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Angels and Devils in the Open Abdomen
Factors Influencing Outcome
SINGAPORE TRAUMA CONFERENCE 2013
CARLOS MESQUITA
COIMBRA - PORTUGAL
CM 2013
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
CM 2013
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
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
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
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
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
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
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
201203, after 3 months…
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
CM 2013
Angels and Devils in the Open Abdomen – Factors Influencing Outcome
2013-04
Decided to go for holidays!
CM 2013
Lord Moynihan of Leeds (1865-1936)
The modern operation is safe for the patient. The modern surgeon must make the patient
safe for the modern operation
“The Barber Surgeon” Jacobus de Cessolis
(séc. XV)
CM 2013
