BURST ABDOMEN

Dr. Toto Imam Soeparmono,

SpOG,K.Onk

Dep Obsgin RSPAD Gatot Soebroto

Jakarta

Halsteds principles

William S. Halsted, M.D.

1 Closing dead space helps prevent seroma formation and infection

2 Careful hemostasis helps improvevisualization and reduce infection

3 Aseptic technique helps prevent infection

4 Sharp anatomic dissection minimizestissue trauma

5 Avoidance of tension ensures adequateblood supply to healing tissues

6 Gentle handling of tissues minimizestissue trauma

2

The goal of tissue managementHelp physicians develop a wound closure

strategy that will lead to optimal patient outcomes

Achieving this in fascial closure can improve healing and reduce wound complications

1.Seiler, et al. Ann Surg

2009;249:576-82

1.Bloemen, et al. Br J Surg 2011;98:633-9

2.Millbourn, et al. Arch Surg 2009; 144:1056-94

4 Complications in comparison of different techniques of fascial closure:

Early complication:

Fascial dehiscence

Infection

Late complication:

Hernia formation

Suture sinus / Incision pain

Interruptions in healing canlead to wound complications Surgical site infection (SSI)

- Postoperative infection of skin and fascia

- Can extend to organs or anatomic spaces1

Wound dehiscence

- Failure of tissue edges to close

- Complete disruption of fascia and overlying tissues can result in burst abdomen2

Incisional hernia

- Fascial closure fails, allowing underlying organs to protrude through defect

- Most common with abdominal surgery1. Mangram, et al. J Infect Control Hosp Epidemiol 1999;20:

247-278. 2. Romano, et al. HSR 2009;44:182-204.

3. Muysoms, et al. Hernia 2009;13:407-414.

6

Wound complications increase risk for more

complications

SSI

- 2x risk of incisional hernia1

- 6x risk of wound separation2

Wound dehiscence

- Associated with 47% incisional hernias3

Incisional hernias

- Associated with SSIs2,3

1.Israelsson, et al. Eur J Surg 1996;62:125-129.

2.van Ramhorst, et al. World J Surg 34:20-27.

3.vant Riet, et al. Am Surg 2004;70:281-6.

Incisional Hernia

WoundDehiscence

SSI

Preventing one complication may prevent others

7

Meta-analysis of techniques for closure of midline abdominal incisions

Reit M, et al. B. J. Surg 2002; 89: 1350-56

15 Studies, 6566 patients

To reduce the incidence of incisional herniawithout increasing wound pain or suturesinus frequency,SLOWLY ABSORBABLECONTINUOUS sutures appear to be THEOPTIMAL METHOD of fascial closure

CONTINUOUSINTERRUPTED

Interrupted versus continuous suture

1. Sissener T. Comp Anim 2006;11:14-19. 2. Boutros S, et al. J Trauma Injury Infect Crit Care

2000;48:495-497. 3. Seiler CM, et al. Ann Surg 2009;249:576-582. 4. Wong NL. J Dermatol Surg

Oncol 1993;19:923-931. 5. Kettle, et al. Cochrane Database Syst Rev 2012; 11:CD000947. 6.

Boutros, et al. J Trauma 2000;48:495-497. 7. Colombo, et al. Obstet Gynecol 1997;89:684-689.

Advantages1,4

Better tension distribution,

less tissue strangulation

Faster to create, shortening procedure time

Less expensive5,6,7

Less material reduces foreign body

introduction

Disadvantages2,3,4

Increased risk of wound closure failure

if there is a break2,3,4

Advantages1,4

May be used to close irregular areas

May minimize spread of infection and

allow for removal of infected stitches

Reduced risk of wound closure failure

if there is a break in only one suture

Disadvantages1-3

Knots increase foreign body material

and risks of complications

Time consuming

10

Mass closure

Reduces risk of wound complications

11

1. Weiland DE, et al. Am J Surg 1998;176:666-670. 2. Berretta R, et al. Austrail N Zealand J Obstet Gynecol 2010;50:391-396.

Meta-analysis of 12,249 patients in 25 studies found that mass closure was associated with significantly lower rates of incisional hernia and wound dehiscence1

2010 RCT of patients undergoing gynecologic cancer surgery found mass closure had lower incidences of wound pain2

Mass Closure

Previous 5 meta-analysis1. Weiland et al.1988

Continuous = Interrupted Absorbable inferior to Non-absorbable Layer by layer closure inferior to One layer

2. Hodgson et al. 2000 Absorbable inferior to Non-absorbable

3. Rucinski et al. 2001 Absorbable inferior to braided non-absorbable Monofilament absorbalble similar to non-absorbable

4. Vant Riet et al. 2002 Continous rapidly absorbable sig. inferior to Continous slowly

absorbable or non-absorbable

5. Gupta et al. 2008 Continuous = interrupted

All did not focus on the study population but rather technique and material

A burst abdomen is

considered present when intestine,omentum or other visceras wereseen in the abdominal woundfollowing surgery

A postoperative complication associatedwith significant morbidity and mortality

Patofisiologi luka terbuka

Significant risk factors

Sepsis *

Cough

Anaemia

Malnutrition

Abdominal distension

* Most important risk factor

Ramshorst, et al. Surg Technol Int. 2010 Apr; 19: 111-9

Usually occurs during the first twoweeks after surgery

23 % to 84 % of wound, leakage ofserosanguineous fluid is observed

Treatment

Conservative management options (wound dehiscence) include use of saline-soaked gauze dressings and negative pressure wound therapy

Operative management options:- temporary closure options (open abdomen treatment)- primary closure with various suture techniques- closure with applicationof relaxing incisions- use of synthetic (non-absorbable or absorbable) and biological meshes- use of tissue flaps

Ramshorst, et al. Surg Technol Int. 2010 Apr; 19: 111-9

Luka dirawat setiap hari sampaiadanya granulasi

Tujuan tatalaksana awal ini:1. Mencegah usus dari kekeringan dan cedera trauma

2. Kontrol infeksi lokal/sistemik3. Debridement semua jaringan mati

4. Persiapan penutupan kulit.

1/3 atas ditutup dengan flap kulit lokaldengan anestesi lokal

24 jam kemudian, 1/3 tengah ditutupdengan cara serupa

24 jam kemudian, 1/3 bawah ditutup.

