The document discusses techniques for abdominal wall closure, including both permanent and temporary options. It describes challenges with abdominal closure, such as risk factors for dehiscence. Several temporary abdominal closure techniques are outlined, including vacuum packs, negative pressure wound therapy, and dynamic retention sutures. The document proposes a 5-stage algorithm to reduce time between temporary abdominal closure and primary fascial closure. Factors determining readiness for closure and indicators for repeated laparotomy are also discussed.

1. T H E
D I F F I C U L T
A B D O M E N
• B Y D R AB U AN IL JOH N
• JU N IOR RE S ID E N T
• G E N E RAL S U RG E RY

2. INTRODUCTION
• Optimal closure of abdominal wall is always a dilemma for surgeons
• Here we discuss regarding
a)Techiniques of permanent as well as temporary closure
of abdominal wall
b)Situation where abdominal closure is difficult(Difficult
abdominal wall)

3. Suture Materials
• AN IDEAL SUTURE MATERIAL
>Resist infection
>adequate tensile strength to prevent abd wall disruption
>Minimise tissue damage
>Absorbable
Current practice we use – PDS (used as double stranded)
which is
>Slowly absorbing
>Monofilment(resist infection)
>High tensile srength

4. Why PDS over Prolene?
• Longer strength rentention profile
• Longer absorption time
• Monofilament

5. Disadvantageof Prolene
• Increased pain
• Sinus track formation
• No difference in incidence of
> incisional hernia
> wound dehiscence
>Surgical Site Infection

6. Abdominal Closure Techinique
1) Similar to that of any surgical site but tissue damage should be minimized :
Done by
i)Limitingincorporation of abdominalwall
musculature
ii) 4:1 ratio of suture bites vs Suture advancement
NB: recent study shows that,smaller fascial bites lowers incidenceof dehiscence
and ventral hernia due to
a) decresed tissue damge
b)decreased tissue ischemia
iii)Mass closure preferred over layered closure
2) Continous techinique with slowly absorbable sutures

7. RETENTIONSUTURES
Intended to prevent evisceration
but
>pain
>inflammation
>wound complication
>skin breakdown
>problems with ostomy appliaces placement
Hence used only in patients with highrisk of acute fascialdehiescence

8. ABDOMINAL FASCIAL DEHISCENCE
• Incidence – 3.5% after major abdominal surgery
•
• SIGNS
•
• > Incresed serosanguinus d/d

9. Predisposing Risk factor to Dehiscence
• Wound closure techinique
• Type of incision
• Operative indication
• High abd pressure
• Age > 65
• COPD
• Hemodynamic instability
• Malnutrition
• Diabetes
• Obesity
• Ascites
• Jaundice
• Steroid Use

10. • Wound dehiscence ∝ infection
Techinical Causes
i)Knot failure
ii)fascial damage (tension,ischemia,SSI)
iii)Suture material damage/failure

11. SURGICAL MX OF A/C DEHISCENCE
• Depending factors
>SSI
>intraabdominal abscess
RISK OF DEHISCENCE
>Max upto 7 days
>may even persist upon 3 weeks
NB: immediate repeat laparotomy is often avoided due to
i)intraperitoneal inflammation
ii)Adhesions
iii)Peritoneal Sclerosis

12. • HENCE:
MX is done by
PLANNED VENTRAL INCISIONAL HERNIA
+
ABDOMINAL WALL RECONSTRUCTION
If repeated lap is possible rectify cause of dehiscence and closure is
done

13. TEMPORARY ABDOMINAL CLOSURE(TAC)
Advanced technique helpful in DAMAGE CONTROL SURGERY
> Application of serial abdominal operation before
primary fascial closure
&
> Creation of a TAC
Tension free atraumatic abdominal visceral coverage
Serial plication of fascia (Dynamic)

14. INDICATIONOF TAC
a)Damge Control
> severe hemorrage
> hypothermia,coagulopathy,acidosis
> Delayed secondary operation
b)Inttraabdominal hypertension/compartment syndrome
c)Doubtful visceral viability
d)Planned a/c reoperations
e)Severe intraabdominal sepsis
f)Triage

15. CURRENT TAC TECHINIQUES
• I)VACCUM PACK
perforated polythene sheets placed under fascia covering
abdominal viscera
+
Sterile surgical towels
+
Suction Drains in continuous suction
EG: BARKER VACUUM PACK

