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Gastrointestinal surgery


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  • 1. GASTROINTESTINAL SURGERYSurgical procedures of the abdominal cavity are several, may include digestive tract, glandsattached, accompanied usually by cutting and suturing of deep connective tissue (fascia),peritoneum, muscle, subcutaneous tissue and skin. In this paper we will focus on surgicaltechniques at the stomach and small intestine.The most common diseasesWHERE ARE THESE PROCEDURES ARE:GATROINTESTINAL HIGH BLEEDING:Upper gastrointestinal bleeding or upper gastrointestinal bleeding refers to bleeding thatoriginates in the esophagus, stomach or duodenum, or was in a region proximal to theligament digestive Treizt may also include the proximal jejunum.This bleeding is caused byhematemesis, melanomesis, as well as for hair.
  • 2. PEPTIC ULCER DISEASE:Peptic ulcer disease is manifested by duodenal ulceration, gastric ulceration and pepticesophagitis. Peptic ulceration, erosion and corrosion of the mucosa by the gastric juice. Thisinjury occurs when the mucosa of vulnerability or abnormal conditions when there is excessgastric or ectopic location when the gastric mucosa. May be aggravated by excessive presenceof Helicobacter pylori.Surgical treatment includes:- Vagotomy.- Vagotomy combined with antrectomy.- Subtotal gastrectomy.DELAYED GASTRIC EMPTYING SYNDROME AND SYNDROME POSTGASTRECTOMÍA:Occurs by delayed emptying of chyme into the duodenum or after gastric surgery. Surgicaltreatment can be very painful and must be done carefully.GASTRIC CANCER:Stomach cancer or gastric cancer is a malignant tissue growth rate produced by the contiguousspread of abnormal cells capable of invasion and destruction of other tissues and organs,particularly the esophagus and small intestine, causing nearly one million deaths worldwideannually. In formasmetastásicas, tumor cells can infiltrate the lymph vessels in tissue, spreadto the lymph nodes and overcome this barrier, enter the bloodstream, after which the road isopen virtually any organ in the body.
  • 3. SymptomsStomach cancer can be difficult to detect in its early and often no symptoms, and in manycases, the cancer has spread before you are. When symptoms occur, they are often sounobtrusive that the person does not care about them.Stomach cancer can cause the following effects:• Indigestion or a burning sensation• abdominal pain or discomfort• Nausea and vomiting• Diarrhea or constipation• Swelling of the stomach after meals• Loss of appetite• Weakness and fatigue• unusual bleeding• Changes in bowel or urinary• Wounds that are slow to heal• Difficulty eating• Sudden changes in the appearance of skin warts• Persistent cough or hoarseness• Weight loss• Bad breathAny of these symptoms may be caused by cancer or by other less serious health problems,such as a stomach virus or an ulcer. Therefore, only a physician can determine the actualcause.If a person has any of these symptoms should see your health professional. Later, thisdoctor, you can send to that person to a doctor who specializes in problemasdigestivos. Thelatter will gastroenterologist who diagnose and determine exactly the correct diagnosis.DiagnosisTo find the cause of symptoms, you start with the patients medical history and physicalexamination, supplemented by laboratory studies. The patient also may have to perform oneor more of the following tests:Fecal occult blood test, is not entirely useful, as a result does not indicate anything negativeand a positive result is present in a number of conditions in addition to gastric cancer.
