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目的 探讨腹部手术切口裂开的防治。方法 注意缝合技术和增加组织张力的强度。降低腹压,避免危险因素和对危险因素的围手术期处理。结果 有效地预防了腹部手术的切口一裂开。结论 减少腹部手术的切口裂开,能进一步提高手术的成功率和降低手术病死率。     

腹部切口裂开的防治体会

腹部切口裂开是腹部手术严重并发症，其发生率为1％-3％，死亡率约为10％，我科自2000年1月至2005年12月，共进行腹部手术1762例，术后发生腹部切口裂开13例，占0．74％，由此导致死亡1例，占7．69％，现就腹部切口裂开的发生、预防分析如下。     

腹壁切口疝与横、纵切口选择的关系——Meta分析

目的比较腹部横切口与纵切口两种不同方式与切口疝发生率之间的关系。方法通过检索PubMed、EMBASE数据库中与之相关的随机对照试验(randomized controlled trials,RCTs)和队列研究(cohort study),并辅以手工检索和文献追溯法收集1990年1月1日至今公开发表的关于腹部切口发生切口疝的相关文献,对最终纳入的文献采用Stata(12.0版)软件进行Meta分析。结果通过数据库检索出文献502篇,根据入选标准和排除标准,通过阅读全文最终纳入22篇研究文献,共累计病例5 405例,其中发生切口疝的病人共654例,切口疝总发生率为12.1%,Meta分析结果显示腹部横切口的切口疝发生率为4%,而腹部纵切口的切口疝发生率为10%。不考虑权重的情况下进行横向切口与纵向切口疝发生率的t检验,发现两者差异有统计学意义(P0.000 1)。结论横向切口可能是预防腹部手术后切口疝发生率高的优选切口。     

Prognostic models of abdominal wound dehiscence after laparotomy

BACKGROUND: Portions of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program were used to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy. METHODS: Perioperative data from 17,044 laparotomies resulting in 587 (3.4%) wound dehiscences performed at 132 Veterans Affairs Medical Centers between October 1, 1996, and September 30, 1998, were used to develop the model. Data from 17,763 laparotomies performed between October 1, 1998, and September 30, 2000, resulting in 562 (3.2%) dehiscences were used to validate the model. Models were developed using multivariable stepwise logistic regression with preoperative, intraoperative, and postoperative variables entered sequentially as independent predictors of wound dehiscence. The model was used to create a scoring system, designated the abdominal wound dehiscence risk index. RESULTS: Factors contributing significantly to the model and their point values (in parentheses) for the risk index include CVA with no residual deficit (4), history of COPD (4), current pneumonia (4), emergency procedure (6), operative time greater than 2.5 h (2), PGY 4 level resident as surgeon (3), clean wound classification (-3), superficial (5), or deep (17) wound infection, failure to wean from the ventilator (6), one or more complications other than dehiscence (7), and return to OR during admission (-11). Scores of 11-14 are predictive of 5% risk of dehiscence while scores of >14 predict 10% risk. CONCLUSIONS: This abdominal wound dehiscence risk index identifies patients at risk for dehiscence and may be useful in guiding perioperative management.     

Vertical compared with transverse incisions in abdominal surgery.

