Covering the "open abdomen": a better technique

"Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.     

Spontaneous rupture of a liver cell adenoma

Temporary closure of the abdomen with a synthetic mesh and multiple planned relaparotomies are the essentials of the modern strategy for treating severe intra-abdominal sepsis or pancreatic necrosis. One of the complications associated with mesh closure of the abdomen is facial necrosis at the wound edges leading to evisceration. Tension of the strictures between mesh and facia called local ischemia, which combined with infection leads to the facial disintegration and separation of the mesh from the abdominal wall. A modified technique of suturing the mesh was developed in our department and its technical details are presented. Twenty-four patients treated with the "open abdominal technique and planned relaparotomies" are presented. The new technique was used in 9 patients for closure of evisceration after mesh separation.     

Use of absorbable mesh as an aid in abdominal wall closure in the emergent setting

A surgeon has many options available to aid in the closure of abdominal wall defects in the elective setting. In the emergent setting, active infection or contamination increases the likelihood of infection of permanent prosthetic material and limits the surgical options. In such settings, we have used absorbable mesh (Dexon) as an adjunct to fascial closure until the acute complications resolve. To evaluate the effectiveness of this technique, we reviewed the outcome of such closures in 26 critically ill patients. Between July 1987 and June 1993, 26 patients were identified who had placement of absorbable mesh as part of an emergent laparotomy at a major urban trauma center. Through a retrospective chart review, the incidence of complications and outcome of the closure were tabulated. Seven patients were initially operated on for trauma. Two of the patients had mesh placement at their initial procedure secondary to fascial loss from trauma. The remainder of the patients hd mesh placement during a subsequent laparotomy for complications related to their initial procedure. Indications for these laparotomies included combinations of wound dehiscence, intra-abdominal abscess, anastomotic disruption, and perforation. Mesh placement in patients with intra-abdominal infection created effectively open abdominal wounds that allowed continued abdominal drainage, but required extensive wound care. Despite the absorbable nature of the mesh and often prolonged hospital stay in these ill patients, none of them required reoperation for dehiscence, recurrence of intra-abdominal abscess, or infection of the mesh.(ABSTRACT TRUNCATED AT 250 WORDS)     

The association of intra-abdominal infection and abdominal wound dehiscence

Concurrent infection is a risk factor for abdominal wound dehiscence. We reviewed our experience with fascial dehiscence to determine the incidence and to identify prognostic factors for associated intra-abdominal infection. Over a 7-year period, 107 patients with abdominal wound dehiscence were identified. Seventeen were managed nonoperatively, and 90 underwent exploratory laparotomy, 43 of whom had no intra-abdominal pathology and 47 of whom had intra-abdominal infections. Demographic factors, comorbid diseases, and potential indicators of systemic infection did not distinguish patients with intra-abdominal infection from those without. Patients with an intra-abdominal infection were more likely to have undergone an emergency operation (74% vs 48%; P < 0.02), an operation on the colon (55% vs 25%; P < 0.005), or an operation with a higher wound classification (P < 0.02). Mortality was higher in patients with intra-abdominal infection than in those without (44% vs 20%; P < 0.02). Wound dehiscence after emergent operations, and operations with a higher wound classification, especially those involving the colon, should raise concern for intra-abdominal infection. Thorough abdominal exploration should be performed at the time of dehiscence repair. Before nonoperative management is chosen, intra-abdominal infection should be excluded.     

Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure

OBJECTIVE: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients. DESIGN: Retrospective analysis of case series from July 1, 1989, to July 31, 1996. SETTING: University-based level I trauma center. PATIENTS: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure. INTERVENTIONS: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation. MAIN OUTCOME MEASURES: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score. RESULTS: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001). CONCLUSION: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.     

Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen

BACKGROUND: Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation. OBJECTIVE: To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen. DESIGN: A prospective clinical trial. SETTING: Two urban trauma centers. PATIENTS: Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg. INTERVENTIONS: Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded. MAIN OUTCOME MEASURES: The results of the clinical evaluation and DPL were compared with the findings of the celiotomy. RESULTS: Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity = 90.0%, specificity = 58.3%, positive predictive value = 85.3%, negative predictive value = 63.6%, phi = 0.52, P < .01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value = 96.7%, negative predictive value = 78.6%, phi = 0.79, P < .01). CONCLUSIONS: Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10 x 10(9)/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.     

Morbidity of colostomy closure

An unexpectedly high morbidity (28 per cent) followed colostomy closure in 100 patients. One patient died postoperatively because of sepsis resulting from disruption of the colon anastomosis. Wound infection (10 per cent), intraperitoneal abscess (1 per cent), bowel obstruction (7 per cent), and fecal fistula (4 per cent) were other significant complications. Wound sepsis was greater after primary than after delayed wound closure. Obstruction did not correlate with the use of either an open or closed technic of anastomosis. Three patients required reoperation for complications. Temporary colostomy was constructed for colon injury in 85 per cent of patients. In view of the considerable morbidity of colostomy closure, alternate technics of managing colon trauma should be considered. Such technics include primary closure and exteriorization of repaired colon. When temporary colostomy is unavoidable, closure is best done by open, two layer anastomosis with delayed wound closure. Colostomy should be recognized as an important procedure associated with significant morbidity.     

Stepwise safety trial of a killed Leishmania vaccine in Iran

We retrospectively analyzed 36 patients requiring temporary abdominal wall closure on admission to a level I trauma center from 1988 to 1992. There were 10 deaths (28%) in the study population. Of the 26 survivors, 8 patients (31%) had primary fascial closure at initial hospitalization, whereas 18 patients (69%) required split-thickness skin grafting to visceral granulation tissue. Of these 18 patients, 13 have had ventral herniorrhaphy at subsequent admission. Eight of these patients had primary fascial closure, 4 required primary fascial approximation with prosthetic onlay reinforcement, and 1 required multiple operations including prosthetic reconstruction and eventual complex tissue transfer. Complications occurred in 3 patients (14%) and included two wound seromas, which were drained nonoperatively, and a wound infection necessitating removal of prosthetic material and subsequent reconstruction with complex tissue transfer. Follow-up reveals no recurrent hernia at 24 months. Abdominal wall reconstruction after temporary closure can be done safely and promptly, with good functional and esthetic results.     

微热管阵列应用于锂电池模块的散热实验

锂离子电池在大功率应用下的热控制和热管理已成为制约电动汽车商业化的瓶颈,为解决此问题,运用微热管阵列设计锂电池模块散热系统,在开放条件下对电池模块进行恒流18 A（1 C）和36 A（2 C）充放电测试,通过测量布置微热管阵列前后电池表面温度可知:在1 C和2 C充放电倍率下,散热系统能够有效的降低电池模块的温度及电池间温度差异,将温度和温度差值分别控制在40℃与5℃之内,可以解决温度对电池寿命和容量的影响问题.基于实验数据,对其中一2 C工况热量进行了计算,得到通过微热管阵列的对流散热量达到模块生热量的40%.      

Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen

Eighty-five consecutive patients were randomized to undergo mass closure of the abdomen with no. 1 polydioxanone mounted on either a blunt-tipped (n = 46) or cutting (n = 39) needle. Gloves were changed before closure and tested for perforation afterwards using standard air or water techniques. Fourteen pairs of gloves were punctured when using a cutting needle, and three pairs when a blunt-tipped needle was used. The majority of punctures were to the non-dominant glove. The surgeon was aware of the puncture in eight of the 14 instances involving a sharp needle and in one of the three involving a blunt-tipped needle. Blunt-tipped needles, while not eliminating the risk, significantly reduced the incidence of surgical glove puncture (P < 0.001, Fisher's exact test). The use of cutting needles for abdominal closure should be abandoned.     

