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Abdominal access
This document discusses abdominal incisions and the management of peritonitis and intra-abdominal abscesses. It describes the midline and paramedian incisions for abdominal access. It defines primary and secondary peritonitis and discusses the surgical management including source control, reducing bacterial contamination, and preventing recurrent infection. It also outlines the clinical features and management of intra-abdominal abscesses.
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Abdominal access
- 1. Abdominal access & Peritonitis S A NAQVI CONSULTANT GENERAL SURGEON MID WESTERN REGIONAL HOSPITALS, LIMERICK, IRELAND
- 2. Abdominal incisions basedon 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
- 4. Midline incision Commonest approach Thefollowing structures are divided: Skin Linea alba Transversalis fascia Extraperitoneal fat Peritoneum Can be extended around the umbilicus
- 5. Falciform ligamentshould 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
- 6. Paramedian incision Parallel toand 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
- 7. Paramedian incision Cont… Thepotential advantages 1. The rectus muscle is not divided 1. The incisions in the anterior and posterior rectus sheath are separated by muscle 2. Closed in layers 3. Had a lower incidence of incisional hernia (when sutures were not so good) The potential Disadvantages 1. Takes longer to make and close
- 8. Peritonitis Intra-abdominal infections resultsin 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
- 9. 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
- 10. Surgical management Themanagement 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
- 11. Peritoneal lavage Peritoneallavage 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
- 12. Intra-abdominal abscesses An intra-abdominalabscess 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
- 13. Clinical features Postoperative abscessesusually 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
- 14. Management Ultrasound scanningmay 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