor healing and frankly necrotic fascia with loose sutures. The wound is closed with retention sutures. The patient ultimately has an uneventful recovery and is discharged home.
OR Questions
1. What patient factors are associated with poor wound healing?
Obesity , advanced age , chronic steroid use , smoking , poor nutrition , diabetes , history of prior radiation , and early excessive physical activity.
2. What surgeon factors are associated with poor wound healing?
Poor closure technique , excessive tension on the fascia inad-equate administration of perioperative antibiotics , and inappropriate closure of a contaminated wound.
3. When closing an incision, is it advisable to suture together the layers of muscle and fat?
No , sutures placed in muscle and fat add no strength to the wound. Only fascia provides the necessary integrity for wound closure .
4. Where are the majority of surgical site infections located?
In the subcutaneous fat , between the skin and the fascia . 5. Can a wound infection be treated with antibiotics alone?
No amount of antibiotics will cure a wound infection in the presence of an undrained purulent collection beneath the skin ; opening the wound is the necessary treatment .
2. Incisions
6. A patient with a well-healed scar from a previous parame-dian incision now requires open surgery again. Is it advis-able to make the incision through the previous scar, or to make a midline incision?
In general , the surgeon should choose the incision that best serves the needs of the current operation. However , it would be ideal to reuse the paramedian site , since a parallel inci-sion may severely limit the blood supply to the area in between , risking tissue necrosis.
Incisions
Thoracic incisions
•Sternotomy: excellent exposure to the entire thoracic cavity, can be complicated by sternal wound infection
•Thoracotomy: provides access to each lung and the esophagus, can be used to clamp the aorta in trauma situations
•Thoracoabdominal: only used when necessary due to the morbidity associated with such a large incision Vertical midline
•Most often used
•Minimal blood loss
•No division of muscle fibers
•No nerve injury
•Easy to open and close
•Good exposure to most abdominal and pelvic structures
Subcostal
•Rectus muscle is divided, which can be more painful
•Provides exposure to gallbladder on the right, and spleen on the left
•A bilateral subcostal (chevron) incision offers excellent exposure to entire upper abdomen
Paramedian
•Better exposure to lateral structures
•Lower incidence of incisional hernia because the abdomen is closed with multiple layers of fascia
•Costal margin limits vertical extension
Pfannenstiel
•Low transverse incision just above the pubis
•Excellent cosmetic results
•Exposure is limited to the pelvis
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Suggested Readings
Roses RE, Morris JB. Incisions, closures, and management of the abdominal wound. In: Zinner MJ, Ashley SW, editors. Maingot's abdominal operations. 12th ed. New York: McGraw-Hill Professional Publishing; 2013.
Buck DW, Galiano RD. Wound care. In: Thorne CH, Chung KC, Gosain AK, Gurtner GC, Mehrara BJ, Rubin PJ, Spear SL, edi-tors. Grabb and Smith's plastic surgery. 7th ed. Philadelphia:
Lippincott Williams & Wilkins; 2014.
Complications
•Infection: most wound infections are superficial to the facial closure:
opening of the skin allows drainage and resolution
•Dehiscence: separation of the fascia, most often secondary to wound infection or excessive tension, may be heralded by the sudden new discharge of fluid from the wound
•Evisceration: protrusion of the abdominal viscera through the wound, due to a dehiscence, requires immediate operative repair
•Incisional hernia: essentially a late fascial dehiscence
•Compartment syndrome: elevated intra-abdominal pressure caused by closing the fascia in the setting of edematous bowel. May present with elevated creatinine or decreased urine output. A bladder pressure
>25mmHg is diagnostic. Abdominal fascia must be opened for relief.
Peri-op orders
•Pre-incision antibiotics for clean-contaminated or clean-contaminated cases
•First dressing change for clean incisions is usually POD#2
•Infected incisions may need dressing changes bid, as indicated
2. Incisions
U. Sarpel, Surgery: An Introductory Guide, 17 DOI 10.1007/978-1-4939-0903-2_3,
© Springer Science+Business Media New York 2014
Introduction
In open surgery, an incision is made and the surgeon directly visualizes and handles the tissues in order to perform the operation. By contrast, laparoscopic surgery avoids a large incision by utilizing a camera and scope system to project images from within the body onto a monitor. A camera attached to a thin, long, lighted scope, and other instruments are inserted through small incisions, typically 1 cm or less in size. The positions of trocars are strategically chosen to pro-vide the best approach to the area of interest. Once access to the abdomen is established, carbon dioxide is insufflated into the peritoneal cavity to create pneumoperitoneum . The insuf-flation pressure distends the abdominal wall outward, creat-ing enough room for the surgeon to work. In the thoracic cavity, once the lung is deflated, the ribs maintain a rigid structure allowing thoracoscopy to be performed without insufflation.