  • 4. Gastroscopy examination.Analysis of the abnormal tissue seen in a gastroscope examination with a biopsy done by thesurgeon or gastroenterologist. This tissue is then sent to a pathologist for histologicalexamination under a microscope to check for the presence of célulascancerosas. A biopsy, withsubsequent histological analysis, is the only sure way to confirm the presence of cancer cells.Hyperplasia, a disorder of the skin, often in the armpit and groin, called acanthosis nigricans,commonly seen in obese people usually generally promotes the need for studies to rule outgastric cancer of the stomach.SurgerySurgical specimen of ulcerated gastric adenocarcinoma and raised edges.Surgery is the most common treatment for stomach cancer, an operationllamadagastrectomía. The surgeon removes part (subtotal gastrectomy) or entire stomach(total gastrectomy) as well as some of the tissue around the stomach. After partialgastrectomy, the remaining portion is anastomosed stomach has been removed with theesophagus or small intestine. After total gastrectomy, the doctor connects the esophagusdirectly to the small intestine. Because cancer can spread through the lymphatic system,lymph nodes near the tumor is removed, usually during the same surgery so that thepathologist can check to see if there are cancer cells in them. If cancer cells are in the nodes,the disease may have spread to other parts of the body.The surgical margin, ie the amount oftissue to be removed around the area affected by gastric cancer is 5 cm of normal tissue.Gastrointestinal surgery is major surgery. After surgery, the activities are limited to allowhealing to occur. The first days after surgery, the patient is fed intravenously (through avein). After several days, most patients are ready for liquids, followed by soft foods and thensolids. Those who have completely removed the stomach being unable to digest lavitaminaB12, which is necessary for blood and nerves, and you are given regular injections of thevitamin. Patients may have temporary or permanent difficulty digesting certain foods, and mayneed to change your diet. Some digestive surgery patients need to follow a special diet forseveral weeks or months, while others need to make a lasting change in their diets. The healthprofessional or a dietitian (nutrition specialist) explain any dietary changes needed.Some patients after gastrectomy with cramps, nausea, diarrhea, and dizziness shortly aftereating because food and liquid enter the small intestine too quickly and without beingdigested. This group of symptoms is called the dumping syndrome. Foods containing highamounts of sugar often make symptoms worse.The dumping syndrome can be treated by
  • 5. changing the patients diet. You can manage the symptoms by eating several small mealsthroughout the day, avoid foods that contain sugar, and eat foods high in protein. To reducethe amount of fluid entering the small intestine, patients are instructed generally not to drinkat meals. Certain medications can also help control the dumping syndrome. The symptomsusually disappear in 3 to 12 months but may be permanent.After digestive surgery, digestive upsets are caused by the bile.They can prescribe medicationsor suggest counter products to control such symptoms.ENTEROCUTANEOUS FISTULAS:Enterocutaneous fistula is the most common presentation of intestinal fistulas, with theparticular characteristic of externalized through the skin integument. The arrangement of thesmall intestine in its long and tortuous course through the peritoneal cavity and enormousmucosal surface, make this an important function in absorbing nutrients and influencingcharged liquid electrolyte, thus, the maintenance of internal environment.Depending on thenature of external fistulas of small intestine are congenital or acquired.
  • 6. ACUTE ABDOMINAL PAIN:In more severe cases, laparoscopy and surgery.ACUTE APPENDICITIS:Appendicitis is inflammation of the appendix, located in the cecum, which is the portion wherethe large intestine begins.Cases of acute appendicitis require a surgical procedure calledlaparoscopic appendectomy or laparotomy it is no more than removal of the inflamedappendix. Treatment is always surgical.In untreated cases, the morbidity rate is high, mainlydue to complications such as peritonitis and septic shock in particular when the inflamedappendix ruptures. The mortality associated with the process is low except when it appearsfree perforation and peritonitis associated with septic shock.EtiologyThe main theory of the pathophysiology of appendicitis, based on experimental evidencepoints to a blockage of the lumen of the appendix by lymphoid hyperplasia, showing how oneof the first causes the second is the blockage of the appendix po an appendicolith.PathogenyInflammation of the appendix produces, over time, an obstruction of the lumen of theorgan. This obstruction leads to an accumulation of secretions of the mucosa with consequentincrease in intraluminal pressure. Proceeding the inflammation and obstruction, compress the
  • 7. veins and arteries causing ischemia and bacterial invasion into the wall of the appendix withnecrosis, gangrene and rupture if not treated immediately.Based on this sequence of evolutionary stages, the appendix with signs of mild inflammationknown as catarrhal or mucosa, phlegmonous, "purulent" then going togangrenosaperforandose and may evolve into an appendiceal abscess or appendicitis Plaston,or a more serious stage of peritonitis acute diffuse.Diagnostic signsIn 75% of cases there is the triad of Cope, the sequence consisting of abdominal pain(described above), food vomiting and fever. The classic signs are located in the right iliac fossa,where the abdominal wall becomes sensitive to slight pressure of palpation. Furthermore, withthe painful sudden decompression of the abdomen, a sign called Rebound sign, indicates areaction to irritation parietal peritoneum.Other diseases of the gastrointestinal system and intestinal obstruction, colonic diverticulardisease, colorectal cancer, and ischemia and intestinal bleeding can be serious risks of surgicaltreatment. GASTRIC BYPASS SURGERYIt is an operation that helps you lose weight by changing how the stomach and small intestinehandle the food you eat.After surgery, your stomach will be smaller and you will feel full with less food.The food you eat and not go to certain parts of your stomach and small intestine break downfood. Because of this, your body will not absorb all the calories from the foods you eat.
