VCU DEATH 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