Colon cancer with post-op problems - Forum

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Treatment guru

Re: Colon cancer with post-op problems - Ärzteforum

Post#11 »

Modern "mass closure" as popularized in the UK during the 70's means only one thing:

Continuous closure of the abdominal wall (NOT THE SKIN) taking huge bites through everything (fascia and muscle) without the skin. This is how most of the world closes now their abdomens: Not interrupted, NOT tiny bites in the anterior sheath only BUT big bites through all layers producing a strong midline scar.


John Dissector

Re: Colon cancer with post-op problems - Ärzteforum

Post#12 »

You are describing how I routinely close midline abdominal wounds--never in my 20 year career have I heard this clled "mass closure"--what "mass" exactly are YOU talking about? At least here in the states, mass closure refers to full thickness Each to his own semantic imaginings, I guess--whatever you say, -- The reference for this bit of wisdom, by the way?

forceps

Re: Colon cancer with post-op problems - Ärzteforum

Post#13 »

I generally agree with you, which is why I took care to mention in my posting that the patient was walking around, with minimal discomfort, and tolerating a diet. I thought seriously about the principles you mentioned and decided that there was no evidence of increased abdominal pressure. I believed that the sutures cut through the fascia because they were pulled too tight. I put in the retention sutures extremely loosely, so that at present they are doing nothing. The patient was extubated after the operation, and still rests comfortably. Also I am leaving town tomorrow for 5 days, and the guy who is covering for me is from the old school.

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Doctor Green

Re: Colon cancer with post-op problems - Ärzteforum

Post#14 »

Mass closure- continuous for the genereal situation. But when the situation requires "tailoring" - as someone else wrote - then interupted.

Proctologist

Re: Colon cancer with post-op problems - Ärzteforum

Post#15 »

I believe that there are two reasons for dehiscence, one is increased intraabdominal pressure, as stated. The other is a technical error, most often pulling the sutures too tightly, and strangulating the fascia.

In the former, there is always frank evisceration. the bowels are found on the bed, and closure is difficult, if not impossible. These cases should be managed along the lines suggested. Tight reTension (with the emphasis on tension) do all the bad things others have described already, and may kill the patient in more than one way (I have seen them cut the small bowel in half) so should never be used IMHO.

If the dehiscence was due to a technical error, with the original sutures strangulating the fascia, primary reclosure is possible.

In the case, the dehiscence was local, the bowels just peeked through the open fascia, and were not pushed out. I therefore think that the dehiscence was due to a technical error. Although the amount of tissue lost by the necrosis may require mesh closure, it may be possible to close primarily, but the risk of necrosing the fascia again is still high. In this case, LOOSE retension - not tension- sutures, can prevent a third trip to the OR in the early postop period, while if the new suture holds, they do nothing. So, I would put them in.

Dottore

Re: Colon cancer with post-op problems - Ärzteforum

Post#16 »

The best option in this case is to close the abdomen using a mesh , I have used Polypropylene mesh and they do very well , no incidence of intestinal fistula or incisional hernias, My Question is if you close with a Vicryl mesh do you get a weak abdominal wall?

Proctologist

Re: Colon cancer with post-op problems - Ärzteforum

Post#17 »

forceps wrote: Are you saying that we should suture the muscle?


Big bites through the rectus muscle and sheats, avoid peritoneum and subcutaneous fat. I suppose that is what I understand with mass closure. Do not pull more than fair approximation.

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A Doctor

Re: Colon cancer with post-op problems - Ärzteforum

Post#18 »

We are dealing here with temporary abdominal closure (TAC) with the emphasis on TEMPORARY. You could use Marlex but it will have to COME OUT sooner or later. If you do not plan re-operation better to use an absorbable mesh and accept a defect (i.e. hernia)- in need for a delayed reconstruction.

Jorjo

Re: Colon cancer with post-op problems - Ärzteforum

Post#19 »

I look at things more critically and wonder what percentage of what we do in the OR and on the ward out of "experience" rather than proper evidence. Unfortuently that meant I'm always discussing with my staff the lack of support for antibiotic irrigation peritoneum or after anorectal procedures. It is amazing that some young surgeons < 40 years have such old notions as triple antibiotics, weaning off TPN in a healthy patient who is eating and normal pancreas. Anyway I'll be done soon and out in the real world where I hope to practice thinds differently and hopefully not make the same mistakes.

Pet

Re: Colon cancer with post-op problems - Ärzteforum

Post#20 »

I just can't keep quiet any more. Heard a lecture by Dr. Baker (of Nyhus & Baker) where he pleaded with the audience of about 500 surgeons NOT to do the 1cm x 1cm thing any more because it makes the fascia like perforated spiral notebook paper. He recommended varying the width and the depth of the bites; use running sutures so that the pressure on the fascia would equalize over the length of the suture; and approximate, don't strangulate.

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