  • 8. DescriptionYou will receive general anesthesia before this surgery and will be asleep and pain.There are two basic steps during gastric bypass surgery:• The first step makes the stomach smaller. The surgeon uses staples to divide the stomachinto a small upper section and a larger bottom section. The upper section of the stomachcalled the pouch is where the food you eat. This bag is about the size of a walnut and storesonly one ounce of food.• The second step is the derivation. The surgeon connects a portion of the small intestinecalled the jejunum, a small hole in the bag. The food you eat will now travel from the pouchinto the new opening in the small intestine. Because of this, the body absorbs fewer calories.Gastric bypass can be done in two ways. With open surgery, the surgeon makes a large surgicalcut open the abdomen and perform the derivation directly manipulating the stomach, smallintestine and other organs.Another way to do this surgery using a tiny camera called a laparoscope, which is placed in theabdomen. The surgery is called laparoscopy.In this surgery:• First, the surgeon will make 4 to 6 small incisions in her abdomen.• The surgeon will then pass the laparoscope through one of these incisions and this will beconnected to a video monitor in the operating room. The surgeon will monitor to see insideyour abdomen.• The surgeon will use thin surgical instruments to make the bypass, which are insertedthrough the other incisions.The advantages of laparoscopy over open surgery include:• Shorter hospital stay and faster recovery• Less pain• Smaller scars and a lower risk of a hernia or infection
  • 9. This surgery takes about 2 to 4 hours.Why is the procedureYou do not usually perform surgery to lose weight, unless you can not lose a lot of weight andkeep it off with diet, changing their behavior and exercise alone.Doctors often use body mass index (BMI) and conditions such as type 2 diabetes andhypertension, to determine which patients are most likely to benefit from weight loss surgery.Gastric bypass surgery is not a "quick fix" for obesity. You must diet and exercise after theoperation. Also need to know the risks of surgery and how will his life after the operation.RisksGastric bypass is major surgery and has many risks, some of which are very serious. You mustbe addressed with the surgeon.Risks for any surgery or anesthesia include:• Allergic reactions to medicines• Blood clots in the legs that may travel to the lungs• Bleeding• Respiratory problems• Heart attack or stroke during or after surgery• Infection, including in the incision, lungs (pneumonia), bladder or kidneyThere are many risks associated with any weight loss surgery.There are also risks that are morelikely after gastric bypass surgery.Before the procedureThe surgeon will ask you to have tests and consult with other doctors before undergoingsurgery.If you smoke, stop smoking several weeks before surgery and not start smoking again aftersurgery. Smoking slows recovery and increases the risk of problems. Tell your doctor or nurse ifyou need help quitting.Always tell your doctor or nurse:
  • 10. • If you are or might be pregnant.• What drugs, vitamins, herbs and other supplements you are taking, including those boughtwithout a prescription.During the week before surgery:• You may be asked to stop taking aspirin (aspirin), ibuprofen (Advil, Motrin), vitamin E,warfarin (Coumadin) and other drugs that affect blood clotting.• Ask your doctor which drugs you should still take on the day of surgery.• Prepare your home for after surgery.After the procedureMost people stay in the hospital for 3 to 5 days after surgery. In the hospital:• You will be asked to sit on the side of the bed and walk around the same day you hadsurgery.• May have a catheter (tube) is passed through the mouth into the stomach for 1 or 2days. This tube helps drain fluid from the abdomen.• You may have a urinary catheter to drain urine.• You can not eat during the first 1 to 3 days. After that, you can take liquids and pureed foodsor soft foods.• You may have a catheter connected to the larger part of his stomach that was bypassed. Itwill come out one side and drain fluids.• Wear special stockings on your legs to help prevent blood clots.• You will receive medication by injection to prevent blood clots.• You will receive pain medication. Take pills for pain and given pain medication through anintravenous catheter that goes into your veins.You can go home when:• Be able to eat liquid or pureed without vomiting.• can be moved around without much pain.• Do not need pain medicine through an IV or administered by injection.Forecast