OBJECTIVE: To reach an evidence-based consensus on the relative merits of vertical and transverse laparotomy incisions. DESIGN: Review of all published randomised controlled trials that compared the postoperative complications after the two main types of abdominal incisions, vertical and transverse. SETTING: Teaching hospital, Denmark. SUBJECTS: Patients undergoing open abdominal operations. INTERVENTIONS: For some of the variables (burst abdomen and incisional hernia) it was considered adequate to include retrospective studies. Studies were identified through Medline, Cochrane library, Embase, and a manual search of relevant journals. The references cited in these studies were reviewed to find out whether any other trials fitted the selection criteria. MAIN OUTCOME MEASURES: Early complications including postoperative pain, pulmonary complications, burst abdomen, wound infection, and hospital stay, and late complications (incisional hernia). RESULTS: Eleven randomised controlled trials and seven retrospective studies were identified. The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The transverse incision results in significantly less postoperative pain and fewer pulmonary complications. Vertical laparotomy, however, is associated with shorter operating time and better possibilities for extension of the incision. The pooled odds ratio for burst abdomen in the vertical incision group was 2.86 (95% confidence interval 1.72 to 4.73, p = 0.0001), and regarding late incisional hernia the pooled odds ratio was 1.68 (95% confidence interval 1.10 to 2.57. p = 0.02). CONCLUSIONS: Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. They should be recommended, as the early postoperative period is associated with fewer complications (pain, burst abdomen, and pulmonary morbidity) and there is lower incidence of late incisional hernia after transverse compared with vertical laparotomy. A midline incision is still the incision of choice in conditions that require rapid intra-abdominal entry (such as trauma) or where the preoperative diagnosis is uncertain, as it is quicker and can easily be extended.     

A comparison of circumumbilical and transverse abdominal incisions for neonatal abdominal surgery

Purpose

Although neonatal bowel surgery traditionally involves a transverse abdominal incision, several authors have reported that the circumumbilical incision is effective and cosmetically appealing. We report the first study comparing the circumumbilical incision to the transverse abdominal incision for a variety of neonatal abdominal operations.

Methods

Retrospective cohort analysis comparing the circumumbilical incision to the transverse abdominal incision for neonates who underwent surgical repair of malrotation, duodenal atresia/web, or intestinal atresia/web was performed between 1999 and 2009.

Results

One hundred thirty-two patients underwent a laparotomy through a transverse abdominal incision (n = 106) or a circumumbilical incision (n = 26). Baseline characteristics between groups were similar. No differences were found when comparing operative time, postoperative days on a ventilator, narcotic infusion, time to full feeds, length of hospital stay, incidence of surgical site infection, and bowel obstruction. Although more incisional hernias occurred in the circumumbilical incision group (38%) than the transverse abdominal incision group (6%), all hernias in the circumumbilical group resolved without intervention, whereas 33% required surgical repair in the transverse abdominal group.

Conclusions

Because of its cosmetic advantages and similar outcomes to the transverse abdominal incision, the circumumbilical incision should be considered as an alternative to the transverse abdominal approach in neonatal surgery.     

Superficial wound dehiscence after median sternotomy: surgical treatment versus secondary wound healing

BACKGROUND: Superficial wound dehiscence after midline sternotomy is considered a minor complication in cardiac surgery, although it is quite frequent and requires prolonged medical treatment. It can be managed conventionally by topical treatment, with delayed secondary healing, or by surgical treatment and primary skin closure. We report the outcome of 96 patients who underwent conventional treatment, compared with a second group of 42 patients who underwent surgical treatment and direct closure. METHODS: From October 1999 to December 2002, 2400 consecutive patients underwent median sternotomy: 207 patients had sternal wound complications: 3 patients (0.125%) had mediastinitis, 66 patients (2.75%) had aseptic deep sternal wound dehiscence, and 138 patients (5.75%) had superficial wound dehiscence. The latter are the object of the present study; patients entered a protocol of skin wound care on an outpatient basis. The first 96 consecutive patients (group 1) required medications three times a week until complete healing. The last 42 patients (group 2) were treated by extensive surgical debridement of skin and subcutaneous tissue, direct closure of the superficial layers, and suture removal after 15 days. RESULTS: The two groups were comparable as to age, sex, and preoperative risk factors. The incidence of contaminated wounds was similar in the two groups (32 of 96 in group 1 and 11 of 42 in group 2; p = NS). The length of treatment was 29.7 days (range 2 to 144 days) for group 1 and 12.2 days (range 2 to 37 days) for group 2 (p < 0.0001). The mean number of medical treatments was 9.4 per patient in group 1 and 3.7 per patient in group 2 (p < 0.0001). CONCLUSIONS: Surgical debridement and primary closure of superficial surgical wound dehiscence after median sternotomy is a safe and valid treatment. Wound infection is not a contraindication to surgical treatment. Primary closure may contribute to reduce the risk for later infection. It also definitely contributes to decreasing healing time and strongly lessens patients' discomfort, diminishing hospital costs and hospital staff workload.     

