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VCUDEATH AND COMPLICATIONS CONFERENCE
Complication
Complication Dehiscence
Procedure Ileocecocetomy with end ileostomy
Primary Diagnosis Perforated terminal ileum
Clinical History
HPI 61 y old male with cc of dizziness,
nausea and vomiting. He was found to be hypotensive (60/39) and tachycardic ( Aflutter). Was admitted to MICU. As part of work up CT of abdomen/pelvis was obtained, it showed free air, free fluid and dilated loops of small bowel.
Clinical History
PMH RA, CHF, COPD, HTN, AFIB, DVT, Prostate CA, HepB,
and lupus. PSH AVR 1996, abdominal surgery for 30 yrs ago for PUD. MEDS : Carvedilol, Coumadin, Prednisone, Omeperazole,
Prevastatin, Valsartan, and Albuterol PE: abdomen obese, soft, slight distention, diffuse
tenderness, no rigidity, no guarding. Rectal exam normal, stool, no blood, no mass, normal tone
Clinical History
LABS: lactate 4.5 wbc 6.5 hgb 12 co2 18 bun 23 creat 2.33 INR 1.2 alb 1.6 LFT’s normal
Chest x-ray ? Vascular congestion, KUB non diagnostic
EKG: Aflutter CT abd/pelvis: extralunminal air, large
free fluid , mesenteric stranding
Overview of Case
Emergently taken to the operating room for Ex-Lap
Greenish brown fluid, undigested vegetables, dilated loops of bowel, dense adhesions, perforation of the terminal ileum
Ileocecocetomy with end ileostomy Fascia was closed in a running #1 PDS
Sutter Skin was left open
Hospital course
Pod 1 extubated off pressors Pod 5 gen floor, OOB, gen diet Pod 12 fascial dehiscence
Analysis of Complication
• Was the complication potentially avoidable?– Yes, may have used retention Sutter
• Would avoiding the complication change the outcome for the patient?– Yes, minimize length of hospital stay, risk of
evisceration
• What factors contributed to the complication?– Given the patient’s high risk for dehiscence
additional measures such as retention sutter should have been utilized.
Background
A prospective, multi-institutional study (132 VA Medical Centers)
Used the National Veterans Affairs Surgical Quality Improvement Program to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy.
Methods. The wanted to build model in order to create a scoring system designated the abdominal wound dehiscence risk index.
b/n Oct 1, 1996, and Sep30, 1998 Perioperative data from 17,044 laparotomies were used to
develop the model 587 (3.4%) wound dehiscence
Data from 17,763 laparotomies between October 1, 1998, and September 30, 2000, resulting
in 562 (3.2%) dehiscence were used to validate the model.
Models were developed using multivariable stepwise logistic regression with preoperative, intraoperative, and postoperative variables entered sequentially as independent predictors of wound dehiscence.
Conclusion
In the high risk patient groups surgeons should consider prophylactic
measures intraoperatively, or early intervention post-operatively.
Finding the best abdominal closure All articles related to abdominal fascia
closure published from 1966 to 2003 were included in the review.
Careful analysis of the current surgical literature, including 4 recent meta-analyses, indicates that an optimal technique exists.
Finding the best abdominal closure There were 4 complications involved in
comparison of the different techniques of fascial closure apparent on review of the literature:
Early Complications 1. Fascial dehiscence 2. Infection
Late Complications 3. Hernia formation 4. Suture sinus/Incision pain
The best technique involves
Involves mass closure, Incorporating all of the layers of the
abdominal wall (except skin) as 1 structure
A simple running technique, using #1 or #2 absorbable monofilament suture material
With a suture length to wound length ratio of 4 to 1