35 Cocanour- Damage Control in the Surgical Patient.pdf
1. Damage Control in the
Damage Control in the
Surgical Patient
Surgical Patient
Christine S. Cocanour, MD, FACS, FCCM
Christine S. Cocanour, MD, FACS, FCCM
Professor of Surgery
Professor of Surgery
Division of Trauma and Emergency Surgery
Division of Trauma and Emergency Surgery
UC Davis Medical Center
UC Davis Medical Center
2. Damage Control
Damage Control
„
„ Used in the Merchant Marine, maritime industry
Used in the Merchant Marine, maritime industry
and navies since the 1950s to describe the
and navies since the 1950s to describe the
emergency control of situations that may hazard
emergency control of situations that may hazard
the sinking of a ship.
the sinking of a ship.
„ US Navy defines it as “the capacity of a ship to
absorb damage and maintain mission integrity”
5. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ Control hemorrhage and contamination
Control hemorrhage and contamination
„
„ Correct physiologic parameters
Correct physiologic parameters
„
„ Definitive injury management and closure
Definitive injury management and closure
6. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1908 Pringle: compression and hepatic packing
1908 Pringle: compression and hepatic packing
for portal venous hemorrhage
for portal venous hemorrhage
Ann Surg 1908; 48:541
7. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1913 Halsted:
1913 Halsted: gutta
gutta
percha
percha sheets to prevent
sheets to prevent
granulation tissue from
granulation tissue from
growing into gauze
growing into gauze
packing
packing
8. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
After WWII through the Viet Nam War era:
After WWII through the Viet Nam War era:
„
„ Packing fell into disfavor with reports of
Packing fell into disfavor with reports of
necrosis, sepsis and hemorrhage.
necrosis, sepsis and hemorrhage.
„
„ Newer surgical techniques were thought to be
Newer surgical techniques were thought to be
better
better
9. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1963:
1963: Shaftan
Shaftan, et al: faster and better
, et al: faster and better
resuscitation and better treatment of wounds to
resuscitation and better treatment of wounds to
limit liver mortality
limit liver mortality
CAPPELLETTI, R R, GLIEDMAN, M L, &
CAPPELLETTI, R R, GLIEDMAN, M L, &
SHAFTAN, G W. (1963). Injuries of the liver: a
SHAFTAN, G W. (1963). Injuries of the liver: a
review of 111 cases.
review of 111 cases. J Trauma;
J Trauma; 3:63
3:63
10. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1979
1979 Calne
Calne, et al: liver hemorrhage temporarily
, et al: liver hemorrhage temporarily
controlled with gauze packing enabling safe
controlled with gauze packing enabling safe
transfer and definitive management at a more
transfer and definitive management at a more
appropriate institution
appropriate institution
11. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1976 Lucas, CE and
1976 Lucas, CE and Ledgerwood
Ledgerwood, AM
, AM
Prospective evaluation of
Prospective evaluation of hemostatic
hemostatic techniques
techniques
for liver injuries
for liver injuries J Trauma
J Trauma 16:442
16:442
12. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1981 Feliciano DV, Mattox KL, Jordan, GL
1981 Feliciano DV, Mattox KL, Jordan, GL Jr
Jr
„
„ “
“Intra
Intra-
-abdominal packing for control of hepatic
abdominal packing for control of hepatic
hemorrhage: a reappraisal
hemorrhage: a reappraisal”
”
„
„ J Trauma.
J Trauma. 1981 Apr;21(4):285
1981 Apr;21(4):285-
-90
90
„
„ 90% survival rate in 10 patients with
90% survival rate in 10 patients with perihepatic
perihepatic
packing
packing
„
„ “…
“…intra
intra-
-abdominal packing for control of
abdominal packing for control of
exsanguinating
exsanguinating hepatic hemorrhage appears to be a
hepatic hemorrhage appears to be a
lifesaving maneuver in highly selected patients in whom
lifesaving maneuver in highly selected patients in whom
coagulopathies
coagulopathies, hypothermia, and acidosis
, hypothermia, and acidosis make
make
further surgical efforts likely to increase hemorrhage.
further surgical efforts likely to increase hemorrhage.”