  • 11. Most people lose 10 to 20 pounds about a month in the first year after surgery. Weight losswill decrease with time, so persevere with diet and exercise will provide the largest earlythinning.You can lose half or more of their extra weight in the first two years and will lose weightquickly right after surgery, if he is still liquid or soft diet.Losing enough weight after surgery can improve many conditions, such as:• Asthma• Gastroesophageal reflux disease (GERD)• Hypertension• High Cholesterol• Obstructive sleep apnea• Type 2 DiabetesWeighing less should also make it much easier to move around and do everyday activities.Bypass surgery itself is not a solution to losing weight. Can train you to eat less, but you stillhave to do much of the work. To lose weight and avoid complications from the procedure, youwill need to follow the exercise and eating guidelines that your doctor and dietician will have.Alternative Names Bariatric surgery (gastric bypass) Bypass Gastric Bypass Roux en Y gastric, gastric bypass Roux en Y
  • 12. SURGERY IN THE ABDOMINAL CAVITYUpon entering, the surgeon needs to roll the vessels of the subcutaneous tissue almostimmediately after making the incision, unless you use a unit Electrosurgical for this purpose.Sutures are generally preferred absorbable.When preparing the bonds, the instruments often prepares a thread a needle to use as sutureligation if the surgeon desires transficción a large glass. Once in the abdominal cavity, the typeof selected suture depends on the nature of the operation and technology the surgeon.Gastrointestinal tractLeakage from the anastomosis or suture site are the main problem faced to close the woundsof the gastrointestinal tract. This problem can lead to localized or generalized peritonitis. Thesutures be too tight knot at the anastomosis. Wounds of the stomach and intestine are rich inblood supply and can be swollen and hard. Tight sutures may cut the tissue and cause leaks.Can be achieved a leak-proof anastomosis with a closing single or double shots.For a simple closure, interrupted sutures should be placed approximately 1 / 4 "(6 mm.) apart.suture is placed through the submucosa, in the muscle and through the serosa. Because thesubmucosa provides strength in the gastrointestinal tract, the effective closure involvessuturing the submucosal layers in apposition without penetrating the mucosa.A continuous suture line provides a more secure seal the sutures interrupted. However, if onesuture breaks, the entire line can be separated.Many surgeons prefer to use a closure in two planes, for safety placed a second layer ofinterrupted sutures through the serosa. In closing single or double absorbable sutures may beused VICRYL, MONOCRYL sutures, PDS II sutures or chromic catgut sutures. Surgical silk mayalso be used in the background of a double closing.
  • 13. Have been used successfully in this area invested closure techniques, everted, or endconextremo, but all have drawbacks. The surgeon must take meticulous care to place thesutures in the submucosa. Even with the best technique leakage can occur. Fortunately, theomentum generally limits the area, and the bodys natural defenses control the problem.Stomach - To be an organ that contains free hydrochloric acid and potent proteolytic enzymes,the stomach heals remarkably quickly. Stomach wounds attain maximum strength 14 to 21days after the operation, and have a maximum rate of collagen synthesis in five days.Absorbable sutures are generally accepted in the stomach, although they may produce a mildreaction in both the wounded and in normal tissue. Sutures VICRYL are the most frequentlyused. PROLENE sutures can also be used to close the stomach.