Teknik Penjahitan Pada Burst Abdomen

Mass closure with / without Mesh

Retention closure

Penjahitan ulang

1. Debridement tepi luka

2. Pembuangan materi jahitan sebelumnya

3. Benang nonabsorbable 1/0 tebalinterrupted atau slow absobable material

4. Mengambil jaringan luas dari tepi luka (> 3cm) dan termasuk semua lapisan.

5. Bisa memakai mesh dan jahitan retensi

Burst abdomen dijahit ulang menggunakan jahitan retensi

Wong SY, Kingsnorth AN. Abdominal wound dehiscence and incisional hernia. Basic Surgical Techniques. Surgery. 2002.

Gambar skematis jahitan figure of eight bilateral terbalik, seperti lasso (jangkar menyusup ke kedua tepi fasia (1

dan 1)

Polipropilene 0.

Jahitan meninggalkan 1 cm antara masuknya jahitan dan titik keluarnya.

Sekuens jahitan (1-4 dan 5-8) dan aspek final (a) setelah implantasi mesh polipropilen. Rectal sheath anterior harus dijahit dengan pola posterior untuk

melengkapi rekonstruksi

Prosedur dilengkapi dengan implantasi mesh polipropilene besar di antara rectus sheath posterior dan muskulurs rektus.

Smead-Jones closure

Rock JA, Jones HW. Te Lindes. Operative Gynecology. 10th ed. Lippincott Williams and Wilkins. 2008

Perbandingan teknik penjahitan interrupteddengan continous pada repair luka operasi terbuka

Tidak adanya konsensus dari metode teknik penjahitan pada repair luka terbuka

Dilakukan kajian meta-analisis untuk mengukur odds rasio (OR)

Kajian 23 studi teknik penjahitan interrupted berhubungan dengan penurunan dehisenssecara signifikan dibandingkan dengan metode penjahitan continous (OR, 0,576; p=0,014; RR 39,8%).

Perbandingan teknik penjahitan interrupteddengan continous pada repair luka operasi

terbuka Teknik penjahitan interrupted juga lebih baik

pada penggunaan dengan benang nonabsorbable, insisi vertikal dan mass closure.

Tidak ada perbedaan risiko terjadinya hernia insisional pada kedua metode ini

Kesimpulan: teknik penjahitan interruped dapat menurunkan odds rasio dari terjadinya dehisenssetengahnya dibandingkan dengan teknik penjahitan continous

Common types of synthetic absorbable sutures and their in-vivo half-lives

Polyglactin 910 (Vicryl) two weeks

Polyglycolic acid (Dexon) two weeks

Poliglecaprone (Monocryl) two weeks

Polydioxanone (PDS) three weeks

Polyglyconate (Maxon) six weeks

Synthetic nonabsorbable sutures

have longer wound security (300 days or more).

Some examples of this type of suture include

polyamide (Nylon)

polypropylene (Prolene)

polybutester (Novafil)

polyester (Mersilene).

Many trials and new techniqueswere developed to prevent or atleast reduce the risk of wounddehiscence, but burst abdomenremain a formidable morbidity

Lofty W. Burst abdomen: is it preventable complication ? Egyptian J Surg 2009; 28, 3: 128-132

Adotey JM. Incisional hernia : A review. Nigerian J Med 2006, Vol 15, 1: 34-43

Despite improved surgicaltechniques and the use of prostheticmesh, incisional herniation remainsa major problem for the generalsurgeon

Summary: factors and treatment concerning surgical wound healing

Factor

SystemicHypoalbuminemia, anemia, vi C deficiency, steroid therapy, active infection, old age

LocalPoor hemostasis & bllod supply, ragged wound edge, contamination of raw wound edges, inadequate drainage of underrcut wounds , poor technique making & closing incision ,anaesthesia

PosoperativeViolent coughing & emesis, ileus, strain at urination & passing flatus

Treatment

Correct imbalances when possible before surgery. When correction is not possible, use retention sutures in addition to standard closure

Good surgical technique and good anaesthesia. Consider antibiotics (systemic and local) if infection is present or contamination un avoidable. Type of anesthesiais not a factor

Preroperativepreparation and postoperative anticipation with institution of appropriate measures immediately

Eisenstat MS. Causes and management ofsurgical wound dehiscence.Cleveland Clinic Quarterly. 2013, vol 39;1: 33-42

KESIMPULAN

Belum adanya konsensus dari metode teknik penjahitan pada repair luka terbuka.

Lebih baik mencegah terjadinya luka operasi dengan manajemen pre, intra, dan post-op yang optimal.

Ucapan terima kasih

dr. Sulaeman Daud dan

dr. Riyan Hari Kurniawan

Ethicon

08/21/08