”
13. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1983 Stone, et al:
1983 Stone, et al: coagulopathy
coagulopathy contributed to
contributed to
poor outcomes. Proposed truncation of
poor outcomes. Proposed truncation of
laparotomy
laparotomy, reversal of
, reversal of coagulopathy
coagulopathy and then
and then
return to the OR for definitive surgical repair
return to the OR for definitive surgical repair
Ann Surg. 1983 May; 197(5): 532
14. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
15. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ Burch, et al 1992
Burch, et al 1992
Ann Surg. 1992 May; 215(5): 476
16. Evolution of Damage Control
Evolution of Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ 1993
1993 Rotondo
Rotondo and the U Penn group coined
and the U Penn group coined
“
“damage control
damage control laparotomy
laparotomy”
”
„
„ 20 year review: mortality 52%, morbidity 40%
20 year review: mortality 52%, morbidity 40%
17. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ Trauma, general surgery, vascular
Trauma, general surgery, vascular
surgery,
surgery, ortho
ortho
„
„ Evolved to combat lethal triad and
Evolved to combat lethal triad and
abort the
abort the ‘
‘bloody, vicious cycle
bloody, vicious cycle’
’
18.
19. The Lethal Triad
The Lethal Triad
HYPOTHERMIA
HYPOTHERMIA
ACIDOSIS
ACIDOSIS COAGULOPATHY
COAGULOPATHY
21. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ Communication essential between resuscitation
Communication essential between resuscitation
team and ED, IR, OR, ICU, blood bank,
team and ED, IR, OR, ICU, blood bank,
laboratory and pharmacy
laboratory and pharmacy
„
„ Damage control patient is at or near the point of
Damage control patient is at or near the point of
physiologic exhaustion
physiologic exhaustion
22. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
Recognition of who needs it
Recognition of who needs it
„
„ Shock
Shock
„
„ Coagulopathy
Coagulopathy
„
„ Hypothermia (temperature
Hypothermia (temperature <
< 35
35º
ºC)
C)
„
„ Massive transfusion or resuscitation
Massive transfusion or resuscitation
„
„ >
> 10 units of
10 units of PRBCs
PRBCs
„
„ Acidosis (pH < 7.3 or worsening base deficit)
Acidosis (pH < 7.3 or worsening base deficit)
„
„ Definitive repair would require prolonged operative time
Definitive repair would require prolonged operative time
or extensive surgical procedures (> 90 minutes)
or extensive surgical procedures (> 90 minutes)
„
„ Surgeon
Surgeon ‘
‘gestalt
gestalt’
’
„
„ High
High-
-energy blunt torso trauma, multiple visceral injuries, multiple
energy blunt torso trauma, multiple visceral injuries, multiple torso
torso
penetrating injuries, multiregional injury
penetrating injuries, multiregional injury
24. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
Components
Components
„
„ 1.
1. Abbreviated surgery for rapid control of
Abbreviated surgery for rapid control of
hemorrhage and contamination
hemorrhage and contamination
„
„ 2.