Umbilical pyloromyotomy: comparison of vertical linea alba and transverse muscle cutting incisions

Background

Pyloromyotomy is commonly performed through a supraumbilical skinfold incision. Entry into the peritoneal cavity can be achieved via a vertical linea alba incision or a transverse muscle cutting approach. The aim of this study was to compare the morbidity associated with these 2 operative techniques.

Methods

Case records of all babies undergoing umbilical pyloromyotomy between January 2000 and December 2004 were retrospectively compared for postoperative dehiscence, mucosal perforation, and wound infection (defined by the need for antibiotics or wound exploration). Data were analyzed with GraphPad Prism contingency tables and results were compared by Fisher exact test (P < .05).

Results

During the study period, 341 umbilical pyloromyotomies were performed at our institution. The surgeon was permitted choice of either operative approach (219 vertical linea alba, and 122 transverse muscle cutting). There were no significant differences between the 2 groups regarding age at presentation, sex, duration of symptoms, biochemical derangement, and operator seniority. No significant differences in morbidity were encountered with either of these 2 operative strategies.

Conclusions

This study demonstrates that the vertical linea alba and transverse muscle cutting incisions have equivalent postoperative morbidity. These findings indicate that neither technique is demonstrably superior.     

Principles of abdominal wound closure. II. Prevention of wound dehiscence.

Among 4,000 abdominal wound closures, there were 11 dehiscences. In eight, the original wound was closed with retention or large figure-of-8 sutures. When the wounds were resutured, the same basic technique of large tissue bites at close intervals was used, but this time the wounds remained intact. Therefore, it was concluded that the cause of the dehiscence was not poor tissues, but poor technique: the first sutures either had too small bites, were placed too far apart, or were tied too tightly. We describe a closure technique using buried figure-of-eight retention sutures tied very loosely. An additional running suture approximates the fascial edges. This method was used in 126 patients, with but one failure, caused by improper knot tying. In a separate clinical study, no difference in wound tension was found between vertical and transverse incisions.     

Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence

The incidence of fascial disruption after major abdominal operations is 1% to 3%, and dehiscence is associated with a mortality rate of 15% to 20%. Although several systemic factors (e.g., malnutrition, increased age, male sex, and chronic treatment with steroids) have been associated with an increased risk of wound disruption, their clinical importance has been overstated. Local, mechanical factors such as wound infections, abdominal distention, and pulmonary complications appear to be more important and should be prevented or treated aggressively should they occur. Paramedian wounds are less secure than are midline wounds, but the latter, when closed properly, are probably equivalent to transverse wounds. The peritoneum need not be closed, but the fascia should be sutured securely. Monofilament suture materials are preferred, and the continuous suturing technique has theoretic and practical advantages. Retention sutures are unnecessary if the fascia is closed properly, and the wound itself should not be violated by a drain or stoma. Although fascial dehiscence may not be eliminated, its incidence can certainly be reduced with proper attention to the mechanics of fascial closure.     