Many if not most procedures that can be performed open can also be performed laparoscopically. In fact, for several operations such as cholecystectomy, appendectomy, and fun-doplication, the laparoscopic approach has become the stan-dard of care. Laparoscopic surgery carries the obvious advantage of smaller incisions and thus a more cosmetic postoperative appearance. However, numerous additional benefits to laparoscopy exist, including reduced postoperative
3
Laparoscopy
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pain, fewer pulmonary complications, lower rates of wound infection, a shorter hospital stay, and fewer adhesions. Of note, the laparoscopic approach is strongly preferable in obese patients, since the morbidities associated with a large incision can be entirely avoided.
Despite the advantages afforded by laparoscopy, there are also certain disadvantages to this approach. In general, laparoscopy is technically more difficult and requires spe-cialized training. In addition, laparoscopic cases carry risks unique to laparoscopy, including those related to trocar placement and pneumoperitoneum. Laparoscopy is not well suited to all patients; indeed, there are several instances where open surgery is advantageous. For example: (1) in trauma patients, rapid control of hemorrhage including direct manual compression of bleeding sites may be needed;
(2) laparoscopy is difficult in the presence of extensive adhesions from previous operations or an intra-abdominal inflammatory process; (3) some patients with borderline pulmonary reserve cannot tolerate the reduced lung volumes caused by pneumoperitoneum and the resultant increased intrathoracic pressures; (4) the presence of extremely dilated bowel can make laparoscopy difficult since there is little room left to work; furthermore, dilated bowel is thin-walled and eas-ily injured when grasped with laparoscopic instruments; and (5) when surgery is being performed for the resection of a large tumor, an incision may be necessary to extract the specimen.
Surgical Technique
The umbilicus is the most frequently used site to gain access to the abdomen, although other locations can also be used depending on the intended operation. The skin incision is made, the underlying fascia and peritoneum are opened, and a 1 cm Hasson trocar is placed through the hole. Rather than using this cut-down technique, percutaneous approaches are also avail-able to gain access to the abdomen, and are used based on surgeon preference. Once the access has been established, 3. Laparoscopy
carbon dioxide is insufflated to create pneumoperitoneum to a pressure of approximately 15 mmHg. The camera is inserted into the abdomen and additional trocars are then placed under direct vision. The position, size, and number of port sites are carefully selected based on the type of operation being per-formed (Fig. 3.1 ).
Different types of scopes are available for laparoscopy.
The most commonly used scopes are either 5 or 10 mm thick, and are available with varying degrees of angulation (0°, 30°, and 45°) to assist in visualizing around corners. New flexible scopes are also emerging onto the market. Throughout the case, the operating table can be tilted back and forth to allow gravity to assist in exposing target structures.
Specimens are typically placed within a plastic bag that is then pulled out the largest trocar site. The incision at this site may be enlarged slightly to facilitate removal. In certain cases
Camera cord
Light cord Trocar sites
Insufflation tubing
Fig. 3.1 Components of laparoscopy: trocar sites, light cord, camera cord, and insufflation tubing. Note the placement of trocars for triangulation around a target organ such as the spleen, and the use of positioning and gravity to optimize exposure
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(e.g., splenectomy) the specimen can be morcellated and removed piecemeal in order avoid enlarging the incision. After the operation is complete, the fascia of all port sites greater than 5 mm must be closed to prevent an incisional hernia.
Complications
In general, the complications of a laparoscopic operation are the same as for its open counterpart. However certain com-plications may be more common during laparoscopy. For example, the risk of inadvertent enterotomy may be greater for some types of laparoscopic surgery. Bowel may be injured during trocar placement—particularly during insertion of the first trocar since this is done with limited visualization.
An inadvertent enterotomy can also occur if a hot cautery appliance strays outside the visual field and touches a loop of intestine. An important concept in laparoscopic surgery is to maintain visualization of all instruments in order to avoid this complication. Finally, the limited sensory feedback in laparo-scopic surgery can lead to situations where bowel is injured by rough handling.
In addition, some patients simply cannot tolerate the ele-vated intra-abdominal pressures that are created by insuffla-tion. Patients with emphysema and limited pulmonary reserve may desaturate during longer laparoscopic procedures, in which case conversion to open surgery should occur. Similarly, the intra-abdominal pressures generated to achieve pneumo-peritoneum cause a measurable decrease in the venous return to the heart, which can compromise the hemodynam-ics of patients with borderline cardiac output.
Classic Case
A 40-year-old woman with recurrent biliary colic under-goes a laparoscopic cholecystectomy. Access to the abdo-men is established via a Hasson trocar inserted below the