2. Resuscitation in the ICU with correction of
Resuscitation in the ICU with correction of
physiologic abnormalities
physiologic abnormalities
„
„ 3. Subsequent definitive repair and abdominal
3. Subsequent definitive repair and abdominal
wall closure
wall closure
25. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
Abbreviated resuscitative surgery
Abbreviated resuscitative surgery
„
„ Do only necessary procedures
Do only necessary procedures
„
„ Control bleeding
Control bleeding
„
„ Ligation
Ligation
„
„ Shunting
Shunting
„
„ Packing
Packing
„
„ Excision/stapling of bowel to prevent further
Excision/stapling of bowel to prevent further
contamination
contamination
„
„ Limit heat loss
Limit heat loss
„
„ Chest/abdomen/extremity all potential candidates
Chest/abdomen/extremity all potential candidates
26. Damage Control
Damage Control
in the Surgical Patient
in the Surgical Patient
„
„ Temporary closure of the
Temporary closure of the
open abdominal defect
open abdominal defect
„
„ Towel clip closure
Towel clip closure
„
„ Zipper closure
Zipper closure
„
„ Bogota bag
Bogota bag
„
„ Velcro Closure
Velcro Closure
„
„ Vacuum pack
Vacuum pack
27. Temporary Closures
Temporary Closures
„
„ Vacuum Pack dressing
Vacuum Pack dressing
„
„ Inexpensive
Inexpensive
„
„ Perforated plastic sheet
Perforated plastic sheet
overlying bowel
overlying bowel
„
„ Covered with towels,
Covered with towels,
drains and adhesive drape
drains and adhesive drape
„
„ Drains placed to suction
Drains placed to suction
to control drainage
to control drainage
28. ICU Resuscitation
ICU Resuscitation
„
„ Warm the patient
Warm the patient
„
„ Correct the acidosis
Correct the acidosis
„
„ Correct the
Correct the coagulopathy
coagulopathy
29. Hypothermia
Hypothermia
„
„ -
-4.6
4.6°
°C per hour even with warm IV fluid,
C per hour even with warm IV fluid,
gases and air convection blankets
gases and air convection blankets
„
„ Burch et al.
Burch et al. Surg
Surg Clin
Clin North Am
North Am 1977; 77:779
1977; 77:779
„
„ Mortality from 40% to 100% with core
Mortality from 40% to 100% with core
temp from 34
temp from 34°
°C to < 32
C to < 32°
°C
C
„
„ Jurkovich
Jurkovich et al.
et al. J Trauma
J Trauma 1987; 27:1019
1987; 27:1019
30. Hypothermia
Hypothermia
„
„ Cardiac
Cardiac dysrhythmias
dysrhythmias
„
„ Reduces cardiac output
Reduces cardiac output
„
„ Shifts the hemoglobin saturation curve to
Shifts the hemoglobin saturation curve to
the left
the left
„
„ Affects clotting cascade
Affects clotting cascade
„
„ Platelet dysfunction, endothelial abnormalities
Platelet dysfunction, endothelial abnormalities
and alterations in the
and alterations in the fibrinolytic
fibrinolytic system
system
„
„ Coagulation assays inaccurate for hypothermic
Coagulation assays inaccurate for hypothermic
patient
patient
„
„ < 35
< 35°
°C
C →
→ PT and PTT prolonged
PT and PTT prolonged
„
„ Reed, et al
Reed, et al Circ Shock
Circ Shock 1990; 32:141
1990; 32:141
31. Rewarming
Rewarming in the ICU
in the ICU
„
„ Warm up the room
Warm up the room
„
„ Keep the patient dry
Keep the patient dry
„
„ Remove wet linen/clothing
Remove wet linen/clothing
„
„ Cover the head (foil, plastic)
Cover the head (foil, plastic)
„
„ Warm the ventilator circuit
Warm the ventilator circuit
„
„ Air
Air-
-convection blanket
convection blanket
„
„ All lines should have warming device
All lines should have warming device
32. Rewarming
Rewarming in the ICU
in the ICU
If the temperature doesn
If the temperature doesn’
’t respond
t respond
„
„ Warm pleural
Warm pleural lavage
lavage with NS via chest tubes
with NS via chest tubes
„
„ Continuous AV warming
Continuous AV warming
„
„ Gel pads simulate water
Gel pads simulate water
immersion connected to a
immersion connected to a
control module
control module
33. Resuscitation
Resuscitation
„
„ Access:
Access:
„
„ At least 2 large bore IVs
At least 2 large bore IVs
„
„ Central access
Central access
„
„ Introducer sheath
Introducer sheath—
—make sure large enough to float
make sure large enough to float
PA catheter if needed
PA catheter if needed
„
„ Poiseuille
Poiseuille’
’s
s Law
Law
„
„ Lines placed in ED or
Lines placed in ED or OR
OR usually considered
usually considered
“
“dirty
dirty”
”, may keep for 24 hours
, may keep for 24 hours
34. Resuscitation
Resuscitation
16 g
16 g IV tubing
IV tubing 125 ml/min
125 ml/min
blood tubing
blood tubing 193 ml/min
193 ml/min
trauma tubing
trauma tubing 247 ml/min
247 ml/min
8.5 Fr
8.5 Fr IV tubing
IV tubing 160 ml/min
160 ml/min
blood tubing
blood tubing 310 ml/min
310 ml/min
trauma tubing
trauma tubing >800 ml/min
>800 ml/min
„
„ Dutky
Dutky et al. Factors
et al. Factors ffecting
ffecting rapid fluid resuscitation with large bore
rapid fluid resuscitation with large bore
introucer
introucer catheters.
