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The first 25 slides, exactly as they appear. The full deck has 182 content slides.
General Surgery
Incisions, Closures, and Management of the Abdominal Wound
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 182 slides
Overview
- Topics covered
- Impact of the incision on surgical outcome
- Requirements of an adequate incision
Choosing the incision
Orientation, site, the evidence behind each choice, and preparing the skin
- Orientation of abdominal incisions
- Flexibility of the vertical midline incision
- Incisions matched to the site of disease
- Anatomical argument for transverse incisions
- Evidence on vertical versus transverse incisions
- Wound infection in the transverse incision trial
- Midline versus paramedian incisions
- Lateral paramedian incision
- Re-entering the abdomen through an old scar
- Preparation of the surgical site
- Choice of skin antiseptic
Vertical incisions
Midline, paramedian and the vertical muscle-splitting incision
- Exposure gained by the midline incision
- Surface marking of the upper midline incision
- Making the midline incision
- Layers divided in a midline incision
- Safe entry into the peritoneum
- Dividing the linea alba and peritoneum
- Protecting the viscera as the wound is opened
- Surface marking of the upper paramedian incision
- Making a paramedian incision
- Freeing the rectus muscle from the anterior sheath
- Hazards during the paramedian dissection
- Lower paramedian incision: skin to rectus muscle
- Lower paramedian incision: vessels and peritoneum
- Vertical muscle-splitting incision
Transverse and oblique incisions
Kocher, McBurney, Rockey-Davis and Pfannenstiel
- Principles of transverse and oblique incisions
- Nerve supply of the rectus muscle
- Indications for the Kocher subcostal incision
- Technique of the Kocher subcostal incision
- McBurney and Rockey-Davis incisions
- Surface markings for appendicectomy incisions
- Placing the appendicectomy incision
- Layers split in the muscle-splitting approach
- Why the muscles are split rather than cut
- Opening the oblique muscles for appendicectomy
- Opening the peritoneum and delivering the appendix
- Enlarging the appendicectomy wound
- Pfannenstiel incision
- Steps of the Pfannenstiel incision
- Advantages and limits of the Pfannenstiel incision
Chest and retroperitoneal approaches
Thoracoabdominal incisions and routes that stay behind the peritoneum
- Exposure gained by a thoracoabdominal incision
- Restrictions on the thoracoabdominal incision
- Corkscrew position and the line of the incision
- Corkscrew position and the abdominal part of the incision
- Entering the chest
- Opening the diaphragm
- Two ways of opening the diaphragm
- Closing a thoracoabdominal incision
- Advantages of retroperitoneal and extraperitoneal approaches
- Structures reached from behind the peritoneum
- Retroperitoneal approach to the lumbar area
- Left lumbar approach to the retroperitoneum
- Landmarks and closure in the lumbar approach
- Posterior approach to the kidney and adrenal gland
- Posterior approach to the kidney and adrenal gland
- Reaching Gerota's fascia
- Managing pleural injury in the posterior approach
- Retroperitoneal approach to the iliac fossa
- Extraperitoneal approach to the iliac vessels and ureter
Laparoscopic access
Getting into the abdomen through small incisions, safely
- Principles of laparoscopic access
- Hand-assisted laparoscopic surgery
- Site of first entry
- Open (Hasson) technique
- Securing the Hasson cannula
- Closed (Veress needle) technique
- Confirming Veress needle placement
- Signs of wrong Veress needle placement
- Radially expanding and optical access trocars
- Open versus closed entry
- Safety data for open versus closed entry
- Rules for placing additional ports
Closing the abdomen
Fascia, suture choice, skin, retention sutures and mesh
- Most common
- Factors that raise the risk of wound failure
- Mass closure versus layered closure
- Arguments over suture material
- Evidence on suture material
- Why braided permanent suture behaves worst
- Rate of resorption of different suture materials
- Suture materials that do not resorb
- Reading the suture resorption table
- Continuous versus interrupted closure
- Recommended approach to laparotomy closure
- Technique of mass closure
- Placing the mass closure bite
- The completed mass closure
- Bite size and tension in mass closure
- Suture length to wound length ratio
- Skin closure options
- Staples versus subcuticular suture
- Tissue glue for skin closure
- Skin closure in contaminated wounds
- Fascial dehiscence and its consequences
- Sources of raised intra-abdominal pressure
- Retention sutures: purpose and evidence
- Drawbacks of retention sutures
- Selecting patients for retention sutures
- Placing retention sutures
- Mesh underlay for the at-risk closure
- Biologic implants and complex reconstruction
- Closure of laparoscopic port sites
- Devices that help port-site closure
Temporary closure and the open abdomen
Damage control, dressings that hold the abdomen open, and later closure
- Origins of temporary abdominal closure
- The three phases of damage control
- Survival data behind damage control
- Patients who benefit from temporary closure
- Bogota bag and plastic drapes
- Absorbable mesh as a temporary cover
- Wittman patch
- Open abdomen technique
- Barrier placed over the abdominal contents
- Drains and dressing over the barrier
- Preventing loss of abdominal domain
- Abdominal vacuum-assisted closure
- Limits of the prolonged open abdomen
Managing the wound after operation
Dressings, and what the evidence says about leaving the wound alone
- Purpose of the postoperative dressing
- Evidence on removing the dressing
- Types of surgical dressing
- Vacuum-assisted closure dressing
Wound complications
Infection, necrotising infection, seroma, haematoma, dehiscence
- 7.3
- Bacterial load and the role of foreign material
- Risk factors for surgical site infection
- Further risk factors for infection
- Classification of surgical site infection by depth
- Reading the infection criteria table
- Criteria for defining surgical site infections
- Criteria for defining surgical site infections, continued
- Classifying wounds by contamination
- Classification of surgical wounds
- Classification of surgical wounds, continued
- Risk scoring systems: SENIC and NNIS
- Organisms responsible for infection
- Antibiotic prophylaxis: which drug
- Antibiotic prophylaxis: timing and dose
- Bowel preparation before colorectal surgery
- Reading the prevention recommendations
- Preoperative measures to prevent surgical site infections
- Team and theatre measures to prevent infection
- Asepsis, surgical technique and surveillance measures
- Wound closure, incision care and reporting of infection rates
- Treatment of incisional infection
- Treatment of deep space infection
- Necrotising wound infection: how it presents
- Signs that should raise suspicion
- Laboratory and imaging findings
- Treatment of necrotising infection
- Repeat inspection after debridement
- Gas gangrene
- Hyperbaric oxygen in clostridial infection
- Two types of necrotising fasciitis
- Type I necrotising fasciitis
- Type II necrotising fasciitis
- Antibiotics in necrotising fasciitis
- Seroma
- Wound haematoma
- When a haematoma needs the operating theatre
- Stitch abscess
- Suture material and stitch abscess
- 1-3%
- Recognising dehiscence
- Patient factors linked with dehiscence
- Managing dehiscence and evisceration
- Choices at reclosure
- Non-operative management of dehiscence
- Incisional hernia
Summary
The points worth carrying away
- Key points: choosing and making the incision
- Key points: closure
- Key points: wound complications
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- Maingot's Abdominal Operations, 12th Edition