Angels and Devils in the Open Abdomen Factors Influencing...
Transcript of Angels and Devils in the Open Abdomen Factors Influencing...
Angels and Devils in the Open Abdomen
Factors Influencing Outcome
SINGAPORE TRAUMA CONFERENCE 2013
CARLOS MESQUITA
COIMBRA - PORTUGAL
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HOSPITAIS DA UNIVERSIDADE DE COIMBRA SERVIÇO DE URGÊNCIA
CENTER REGION: ~ 2.400.000 inh Coimbra District: ~ 430.000 COIMBRA UNIVERSITY HOSPITAL: 1.500 adult beds ~ 1.800.000 (3/4) EMERGENCY DPT: • Admissions / yr ~ 150.000
> 400 / d • Inpatiens / yr = 14.000 – 15.000
> 40 / d
• Rec colour pts / yr = 1.400 – 1.500 > 4 / d
• Surgical pts / yr = 3.500 – 3.600
= 9 - 10 / d
EMERGENCY SURGERY
Others 306 - 20 %
Sepsis 810 – 53 %
Trauma 413 - 27 %
CM, n=1529, 31 years (1982 – 2012)
EMERGENCY SURGERY
OPEN ABDOMEN – 2005/2012 Mt. % Delayed
closure
Nbr. pts. 35 19M / 16F 8 22,9 27
Age (limits) 59 28-90
Trauma / Hypovolemic shock 8 22,9 1 12,5 7
After abdominal septic / ACS situations:
• peritonitis / perforations / leaks 15 42,9 4 26,7 11
• necrotizing pancreatitis 6 17,1 2 33,3 4
• bowell isquemia 4 11,4 1 25,0 3
• strangulated hernias 2 5,7 0 - 2
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TEMPORARY ABDOMINAL CLOSURE (TAC) It must
• prevent evisceration • control peritoneal fluids • prevent ACS • prevent contamination • be economical as possible • be fast to execute • be easy to maintain • be radiolucent • allow second look • allow definitive closure a few hours or days later with minimal
prejudices to the wall
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Mark Kaplan et all. Guidelines for the Management of the Open Abdomen. Supplement to “Wounds: a compendium of clinical research and practice”. 2005
VAC Abdominal Dressing System
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Rotondo and Schwab Technique • interposition of a plastic towel between the abdominal contents and the wall
Opsite® inside Inner swab Suction drains Outer swab
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Rotondo and Schwab Technique
definitive closure a few hours or days later with minimal prejudices to the wall
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Luís, 48 year old
2009-12
Time of injury 19h00
M: 3 low velocity gunshot wounds
I: Head, low precordium and right upper quadrant
S: RR 20/m - P 90/m - BP 120/80 - GCS 15
T: 2 litres iv crystalloid
Primary Survey
Arrival at 20h00 (30 minutes later)
A: Patient talking
B: Air entry normal. RR 20/m
C: P 120/m - BP 90/60 – Pale - Haematemesis
D: GCS 15
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
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Angels and Devils in the Open Abdomen – Factors Influencing Outcome
Management
Transfer to OR 20h30
• Urgent laparotomy
• Diafragmatic perforation near the xiphoid / trans-
diaphragmatic pericardial window, no tamponade / no
treatment done
• Gastric body perforation, both walls / sutured
• 2 small bullets, one near the left kydney, the other in the left
lobe of the liver / no treatment done
• No other lesions found CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
Management
After PO Day 7…
• Complete dehiscence of the abdominal wound with
evisceration / Back to OR
• Dificult abdominal closure / TAC
• Loss of domain / temporary coverage with skin grafts
• Three-vessel coronary disease diagnosed / angioplasty
• Quit smoking…
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
2010-12, one year later…
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
2011-11, two years later
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
2013-04
Decided to go for holidays!
CM 2013