catheters. J Trauma
J Trauma 1989; 29:856
1989; 29:856
35. Resuscitation
Resuscitation
„
„ A
A-
-line
line
„
„ Urinary bladder pressure
Urinary bladder pressure
„
„ Baseline fluid rate 125 cc/hr with boluses as
Baseline fluid rate 125 cc/hr with boluses as
necessary
necessary
„
„ PA catheter
PA catheter
„
„ Older patients
Older patients
„
„ Large volume resuscitation
Large volume resuscitation
„
„ Base deficit/lactic acidosis not improving
Base deficit/lactic acidosis not improving
„
„ May need to consider
May need to consider inotropes
inotropes---
---but only after
but only after
tank is full
tank is full
„
„ H/H,
H/H, Chem
Chem profile including Ca
profile including Ca++
++,
, Phos
Phos, Mg
, Mg++
++,
,
lactic acid, INR, fibrinogen, platelet q 4 hours
lactic acid, INR, fibrinogen, platelet q 4 hours
36. Resuscitation
Resuscitation
Endpoints of Resuscitation
Endpoints of Resuscitation
„
„ Re
Re-
-establish end
establish end-
-organ perfusion
organ perfusion
„
„ Adequate urinary output
Adequate urinary output
„
„ Hematocrit
Hematocrit > 20% (value depends upon age/
> 20% (value depends upon age/sx
sx)
)
Keep > 30 if still bleeding!
Keep > 30 if still bleeding!
„
„ Restoration of vital signs
Restoration of vital signs
„
„ Normal mixed venous oxygenation
Normal mixed venous oxygenation
„
„ Normal or high cardiac output
Normal or high cardiac output
„
„ Clearance of lactic acidosis/base deficit
Clearance of lactic acidosis/base deficit
„
„ Normalize pH
Normalize pH---
---preferably without NaHCO
preferably without NaHCO3
3 or
or
THAM
THAM
37. Resuscitation
Resuscitation
„
„ Standardized resuscitation
Standardized resuscitation
„
„ Computerized (although
Computerized (although
started as a paper protocol
started as a paper protocol
„
„ Helped streamline
Helped streamline
resuscitations
resuscitations
„
„ Less dependence on junior
Less dependence on junior
residents knowing when to
residents knowing when to
call
call
38. DO2I goal
1) Hb (PRBC; Hb > 10 )
2) volume (LR; PCWP >15 )
3) Optimize CI - PCWP
(Starling curve)
4) low dose Inotropes
5) vasopressor
Yes No
Yes
No
Met inclusion criteria
On ICU admission:
art, PA, NG tonometer catheters
baseline ABG, Hb, lactate
24 hours?
24 hours?