18. • II) NEGATIVE PRESSURE WOUND THERAPY
Polythene foam under fascia
+
Negative Pressure Sponge
+
Vacuum Device
EG:KCI ABThera OPEN ABDOMEN NEGATIVE PRESSURE THERAPY

19. • Easily applied
• Inexpensive
• Atraumatic
• Control of abdominal fluids

22. • III) ARTIFICIAL BURR
2 Opposing Velcro sheets with hooks and loops sutured
to fascial edges (Velcro connects at midline)
EG: WHITTMAN PATCH

27. • IV) DYNAMIC RETENTION SUTURES
Sutures /elastomersplaced transabdominally,lateral
to rectus fascia bilaterally.
EG:CANICA ABRA SILICON ELASTOMER

29. • V) INLAY PATCH
impermeable prosthesis sutured to fascial edges
EG:BOGOTA BAG

31. • VI) SKIN ONLY CLOSURE
Using only towel clips

32. 5 STAGE PROPOSED ALGORITHM
• Devised to reduce the time between TAC to Primary Closure
• ABD fascia closed at stage 3
• Ideal time of closure is within 1st 8 days to minimize potential
complication

33. Why delay fascial closure?
• Intrabdominal hypertension/compartment syn
• Visceral edema
• Lack of source control
• Intra abd abscess
• Enterocutaneous fistula

34. 5 STAGE PROPOSED ALGORITHM

35. • Vacuum pack and Artificial burr are the 2 techiniques with high
success rate and low mortality
• Artificial Burr – Highset success rate

36. READINESS FOR ABD CLOSURE ASSESMENT
• After adequate resuscitation
GOALS
a)correct hypothermia
b)correct coagulopathy
c)Acidosis correction
These correction must be done within 36 hrs in trauma patients

37. ENTEROSTOMY NEEDED?
• In normal healthy patients
its best to
>Resect injured/devitalized tissue
>Anastomose if there is bowel injuries which
needed resection
.BUT in high risk patients ( septic perforation,post op bleeding or
intraop hypotension)
ITS BEST TO DO ENTEROSTOMY

38. WHY STAGING RECONSTRUCTION
• 1 )Decrease contamination and control of intraabd sepsis
• 2 )Debridement of devitalized tissue
• 3) Source control
which inturn increase the outcome

39. INDICATORSFOR REPEATED LAPAROTOMY
• A)Renal Dysfuction Values
• B)APACHE II Score
• C)MODS Score
these parameters are predictive of ongoing sepsis
BEFORE CLOSURE
Assess
> Intraabd pressure
> PIP

40. • IAP > 20mm hg & Rise of PIP - Warning sign for abdominal wall
compromise ,Visceral damage,renal dysfn
• IAP – Intra abd pressure
• PIP – peak inspiratory pressure

41. TIMING FOR REOPERATION
• Early post op period ( within 14 days ) – best
• Delay (14 – 21 days) – increased inflammatory reactions in
peritoneal cavity
• PINCH TEST – ideal time for reoperation in abd graft patients

42. COMPLICATION OF ABD WALL RECONSTRUCTION
• Seroma formation
• Skin Necrosis

43. Preparation for ABD WALL RECONSTRUCTION
• Optimize patient condition → then restore the structure &
functional continuity of musculofascial system
+
provide stable and durable wound coverage
Control infection
Control diabetes
Lifestyle changes

44. DEFINITIVEREPAIR:DYNAMICABDOMINAL WALL
• Tension free fascia to fascia closure using component separation
+
Mesh reinforcement
▼
WALL RECONSTRUCTION
Rectorectus repair + Underlay → Best method

45. RAMIREZ TECHINIQUE
• For component separation → requires large subcutaneous flaps for
access to be gained to the lateral abdominal wall to release ext
oblique fascia

47. Rives Stoppa Repair (RSR)+ Transverse Abd
Realease techinique
• Posterior rectus sheath incised to 0.5cm from fascial edge to defect
Rectomuscular plane is developed to lateral extent of dissection
If above dissection is inadequate → we use TRANVERSE ABD REALEASE
(where TA muscle is divided which then permitsentrance into space of
transversalis fascia and lateral edge of the divided tra abd muscle.

48. FACTORS DETERMINING OUTCOME
PATIENT
FACTOR
PROSTHESIS
FACTOR
SURGICAL
PROCEDURE
POST OP
OCCURENCE

49. THANK YOU .. ☺