Measurement of histidinohydroxylysinonorleucine and hydroxyproline in skin collagen by reversed-phase high-performance liquid chromatography after 9-fluorenylmethyl chloroformate labeling

The management of intra-abdominal desmoid tumors in patients with familial adenomatous polyposis (FAP) is very difficult. Non-steroidal anti-inflammatory drugs (NSAIDs), anti-estrogenic agents, and steroids are most commonly used, because surgical removal of these tumors may result in severe morbidity, with local recurrence being common. We report a patient with FAP and intra-abdominal desmoid tumors that regressed markedly after prednisolone therapy. The patient, a 38-year-old woman, had undergone total colectomy and ileorectal anastomosis with a diagnosis of FAP with colon cancer. Approximately 17 months after the surgery, she noticed an elastic firm lump in the abdominal wall. She also experienced lower abdominal distension. Computed tomography (CT) of the lower abdomen showed an invasive heterogenous low-density mass occupying the intra-abdominal space. She was treated with sulindac, NSAID, at 300 mg/day, the diagnosis being intra-abdominal desmoid tumors. She exhibited an intestinal obstruction about 9 months after the initiation of sulindac therapy. We changed the treatment and began prednisolone (initial dose, 40 mg/day). This treatment was continued for two years; subsequently, the lesions regressed markedly. She is currently well, more than 3 years after the withdrawal of prednisolone.     

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.     

Colostomy complications in children. An analysis of 146 cases

This report analyzes the course of 146 pediatric patients with colostomies in reference to problems with colostomy formation, management, and subsequent closure. Colostomy was performed predominantly for Hirschsprung's disease (70 cases) and imperforate anus (46 cases). A transverse colostomy was done in 120 patients (82%), and a sigmoid colostomy in the remaining patients. Loop colostomies were five times more frequent than divided colostomies. Early major complications occurred in 24 patients (16%). Stomal complications occurred in 69 patients and were more frequent after loop colostomies. Colostomy revision was required in 24 cases. Sigmoid colostomy had a significantly lower complication rate (P less than .01). One hundred nine patients underwent colostomy closure. Major complications occurred in 16 cases (15%). There were no deaths related to colostomy closure. The use of a sigmoid colostomy when possible and close attention to technical details, principles of stomal care, and proper parental instruction should minimize morbidity.     

When does your liposuction patient require an abdominoplasty?

BACKGROUND: Abdominal surgery has evolved from one operation applied to all patients requesting contouring, to a group of procedures based on individual variations in anatomy. Currently, the authors favor four (Types I-IV) different procedures. Liposuction alone (Type I) is performed in the majority of patients. In the remainder (procedures Type II-IV) liposuction combined with modifications of open, traditional abdominoplasty are utilized. These additional methods are appropriate in patients that necessitate rectus muscle reinforcement or skin reduction procedures in order to adequately contour the abdomen. OBJECTIVE: This report describes the indications for abdominal contour surgery, beyond just liposuction. METHODS: A consecutive series of over 300 abdominal contour patients were reviewed and analyzed, with recommendations based on individual variations in their soft tissue anatomy. RESULTS: We demonstrate that the majority of patients benefit from a "closed" procedure (liposuction or ultrasonic assisted liposuction) but that patients with muscle flaccidity or laxity in their skin may require an open procedure. CONCLUSION: Abdominal contour surgery should be considered a group of operations (abdominolipoplasty system of classification and treatment) based on individual varieties in anatomy.     

Numerous PCR-RFLPs within the porcine CYP21 (steroid 21-hydroxylase) gene

Mesenteric cysts are rare intra-abdominal tumors with an incidence around one case per 100,000 hospital admissions. The clinical presentation is variable; patients may be asymptomatic or present with either acute or chronic abdominal pain. Physical examination commonly demonstrates a smooth, round and mobile abdominal mass. Differential diagnosis includes any abdominal cyst or tumor. Laboratory tests are usually helpless. Ultrasonography and CT scans are the best diagnostic tools. The treatment of choice is the total resection of the cyst, which is regularly performed by open surgery. This paper reports a case of a mesenteric cyst successfully resected by laparoscopy, and addresses the possible uses of this approach.     

