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TAC

Duchesne, Juan C jduchesn at tulane.edu
Thu Aug 28 21:39:23 BST 2008


Dear Ranjith-
The best recommendation I can give you is to have a game plan early in the game........placing retention sutures , alternating wound vacs every other day, slowly re-approximating the wound edges......all these points are important but not necessary will guarantee you success . In other words besides the mechanical aspect of abdominal closure you need to consider the physiologic status of the patient . ..........This is what work for us........after damage control laparotomy (DCL) and full resuscitation.... we switch to low volume resuscitation in order to minimize unnecessary tissue edema (this include simple maneuvers like: volume restriction, or low volume 3% saline or even lasix).........then we set a 7 day game plan of repeated visits to OR for washouts and skin re-approximation.......after this period if the patient can not be closed we have 2 options: 1)skin flap undermining and skin closure (NO SKIN GRAFT) with plan to return to OR in 6 month for final hernia repair....... OR.........2) Component separation closure (our favorite)..............It is crucial to remember that going back and forth for weeks for meaningless washout is an excercise of futility and more importantly it is detrimental to the patient nutrition  due to the huge amount of protein loss.........always aim for primary closure but if not possible then consider the other 2 options in conjunction with low volume resuscitation..............
My 2 cents
 
Duchesne
 
 
Juan C Duchesne MD, FACS, FCCP
Director Surgical Hospital Center 
Director Tulane Surgical Intensive Care Unit  
Louisiana ATLS / PHTLS State Faculty
Trauma and Critical Care Surgery Section
Surgery and Anesthesiology Department
 
 
 
Tulane University School of Medicine
1430 Tulane Ave., SL-22
New Orleans LA 70112-2699
Tel. 504-988-5111
Fax. 504-988-3683
 
 
 
 

________________________________

From: trauma-list-bounces at trauma.org on behalf of rwolfer at aol.com
Sent: Thu 8/28/2008 2:47 PM
To: trauma-list at trauma.org
Subject: Re: TAC



we change every couple of days. If just a "dressing change" we can do at bedside in ICU and just drape everything out.  The last time "back" we try to close and if still tight or cannot close will sew in vycryl mesh and wound vac or do dressing changes on top of that. another thing my chairman taught me is to just place a lot of retentions close to each other and use "bridges that can be tighened or loosended by turning dial. Will use this in pts that we can get the fascia close but not completely closed. Every couple of days just tighten up a bit and the fasica comes together .  You just have to be careful that you do not catch a piece of bowel in the closure. You can lay a piece of vicryl mesh just under fascia and close with these over top to help prevent this Even if you get it really close a small ventral hernia to fix down the road is better than a giant one.  Have tired a couple of times and seems to work well
RW



-----Original Message-----
From: Ranjith Ellawala <ranjithellawala at yahoo.com>
To: Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>
Sent: Thu, 28 Aug 2008 2:52 pm
Subject: Re: TAC



Thank you.
 When we use a temp closure just as you described, We change every 2 nd day or
o. Otherwise infection will sets in. 1.
 1.Is that your experience as well?
 2. If you are using absorbable mesh, how soon you could apply after DC
urgery?
 Ranjith
rwolfer at aol.com wrote:
 if no wound vac we use a sandwich of blue towe
ls and ioban and put a large NG
etween the layers to "suck out' the fluid that is hooked to low continous wall
uction. I t works very well
 would not use prolene mesh but if you want mesh would use vicryl as it is
bsorbable. you just end up with large ventral hernia later.  you could wait
ntil it all granulates and then skin graft the defect. In 6 or so months when
he pt is we.. and you can "pick skin graft off underlying tissue" we would
emove and repair ventral hernia.
W

-----Original Message-----
rom: Ranjith Ellawala
o: Trauma & Critical Care mailing list
ent: Wed, 20 Aug 2008 1:25 pm
ubject: TAC

I use âEUR~opsite sandwitchâEUR(tm) initially for DC. We donâEUR(tm)t have vaccum assisted
ainage device nor absorbable mesh. but we have Plastic IV bags.
. Could I use polypropalene mesh safely?
. When do you think the best to change over to mesh if abdomen appears
 be too tight for closure?
. Could you use either type of mesh in the presence of wound infection?
. What can you use to cover the mesh temporally?
our comments please
anjith Ellawala
olombo
ri lanka
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