  • 14. Small Intestine - The closure of the small intestine has the same considerations as thestomach. The proximal bowel contents, primarily bile or pancreatic juice, can cause severechemical peritonitis (rather than bacterial).If using an inverted closure technique, care must be taken to minimize the amount of tissuethat protrudes into the intestinal lumen to avoid partial or complete obstruction.Generally preferred because it absorbable sutures to permanently limit the lumen diameter.You can use a non-absorbable suture in the serosa layer for added security.The small intestine heals very quickly and reaches its maximum strength in about 14 days.Colon - The high microbial content of the colon that once made the biggest concern furapollution. Absorbable sutures But once you have absorbed, leaving no bacterial migrationchannels. Still concerned about the output of the large intestine content as it is potentiallymore severe consequences that the leak in other areas of the gastrointestinal tract.The colon is a strong body about twice in the sigmoid region in the cecum.However, the wounds of the colon regain strength with the same speed, regardless of location.This lets you use the same size suture at either end of the colon. The colon heals at a ratesimilar to that of the stomach or small intestine. Maintain a high rate of collagen synthesis fora prolonged period (over 120 days). Entire gastrointestinal tract shows loss of collagen andcollagen activity increased immediately after the anastomosis of the colon.Can be used for closing the colon both absorbable and nonabsorbable sutures. Helps preventcomplications placing sutures in the submucosa and prevent penetration of the mucosa.Rectum - The rectum heals very slowly. Because the lower portion is located below the pelvicperitoneum has no serosa. It should include a portion of muscle at the anastomosis, andsutures should be cut carefully to avoid tying the tissues. Monofilament sutures reduce the riskof bacterial proliferation in the rectum.Closing The AbdomenWhen closing the abdomen, may be more important than the type of technical materialsuturaempleado.Peritoneum - The peritoneum, the thin membrane of the abdominal cavity is located belowthe rear fascia. Heal quickly. Some think that the peritoneum does not require sutures, whileothers disagree. If the fascia is closed tightly after the suture of the peritoneum may or maynot help prevent an incisional hernia. The surgeons closed the peritoneum, usually prefer acontinuous line with absorbable suture. You can also use separate points.Fascia - This layer of firm, strong connective tissue covering the muscles is the main supportstructure of the body. By closing the abdominal incision, the fascia sutures hold the woundclosed and help to resist changes in intraabdominal pressure. Occasionally synthetic materialmay be used when the fascia graft is absent or weak. You can use a polypropylene meshPROLENE to replace and repair abdominal wall hernias, whenever there is great tension in the
  • 15. suture line during healing. Nonabsorbable sutures may be used as suture PROLENE to suturethe graft tissue.The fascia recovers approximately 40% of its original strength in two months. It may take up toa year or more to regain full strength. The full original strength is never recovered.The anatomical location and type of abdominal incision influence the fascia layers to besutured.The posterior layer of the fascia is always closed. The previous layer can be cut and requiredstitches. Closing techniques with full-thickness sutures are becoming more popular.Most suture materials have some degree of inherent elasticity. If you are not tied tightly, thesuture "give" to accommodate the postoperative edema. Stainless steel sutures, if tied tootight, cut like a knife to the swollen tissue or increasing the tension on the suture line. In viewof slow healing and suturing the fascia must withstand the maximum voltage of the wound,you can use a gauge nonabsorbable suture moderate. It can also provide adequate support anabsorbable suture with longer tensile strength, such as PDS II sutures.PDS II sutures are particularly suitable for young, healthy patients. Many surgeons use aninterrupted technique to close the fascia. In the absence of obvious infection orcontamination, the surgeon can choose monofilament or multifilament sutures. In thepresence of infection can use a monofilament absorbable material like PDS II sutures or inertnonabsorbable sutures like stainless steel, or sutures PROLENE .Muscle - Muscle does not tolerate well the suture. However, there are several options in thisarea. The abdominal muscles can be cut, paragraphs (separated), or withdrawn, depending onthe location and type of incision chosen. Whenever possible, the surgeon prefers to avoidinterfering with the blood supply and innervation by making an incision to separate themuscle, or retracting the entire muscle to its innervation.During the closure, muscles handled in this way need not be sutured. Fascia is sutured ratherthan muscle.