The impact of midline versus transverse incisions on wound complications and outcome in simultaneous pancreas-kidney transplants: a retrospective analysis

Intraperitoneal placement of the pancreas allograft, usually through a midline incision, has so far achieved the best results in pancreas transplantation. The usefulness and safety of a transverse incision has not been previously reported. The purpose of this study was to compare midline and transverse incisions, with respect to wound complications and outcome, in simultaneous pancreas-kidney transplant recipients with intraperitoneal placement of the pancreatic graft. The incidence of deep abscess formation, superficial abscess formation, wound leak, and fascial dehiscence, as well as graft survival, were retrospectively compared in 41 bladder-drained simultaneous pancreas-kidney recipients with a midline incision and in 15 with a transverse incision. The overall incidence of wound complications was similar (34% vs 20%, P=NS) in the two groups. Deep abscess formation occurred more frequently in the midline group (27% vs 0%, P=0.02). Staphylococcus epidermidis and Candida albicans were the most common microbial isolates from deep abscesses. Multivariate logistic regression analysis revealed donor age 40 years or older (P=0.04), the occurrence of a bladder leak (P=0.05), and a peak serum amylase in the 1st week of 1000 IU/l or greater (P=0.02) to be independent risk factors for the development of wound complications. The type of incision, however, was not found to be an independent risk factor. Patient (90% vs 83%, P=NS), pancreas allograft (78% vs 82%, P=NS), and kidney allograft (83% vs 70%, P=NS) survival rates were similar for the midline and transverse groups. We conclude that the transverse incision is a reasonable alternative to the midline incision in simultaneous pancreas-kidney transplantation and it is presently the incision of choice at our institution. It offers excellent exposure and is associated with a similar wound complication rate and outcome when compared to the midline incision.     

Comparison of transverse and vertical skin incisions for Caesarean section.

A comparison is made of the transverse and the vertical skin incision for Caesarean section. The advantages of the transverse incision are clearly demonstrated and discussed.     

Incidence of incisional hernia after dehiscence of the abdominal wound

The records of 103 patients whose abdominal wounds burst were studied in an attempt to assess the subsequent incidence of incisional hernia. Sufficient information about seventy patients was obtained. Forty-nine patients (47.6 per cent) had a hernia whereas twenty-one patients (20.4 per cent) definitely did not have a hernia. The incidence of hernia was associated with the age of the patient, the site of the wound, the day of resuture, an original diagnosis of malignancy, and the postoperative blood urea level but not with the technic employed in the resuture nor with infection.It is suggested that a blood-stained serous discharge and the “dip sign” should enable an early diagnosis of dehiscence to be made before the small bowel appears in the wound; after diagnosis, the wound should either be explored electively or the skin sutures left for at least three weeks until the skin heals.     

Complete dehiscence of the abdominal wound and incriminating factors.

OBJECTIVE: To find out the causes of abdominal wound dehiscence. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%). INTERVENTIONS: In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence. MAIN OUTCOME MEASURES: Statistical analysis using the chi square test. RESULTS: Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors. CONCLUSION: Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.     

Rectus abdominis atrophy after ventral abdominal incisions: midline versus chevron

Purpose

Although many outcomes have been compared between a midline and chevron incision, this is the first study to examine rectus abdominis atrophy after these two types of incisions.

Methods

Patients undergoing open pancreaticobiliary surgery between 2007 and 2011 at our single institution were included in this study. Rectus abdominis muscle thickness was measured on both preoperative and follow-up computed tomography (CT) scans to calculate percent atrophy of the muscle after surgery.

Results

At average follow-up of 24.5 and 19.0 months, respectively, rectus abdominis atrophy was 18.9% greater in the chevron (n = 30) than in the midline (n = 180) group (21.8 vs. 2.9%, p < 0.0001). Half the patients with a chevron incision had >20% atrophy at follow-up compared with 10% with a midline incision [odds ratio (OR) 9.0, p < 0.0001]. No significant difference was observed in incisional hernia rates or wound infections between groups.

Conclusion

In this study, chevron incisions resulted in seven times more atrophy of the rectus abdominis compared with midline incisions. The long-term effects of transecting the rectus abdominis and disrupting its innervation creates challenging abdominal wall pathology. Atrophy of the abdominal wall can not be readily fixed with an operation, and this significant side effect of a transverse incision should be factored into the surgeon’s decision-making process when choosing a transverse over a midline incision.