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Wed Feb 4 14:40:57 GMT 2009

Mike-
1. What kind of fascial closure if it comes together without tension: running or interrupted and what suture?
- No statistical difference in general surgery patients, dont know if there is any data specific to damage control patients. My preference is Ethibond #1 CT needle interrupted

2. Any role for retention sutures?
- Not in first run. Although some of our faculty do retention sutures closures. In patients with fresh bowel repairs, severe intra-abdominal solid organ injuries closing the abdomen under tension will drive up your intra-abdominal pressures whish will decrease your abdominal perfusion pressures (APP). This lower APP will adversely impact any wound healing in the abdominal wall and / or intra-abdominal repairs. All this will increase the likelihood of SIRS and if not properly recognize (Abdominal Compartment Syndrome) tension abdominal wall closure will precipitate a second hit insult......all IATROGENIC....... 
My preference: by day 7 if I cant close loosely, tension free the abdominal wall, I do component separation with or without alloderm graft if no sign of intra-abdominal sepsis. Perpetuating the vicious cycle of abdominal washouts without an endpoint only creates more numbers for your residents and at the end a malnourished/imunocompromised patient. If positive signs of abdominal sepsis I continue washouts with later close the skin as described by the group in Orlando. No skin graft.

3. Skin closure: when and how - complete closure , place wicks or drains?
-complete closure if there was no evidence of enteric spillage and no sign of intra-abdominal sepsis.

j

Juan C. Duchesne MD, FACS, FCCP
Director Surgical Hospital Center 
Director Tulane Surgical Intensive Care Unit  
AMR Regional Director Louisiana Emergency Response Network

Division of Trauma and Critical Care Surgery
Tulane & LSU Department of Surgery and Anesthesiology 
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 Sise, Mike MD
Sent: Wed 2/4/2009 7:44 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: skin closure

Regarding abdominal wound management following damage control: please consider and answer 3 questions in stable patient with non contaminated abdomen post op 24 to 72 hrs at first take back:

1. What kind of fascial closure if it comes together without tension: running or interrupted and what suture?
2. Any role for retention sutures?
3. Skin closure: when and how - complete closure , place wicks or drains?

Mike Sise 
San Diego

________________________________

From: Ruy Cabello-Pasini [mailto:ruycabello at yahoo.com]
Sent: Tue 2/3/2009 8:42 PM
To: Trauma & Critical Care mailing list
Subject: Re: skin closure

I also always close the skin, if patient has a thick subcutaneous layer, I use a penrose drain over the aponeurosis and through the same incision, anybody?
Ruy Cabello-Pasini, MD
MEXICO 

--- On Wed, 2/4/09, Robert Nitt <robertnitt at yahoo.com> wrote:

> From: Robert Nitt <robertnitt at yahoo.com>
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Wednesday, February 4, 2009, 3:35 AM
> Close skin whenever can.  If damage control with extensive
> resuscitation or bowel spillage, pack open and delayed
> closure
>
>  Kumash Patel, MD, FACS
> Scottsdale Surgical Specialists
> General / Acute Care / Trauma / Critical Care Surgery
>
>
>
>
> ________________________________
> From: "McSwain, Norman E Jr."
> <nmcswai at tulane.edu>
> To: trauma-list at trauma.org
> Sent: Tuesday, February 3, 2009 5:39:42 AM
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
>
> This "older surgeon" would likely close the skin.
>
> Preferences & principles again...
>
> principle: skin needs to closed sometime.
>
> Preference - when?.........What is the condition of the
> wound. It is less than 72 hours; no bowel injury; was the
> patient overloaded with fluid?; how much pull on the skin to
> close?.
>
>
> Typed by the thumbs of
> Norman on his BlackBerry
>
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org
> To: trauma-list at trauma.org
> Sent: Mon Feb 02 22:39:54 2009
> Subject: RE: trauma-list Digest, Vol 67, Issue 43
>
>
> To all trauma-listers, a question from one of my partners:
>
>
> You have a damage control closure with a vac closure after
> a laparotomy for trauma without bowel injury (ie just spleen
> or liver, mesentery, whatever) - you take back in 24 to 48
> hours and are able to close the fascia.  What do you do with
> the skin?  Leave open or staple closed? 
>
> We're having a debate over this in our group. Older
> surgeons pack skin and subQ open, younger surgeons
> frequently close skin.
>
> Mike Sise
> San Diego
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org on behalf of
> trauma-list-request at trauma.org
> Sent: Tue 1/27/2009 12:35 AM
> To: trauma-list at trauma.org
> Subject: trauma-list Digest, Vol 67, Issue 43
>
>
>
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