Echocardiography
stop resuscitation
standard ICU care
stop resuscitation
standard ICU care
lactate, BD, PrCO2
bladder pressure
Q 4h (reassess sooner if
abnormal)
Monitor:
Q 4h (reassess sooner if
abnormal)
39. Resuscitation
Resuscitation
„
„ Intravascular volume restoration best
Intravascular volume restoration best
accomplished using FFP in a 1:1 ratio with
accomplished using FFP in a 1:1 ratio with
PRBCs
PRBCs
„
„ Crystalloid use is more limited
Crystalloid use is more limited
41. Massive Transfusion
Massive Transfusion
„
„ Massive transfusion
Massive transfusion
„
„ >
> 10 units in first 24 hrs
10 units in first 24 hrs
„
„ More than one blood volume in first 12 hrs
More than one blood volume in first 12 hrs
„
„ Traditional transfusion regimen: 6 units of
Traditional transfusion regimen: 6 units of
PRBCs
PRBCs, then start FFP
, then start FFP
„
„ Hirshberg
Hirshberg et al: computer model suggested that
et al: computer model suggested that
FFP:PRBC is 2:3
FFP:PRBC is 2:3
„
„ FFP:PRBC of 1:1 is associated with decreased
FFP:PRBC of 1:1 is associated with decreased
mortality and decreased transfusion
mortality and decreased transfusion
requirements
requirements
42. Resuscitation
Resuscitation
„
„ Blood Products
Blood Products
„
„ Fresh whole blood
Fresh whole blood
„
„ PRBCs
PRBCs + FFP
+ FFP
„
„ 1:1 or 1:2 ratio
1:1 or 1:2 ratio
„
„ Platelets
Platelets
„
„ > 70,000
> 70,000
„
„ > 100,000 if
> 100,000 if intracerebral
intracerebral injury or eye injury
injury or eye injury
„
„ Cryoprecipitate
Cryoprecipitate
„
„ < 100 mg/
< 100 mg/dL
dL
„
„ Recombinant factor
Recombinant factor VIIa
VIIa (
(rFVIIa
rFVIIa)
)
„
„ Diffuse
Diffuse coagulopathy
coagulopathy
43. Massive Transfusion Protocol
Massive Transfusion Protocol
Factor
Factor VIIa
VIIa
„
„ No FDA indication for traumatic shock
No FDA indication for traumatic shock
„
„ Should only be considered on a compassionate use
Should only be considered on a compassionate use
basis
basis after
after surgical bleeding controlled, aggressive
surgical bleeding controlled, aggressive
coagulation factor and platelet replacement has
coagulation factor and platelet replacement has
occurred and acidosis corrected
occurred and acidosis corrected
„
„ Thrombotic
Thrombotic events in this patient population not well
events in this patient population not well
characterized
characterized
„
„ Use remains controversial
Use remains controversial
„
„ More use of 1:1 PRBC to FFP, decreased use of Factor
More use of 1:1 PRBC to FFP, decreased use of Factor
VIIa
VIIa
44. Metabolic Acidosis
Metabolic Acidosis
„
„ Hypoperfusion
Hypoperfusion
„
„ Shift from aerobic to anaerobic metabolism at the
Shift from aerobic to anaerobic metabolism at the
cellular level,
cellular level, ie
ie cellular hypoxia
cellular hypoxia
„
„ Lactic acidosis
Lactic acidosis
„
„ Able to clear lactate within 24 hours = 100%
Able to clear lactate within 24 hours = 100%
survival
survival
45. Metabolic Acidosis
Metabolic Acidosis
„
„ Usually corrects on its own once patient is warm
Usually corrects on its own once patient is warm
and volume resuscitated
and volume resuscitated
„
„ O
O2
2 debt repaid
debt repaid
„
„ Anaerobic
Anaerobic →
→ aerobic metabolism
aerobic metabolism
„
„ Need for NaHCO
Need for NaHCO3
3 rare but
rare but…
…
„
„ If
If cardiotonic
cardiotonic agents needed, keep pH > 7.2
agents needed, keep pH > 7.2
„
„ Avoid use of
Avoid use of bicarb
bicarb and THAM as this eliminates
and THAM as this eliminates
the use of base deficit for monitoring resuscitation
the use of base deficit for monitoring resuscitation
47. Pitfalls
Pitfalls
„
„ Continued hemorrhage
Continued hemorrhage
„
„ Expect H/H to decrease
Expect H/H to decrease
„
„ Equilibration
Equilibration
„
„ Continued non surgical losses especially if
Continued non surgical losses especially if coagulopathy
coagulopathy and
and
hypothermia are not yet corrected