Extra-abdominal closure of enterocutaneous fistula

Enterocutaneous fistula is a dread complication of gastrointestinal disease and gastrointestinal operation. These patients typically have undergone numerous abdominal operations, often with peritoneal contamination, carcinoma, and/or a history of radiation, making operation for repair daunting, if not impossible. We describe a method for closure of enterocutaneous fistula, which we have used successfully in four such patients. After failure of nonsurgical management, each patient's fistula was closed with a combination of skin, muscle, and fascial flaps after intubation of the fistula with a Malecot catheter. No intra-abdominal dissection was necessary. All fistulas healed completely. We recommend this closure in any patient who has failed surgical or nonsurgical therapy or in whom celiotomy is contraindicated or is to be avoided.     

Novel approach to the treatment of intestinal fistula in the inaccessible abdomen: transbursal end-to-side duodenogastrostomy

BACKGROUND: Treatment of enterocutaneous fistula in patients with intra-abdominal sepsis and a surgically inaccessible abdomen is frequently unsuccessful. METHODS: A new approach has been devised: total disconnection of the proximal digestive tract, which can be performed through the bursa omentalis without entering the scarred abdomen. RESULTS: The procedure was carried out in four patients with high-output small bowel fistula and an inaccessible abdomen. Output of fistulas stopped promptly, recovery from intra-abdominal sepsis was achieved, the abdomens became accessible again and continuity of the digestive tract could be restored in all patients after intervals of 2-5.5 months. CONCLUSION: Transbursal end-to-side duodenogastrostomy is a useful procedure when traditional surgical interventions have failed or cannot be applied.     

Deceptive packaging: Are the deceivers being deceived?

To investigate the effects of deceptive packaging, sample packages of potato chips containing various amounts were distributed to consumers who purchased a regular pack of the same brand. The only difference between the sample and the purchased pack was in terms of quantity of chips with the sample packs having various deficits. Preference data were obtained via a follow-up interview. The analyses of the questionnaire data indicated that: (a) consumers did not perceive weight differences between packs, (b) all indices of consumer preference favored the free pack when the two were of equal weight, and (c) all indices showed a marked decrease in preference for the experimental pack as the contents of the experimental packs were decreased. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of barium enema in colostomy closure in trauma patients

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.     

Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is associated with a higher incidence of iatrogenic perforation of the gallbladder than open cholecystectomy. The long-term consequences of spilled bile and gallstones are unknown. Data were collected prospectively from 1059 consecutive patients undergoing laparoscopic cholecystectomy over a 3-year period. Details of the operative procedures and postoperative course of patients in whom gallbladder perforation occurred were reviewed. Long-term follow-up (range 24 to 59 months) was available for 92% of patients. Intraoperative perforation of the gallbladder occurred in 306 patients (29%); it was more common in men and was associated with increasing age, body weight, and the presence of omental adhesions (each P < 0.001). There was no increased risk in patients with acute cholecystitis (P = 0.13). Postoperatively pyrexia was more common in patients with spillage of gallbladder contents (18% vs. 9%; P < 0.001). Of the patients with long-term follow-up, intra- abdominal abscess developed in 1 (0.6%) of 177 with spillage of only bile, and in 3 (2.9%) of 103 patients with spillage of both bile and gallstones, whereas no intra- abdominal abscesses occurred in the 697 patients in whom the gallbladder was removed intact ( P < 0.001). Intraperitoneal spillage of gallbladder contents during laparoscopic cholecystectomy is associated with an increased risk of intra-abdominal abscess. Attempts should be made to irrigate the operative field to evacuate spilled bile and to retrieve all gallstones spilled during the operative procedure.