  • 16. The technique of Smead-Jones far-and-close for abdominal closure is strong and fast, providesgood support during the early healing with low incidence of wound separation, and has a lowfrequency of late incisional problems. Its a close in a plane through both layers of theabdominal wall fascia, abdominal muscles, peritoneum, and anterior layer of the fascia.Shaped interrupted sutures of 8 when placed. Absorbable sutures are usually used Vicryl orPDS II.Can also be used stainless steel sutures. Monofilament sutures PROLENE also provide all theadvantages of steel sutures: strength, minimal tissue reaction, and resistance to bacterialcontamination. Mas are tolerated by patients than steel sutures in the late months of theoperation and are easier to handle and tying by the surgeon. However, both stainless steelsutures as PROLENE can be detected under the skin in thin patients. To avoid this problem, theknots should be buried in the fascia and subcutaneous space.Subcutaneous fat - not muscle or fat is well tolerated by suture. Some surgeons question theappropriateness of placing sutures in the fat tissue because it has little tensile strength due toits composition, which is mostly water. However, others think it is necessary to place at least afew stitches in a thick layer of subcutaneous tissue to avoid dead spaces, especially in obesepatients. The dead spaces are more likely to occur in this type of tissue, so that the edges ofthe wound must approach carefully. Tissue fluids can accumulate in these spaces, delayinghealing and predisposing to infection. Usually you select absorbable sutures for thesubcutaneous plane. The suture VICRYL is especially suitable for use in fatty tissue, avascular,since it is absorbed by hydrolysis. The surgeon may use the same type and size of materialused earlier to tie the vessels in this plane.Closing the abdomenSubcuticular tissue - To minimize scarring, suturing the subcuticular plane of connective tissuekeeps the wound edges in close approximation. At one end of a single plane can be seensubcuticular smaller scar after a period of 6 to 9 months when performing a simple skinclosure. The surgeon places short side continued below the plane of the skin epithelium. Youcan use absorbable or nonabsorbable sutures. If you choose non-absorbable material, the
  • 17. suture protruding at each end of the incision, the surgeon can be knotted together to form aloop or knot the ends out of the incision. To be only one line of scar as a hair (on the face, forexample), you can keep the skin in very close approximation with strips of skin closure inaddition to the subcuticular suture. Depending on the location of the tape can be left in thewound a long time. When there is great tension in the wound, as in facial surgery or neck, youcan use very fine sizes in subcuticular sutures. Abdominal wounds they bear more tensionsutures require a larger caliber. Some surgeons prefer to close both the subcuticular plane asthe skin to have a minimal scar. The chromic surgical gut sutures and polymeric materials suchas sutures MONOCRYL are acceptable in the dermis. They are able to maintain sufficienttensile strength in collagen synthesis phase, which lasts about six weeks. Sutures should not beplaced too close to the epidermal surface to reduce the extrusion. If the skin is thin and non-pigmented, clear or white suture as the suture monofilament MONOCRYL invisible. Afterclosing this plane can be approximated skin edges.Skin - The skin is composed of epithelium and underlying dermis. It is so strong that it takes asharp needle at each point to minimize tissue trauma. (See the section on Selection ofNeedles).The wounds of the skin regain tensile strength slowly. However, surgeons usually remove thesutures between 3 and 10 days after the operation, when the wound has recoveredapproximately 5% to 10% of its strength. This is possible because the fascia absorbs theincreased tension on the wound, the surgeon relies on it to keep the wound closed. The skinsutures or subcuticular need to support only the natural tension of the skin and keep the edgesin apposition.The suture technique for skin closure can be continuous or interrupted nonabsorbable suturematerial. The skin edges are everted. Preferably, each suture is passed through the skin once,reducing the likelihood of contamination along the suture line. Technique is generallypreferred interrupted.The skin sutures are exposed to the external environment, thus become a serious threat ofpollution and abscesses. The interstices of multifilament sutures may provide a shelter formicroorganisms. Therefore, to close the skin usually prefer monofilament absorbable sutures.Monofilament sutures