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Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
Abdominal access
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Abdominal access

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  • 1. Abdominal access & Peritonitis S A NAQVI CONSULTANT GENERAL SURGEONMID WESTERN REGIONAL HOSPITALS, LIMERICK, IRELAND
  • 2. Abdominal incisions based on anatomical principles adequate assess capable of being extended Ideally muscle splitting Nerves preserving The rectus muscle has a segmental nerve supply It can be cut transversely without weakening a denervated segment Above the umbilicus tendinous intersections prevent retraction of the muscle
  • 3. Midline incisionCommonest approachThe following structures are divided:  Skin  Linea alba  Transversalis fascia  Extraperitoneal fat  PeritoneumCan be extended around the umbilicus
  • 4.  Falciform ligament should be avoided The bladder can be accessed via an extraperitoneal approach through the space of Retzius Mass closure technique The most popular sutures are either non-absorbable or absorbable monofilaments At least 1 cm bits should be taken 1 cm apart Length of sutures, four times the wound length
  • 5. Paramedian incisionParallel to and approximately 3 cm from the midlineThe incision Cut  Skin  Anterior rectus sheath  Rectus - retracted laterally  Posterior rectus sheath (above the arcuate line)  Transversalis fascia  Extraperitoneal fat  Peritoneum
  • 6. Paramedian incision Cont…The potential advantages1. The rectus muscle is not divided 1. The incisions in the anterior and posterior rectus sheath are separated by muscle2. Closed in layers3. Had a lower incidence of incisional hernia (when sutures were not so good)The potential Disadvantages1. Takes longer to make and close
  • 7. PeritonitisIntra-abdominal infections results in two major clinical manifestations  Early or diffuse infection results in localised or generalised peritonitis  Late and localised infections produces an intra- abdominal abscessPathophysiology depend on competing factors of bacterial virulence and host defencesBacterial peritonitis is classified as primary or secondary
  • 8.  Primary peritonitis Secondary peritonitis Diffuse bacterial infection  Acute peritoneal infection without loss of integrity of resulting GI tract  GI perforation Often occurs in adolescent  Anastomotic dehiscence girls  Infected pancreatic necrosis Streptococcus pneumonia  Often involves multiple commonest organism organisms - both aerobes involved and anaerobes  Commonest organisms are E. coli and Bacteroides fragilis
  • 9. Surgical management The management of secondary peritonitis involves  Elimination of the source of infection  Reduction of bacterial contamination of the peritoneal cavity  Prevention of persistent or recurrent intra-abdominal infections Could be combined with fluid resuscitation, antibiotics and ITU / HDU management Source control achieved by closure or exteriorisation of perforation Bacterial contamination reduced by aspiration of faecal matter and pus Recurrent infection prevented by the used of:  Drains  Planned re-operations  Leaving the wound open / laparostomy
  • 10. Peritoneal lavage Peritoneal lavage often used but benefit is unproven Simple swabbing of pus from peritoneal cavity may be of same value Has been suggested that lavage may spread infection or damage peritoneal surface No benefit of adding antibiotics to lavage fluid No benefit of adding Chlorhexidine or Betadine to lavage fluid If used, lavage with large volume of crystalloid solution probably has best outcome
  • 11. Intra-abdominal abscessesAn intra-abdominal abscess may arise following:  Localisation of peritonitis  Gastrointestinal perforation  Anastomotic leak  Haematogenous spreadThey develop in sites of gravitational drainage  Pelvis  Subhepatic spaces  Subphrenic spaces  Paracolic gutters
  • 12. Clinical featuresPostoperative abscesses usually present at between 5 and 10 days after surgerySuspect if unexplained persistent or swinging pyrexiaMay also cause abdominal pain and diarrhoeaA mass may be present with overlying erythema and tendernessA pelvic abscess may be palpable only on rectal examination
  • 13. Management Ultrasound scanning may reveal the diagnosis Contrast-enhanced CT is probably the investigation of choice May delineate a gastrointestinal or anastomotic leak Identifies collection and often allows percutaneous drainage Operative drainage may be required if:  Multi-locular abscess  No safe route for per cutaneous drainage  Recollection after percutaneous drainage Patients should receive antibiotic therapy guided by organism sensitivities

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