VCUDEATH AND COMPLICATIONS CONFERENCE

Complication

Complication Dehiscence

Procedure Ileocecocetomy with end ileostomy

Primary Diagnosis Perforated terminal ileum

Clinical History

HPI 61 y old male with cc of dizziness,

nausea and vomiting. He was found to be hypotensive (60/39) and tachycardic ( Aflutter). Was admitted to MICU. As part of work up CT of abdomen/pelvis was obtained, it showed free air, free fluid and dilated loops of small bowel.

Clinical History

PMH RA, CHF, COPD, HTN, AFIB, DVT, Prostate CA, HepB,

and lupus. PSH AVR 1996, abdominal surgery for 30 yrs ago for PUD. MEDS :   Carvedilol, Coumadin, Prednisone, Omeperazole,

Prevastatin, Valsartan, and Albuterol PE: abdomen obese, soft, slight distention, diffuse

tenderness, no rigidity, no guarding. Rectal exam normal, stool, no blood, no mass, normal tone

Clinical History

LABS: lactate 4.5 wbc 6.5 hgb 12 co2 18 bun 23 creat 2.33 INR 1.2 alb 1.6 LFT’s normal

Chest x-ray ? Vascular congestion, KUB non diagnostic

EKG: Aflutter CT abd/pelvis: extralunminal air, large

free fluid , mesenteric stranding 

Overview of Case

Emergently taken to the operating room for Ex-Lap

Greenish brown fluid, undigested vegetables, dilated loops of bowel, dense adhesions, perforation of the terminal ileum

Ileocecocetomy with end ileostomy Fascia was closed in a running #1 PDS

Sutter Skin was left open

Hospital course

Pod 1 extubated off pressors Pod 5 gen floor, OOB, gen diet Pod 12 fascial dehiscence

Analysis of Complication

• Was the complication potentially avoidable?– Yes, may have used retention Sutter

• Would avoiding the complication change the outcome for the patient?– Yes, minimize length of hospital stay, risk of

evisceration

• What factors contributed to the complication?– Given the patient’s high risk for dehiscence

additional measures such as retention sutter should have been utilized.

Background

A prospective, multi-institutional study (132 VA Medical Centers)

Used the National Veterans Affairs Surgical Quality Improvement Program to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy.

Methods. The wanted to build model in order to create a scoring system designated the abdominal wound dehiscence risk index.

b/n Oct 1, 1996, and Sep30, 1998 Perioperative data from 17,044 laparotomies were used to

develop the model 587 (3.4%) wound dehiscence

Data from 17,763 laparotomies between October 1, 1998, and September 30, 2000, resulting

in 562 (3.2%) dehiscence 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.

Conclusion

In the high risk patient groups surgeons should consider prophylactic

measures intraoperatively, or early intervention post-operatively.

Finding the best abdominal closure All articles related to abdominal fascia

closure published from 1966 to 2003 were included in the review.

Careful analysis of the current surgical literature, including 4 recent meta-analyses, indicates that an optimal technique exists.

Finding the best abdominal closure There were 4 complications involved in

comparison of the different techniques of fascial closure apparent on review of the literature:

Early Complications 1. Fascial dehiscence 2. Infection

Late Complications 3. Hernia formation 4. Suture sinus/Incision pain

The best technique involves

Involves mass closure, Incorporating all of the layers of the

abdominal wall (except skin) as 1 structure

A simple running technique, using #1 or #2 absorbable monofilament suture material

With a suture length to wound length ratio of 4 to 1