also induce less tissue reaction than multifilament sutures. May bepreferred for cosmetic reasons or monofilament nylon sutures of polypropylene.Many skin wounds closed well with silk and polyester multifilament. The tissue reaction tononabsorbable sutures decreases and remains relatively acellular fibrous tissue to grow andform a thick capsule around the suture. (It is known that surgical catgut produces an intensetissue reaction. However, surgical gut is absorbed quickly tends to be less reactive due to itsrapid absorption profile). The key to success is early suture removal occurs beforeepithelialization of the suture and before contamination becomes infection.A word about the scar (epithelialization) - When a wound is kept on the skin - eitheraccidentally or during a surgical procedure - the epithelial cells of the basal layer of the wound
  • 18. margins flatten and move into the area wound. Migrate down the edge until they find livingtissue is not damaged at the base of the wound. Then move along the wound bed to makecontact with similar cells that are migrating from the opposite side. They move down thesuture after it has been embedded in the skin. When the suture is removed, it is the path ofepithelial cells. May eventually disappear, but may be slightly and form keratin. Usually yousee a dotted scar the skin and can lead to the appearance of "railroad" or "grid" of the wound.This is relatively rare if the skin sutures are placed with excessive tension and are pulledtowards the seventh day after the operation.The forces that create the distance between the edges of the wound remain long after youhave removed the sutures. There is significant collagen synthesis between 5 and 42 days aftersurgery. After this time, any additional gain in tensile strength is due to remodeling orcrosslinking of collagen fibers rather than synthesis. The tensile strength increases continueuntil two years, but the tissue never regains its original strength.Closing the abdomenRetention suture closure - We have already discussed the techniques for placing retentionsutures, and use them in a secondary suture. (See section Suturing Techniques.) Generallyused high rating (0 to 5) of nonabsorbable material, not by force, but because larger sizes areless likely to cut tissue when there is a sudden increase in intraabdominal pressure ascoughing, vomiting, straining, or distention. To avoid cutting the suture material to tension theskin can pass one end of the retention suture through a plastic or rubber tube of short lengthas a support or protection before tying. You can also use a plastic clip bridge to protect the skinand primary suture line and allow a comfortable postoperative wound management for thepatient.
  • 19. The properly placed retention sutures provide strong reinforcement of abdominal wounds, butalso cause more pain to the patient that the closure plans. The best technique is to use aneedle suture material assembled at each end (double armed). They should be placed from theinside out of the skin to avoid passing potentially contaminated epithelial cells through theabdominal wall.The suture line ETHICON retention suture includes ETHILON, MERSILENE, EthibondExtra PROLENE and PERMA-HAND . You can also use steel surgical sutures. Retention suturesmay be left 14 to 21 days after the operation. The average is three weeks.The factor in deciding when to remove retention sutures is the evaluation of the patient.Sutures Drain - If a drainage tube placed in an organ or inserted deep bladder drainage, youcan make the wall of the body with absorbable sutures. The surgeon may prefer to minimizethe distance between the body and the abdominal wall using sutures to attach the body thatdrains into the peritoneum and fascia. Sutures may be placed around the circumference of thedrain, either two sutures at 12 and 6 oclock, or four sutures at 12, 3, 6, and 9 oclock andsecured to the skin with temporary handles. When drainage is no longer necessary, the skinsutures can be removed easily for removal. You can leave the opening to allow additionaldrainage until it closes naturally.A drainage tube inserted into the peritoneal cavity through a puncture in the abdominal wallusually is anchored to the skin with one or two nonabsorbable sutures. This prevents the drainfrom slipping into or out of the wound.The importance of repairing the mesentery - When closing, the surgeon should know howimportant it is to repair any defect created in the mesentery during the surgical procedure toavoid a possible hernia. The mesentery is a fold membrane that holds the different organs tothe abdominal wall. Technique can be used continuously or interrupted catgut sutures orsurgical VICRYL.