hypothermia are not yet corrected
„
„ > 2 units PRBC/hour x
> 2 units PRBC/hour x 3
3 hours
hours
„
„ Especially in a warm, non
Especially in a warm, non coagulopathic
coagulopathic patient
patient
48. Pitfalls
Pitfalls
„
„ Continued hemorrhage
Continued hemorrhage
„
„ Expect H/H to decrease
Expect H/H to decrease
„
„ Equilibration
Equilibration
„
„ Continued non surgical losses especially if
Continued non surgical losses especially if coagulopathy
coagulopathy and
and
hypothermia are not yet corrected
hypothermia are not yet corrected
„
„ > 2 units PRBC/hour x 2 hours
> 2 units PRBC/hour x 2 hours
„
„ Especially in a warm, non
Especially in a warm, non coagulopathic
coagulopathic patient
patient
Vessels that were constricted and NOT
Vessels that were constricted and NOT ligated
ligated at time of Op
at time of Op
may begin bleeding as patient is warmed and resuscitated
may begin bleeding as patient is warmed and resuscitated
RETURN TO THE OR (or IR)
RETURN TO THE OR (or IR)
49. Pitfalls
Pitfalls
„
„ Continued shock
Continued shock
„
„ Missed injury
Missed injury
„
„ Failed repair with leakage
Failed repair with leakage
„
„ Insufficient replacement of fluid from open
Insufficient replacement of fluid from open
abdomen
abdomen
50. Urgent
Urgent Reoperation
Reoperation
„
„ OR is best place to be
OR is best place to be
„
„ Vent requirements too much for the OR
Vent requirements too much for the OR
„
„ Use bedside vent in the OR (if you can transport
Use bedside vent in the OR (if you can transport
on vent)
on vent)
„
„ Bring the OR to the ICU bedside
Bring the OR to the ICU bedside
„
„ Not optimal if bleeding expected
Not optimal if bleeding expected
51. Primary Abdominal Compartment
Primary Abdominal Compartment
Syndrome (ACS)
Syndrome (ACS)
„
„ Complication of damage control
Complication of damage control laparotomy
laparotomy
„
„ Abdominal packs
Abdominal packs
„
„ Ongoing bleeding
Ongoing bleeding
„
„ Progressive bowel edema
Progressive bowel edema
„
„ Failure of non operative management of solid
Failure of non operative management of solid
organ injuries
organ injuries
52. Secondary ACS
Secondary ACS
„
„ No abdominal injuries
No abdominal injuries
„
„ Severe shock requiring massive
Severe shock requiring massive
resuscitation
resuscitation
„
„ Pelvic fractures
Pelvic fractures
„
„ Bowel edema and
Bowel edema and ascites
ascites
53. Definitive Repair
Definitive Repair
„
„ When to return to the OR?
When to return to the OR?
„
„ When patients are warm, acidosis and
When patients are warm, acidosis and coagulopathy
coagulopathy
corrected
corrected
„
„ 36
36-
-72 hours had reduced risk of
72 hours had reduced risk of rebleeding
rebleeding for
for
patients with
patients with perihepatic
perihepatic packing
packing
„
„ Caruso, et al
Caruso, et al Arch
Arch Surg
Surg 1999; 134:962
1999; 134:962
„
„ Coincides with fluid mobilization
Coincides with fluid mobilization
„
„ ? Use of diuretics
? Use of diuretics
54. Definitive Repair
Definitive Repair
„
„ Bowel injuries:
Bowel injuries:
„
„ Colostomy or
Colostomy or anastomosis
anastomosis?
?
„
„ Delayed
Delayed anastomoses
anastomoses were as safe as colostomy
were as safe as colostomy
„
„ Miller, et al
Miller, et al Am
Am Surg
Surg 2007; 73:606
2007; 73:606
„
„ Stapled
Stapled vs
vs hand
hand-
-sewn
sewn anastomosis
anastomosis?
?
„
„ Controversial as to which is best
Controversial as to which is best
„
„ Surgeon comfort with technique
Surgeon comfort with technique
„
„ Presence of bowel edema?
Presence of bowel edema?
„
„ Edematous bowel more prone to leak
Edematous bowel more prone to leak
„
„ Wait for edema to resolve to do
Wait for edema to resolve to do anastomosis
anastomosis
59. “
“The art of medicine consists in amusing the patient
The art of medicine consists in amusing the patient
while nature cures the disease
while nature cures the disease”
”
Voltaire
Voltaire
