1. GASTROINTESTINAL SURGERY
Surgical procedures of the abdominal cavity are several, may include digestive tract, glands
attached, accompanied usually by cutting and suturing of deep connective tissue (fascia),
peritoneum, muscle, subcutaneous tissue and skin. In this paper we will focus on surgical
techniques at the stomach and small intestine.
The most common diseases
WHERE ARE THESE PROCEDURES ARE:
GATROINTESTINAL HIGH BLEEDING:
Upper gastrointestinal bleeding or upper gastrointestinal bleeding refers to bleeding that
originates in the esophagus, stomach or duodenum, or was in a region proximal to the
ligament digestive Treizt may also include the proximal jejunum.This bleeding is caused by
hematemesis, melanomesis, as well as for hair.

2. PEPTIC ULCER DISEASE:
Peptic ulcer disease is manifested by duodenal ulceration, gastric ulceration and peptic
esophagitis. Peptic ulceration, erosion and corrosion of the mucosa by the gastric juice. This
injury occurs when the mucosa of vulnerability or abnormal conditions when there is excess
gastric or ectopic location when the gastric mucosa. May be aggravated by excessive presence
of Helicobacter pylori.
Surgical treatment includes:
- Vagotomy.
- Vagotomy combined with antrectomy.
- Subtotal gastrectomy.
DELAYED GASTRIC EMPTYING SYNDROME AND SYNDROME POSTGASTRECTOMÍA:
Occurs by delayed emptying of chyme into the duodenum or after gastric surgery. Surgical
treatment can be very painful and must be done carefully.
GASTRIC CANCER:
Stomach cancer or gastric cancer is a malignant tissue growth rate produced by the contiguous
spread of abnormal cells capable of invasion and destruction of other tissues and organs,
particularly the esophagus and small intestine, causing nearly one million deaths worldwide
annually. In formasmetastásicas, tumor cells can infiltrate the lymph vessels in tissue, spread
to the lymph nodes and overcome this barrier, enter the bloodstream, after which the road is
open virtually any organ in the body.

3. Symptoms
Stomach cancer can be difficult to detect in its early and often no symptoms, and in many
cases, the cancer has spread before you are. When symptoms occur, they are often so
unobtrusive that the person does not care about them.
Stomach cancer can cause the following effects:
• Indigestion or a burning sensation
• abdominal pain or discomfort
• Nausea and vomiting
• Diarrhea or constipation
• Swelling of the stomach after meals
• Loss of appetite
• Weakness and fatigue
• unusual bleeding
• Changes in bowel or urinary
• Wounds that are slow to heal
• Difficulty eating
• Sudden changes in the appearance of skin warts
• Persistent cough or hoarseness
• Weight loss
• Bad breath
Any of these symptoms may be caused by cancer or by other less serious health problems,
such as a stomach virus or an ulcer. Therefore, only a physician can determine the actual
cause.If a person has any of these symptoms should see your health professional. Later, this
doctor, you can send to that person to a doctor who specializes in problemasdigestivos. The
latter will gastroenterologist who diagnose and determine exactly the correct diagnosis.
Diagnosis
To find the cause of symptoms, you start with the patient's medical history and physical
examination, supplemented by laboratory studies. The patient also may have to perform one
or more of the following tests:
Fecal occult blood test, is not entirely useful, as a result does not indicate anything negative
and a positive result is present in a number of conditions in addition to gastric cancer.

4. Gastroscopy examination.
Analysis of the abnormal tissue seen in a gastroscope examination with a biopsy done by the
surgeon or gastroenterologist. This tissue is then sent to a pathologist for histological
examination under a microscope to check for the presence of célulascancerosas. A biopsy, with
subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.
Hyperplasia, a disorder of the skin, often in the armpit and groin, called acanthosis nigricans,
commonly seen in obese people usually generally promotes the need for studies to rule out
gastric cancer of the stomach.
Surgery
Surgical specimen of ulcerated gastric adenocarcinoma and raised edges.
Surgery is the most common treatment for stomach cancer, an operation
llamadagastrectomía. The surgeon removes part (subtotal gastrectomy) or entire stomach
(total gastrectomy) as well as some of the tissue around the stomach. After partial
gastrectomy, the remaining portion is anastomosed stomach has been removed with the
esophagus or small intestine. After total gastrectomy, the doctor connects the esophagus
directly to the small intestine. Because cancer can spread through the lymphatic system,
lymph nodes near the tumor is removed, usually during the same surgery so that the
pathologist can check to see if there are cancer cells in them. If cancer cells are in the nodes,
the disease may have spread to other parts of the body.The surgical margin, ie the amount of
tissue to be removed around the area affected by gastric cancer is 5 cm of normal tissue.
Gastrointestinal surgery is major surgery. After surgery, the activities are limited to allow
healing to occur. The first days after surgery, the patient is fed intravenously (through a
vein). After several days, most patients are ready for liquids, followed by soft foods and then
solids. Those who have completely removed the stomach being unable to digest lavitamina
B12, which is necessary for blood and nerves, and you are given regular injections of the
vitamin. Patients may have temporary or permanent difficulty digesting certain foods, and may
need to change your diet. Some digestive surgery patients need to follow a special diet for
several weeks or months, while others need to make a lasting change in their diets. The health
professional or a dietitian (nutrition specialist) explain any dietary changes needed.
Some patients after gastrectomy with cramps, nausea, diarrhea, and dizziness shortly after
eating because food and liquid enter the small intestine too quickly and without being
digested. This group of symptoms is called the dumping syndrome. Foods containing high
amounts of sugar often make symptoms worse.The dumping syndrome can be treated by

5. changing the patient's diet. You can manage the symptoms by eating several small meals
throughout the day, avoid foods that contain sugar, and eat foods high in protein. To reduce
the amount of fluid entering the small intestine, patients are instructed generally not to drink
at meals. Certain medications can also help control the dumping syndrome. The symptoms
usually disappear in 3 to 12 months but may be permanent.
After digestive surgery, digestive upsets are caused by the bile.They can prescribe medications
or suggest counter products to control such symptoms.
ENTEROCUTANEOUS FISTULAS:
Enterocutaneous fistula is the most common presentation of intestinal fistulas, with the
particular characteristic of externalized through the skin integument. The arrangement of the
small intestine in its long and tortuous course through the peritoneal cavity and enormous
mucosal surface, make this an important function in absorbing nutrients and influencing
charged liquid electrolyte, thus, the maintenance of internal environment.Depending on the
nature of external fistulas of small intestine are congenital or acquired.

6. ACUTE ABDOMINAL PAIN:
In more severe cases, laparoscopy and surgery.
ACUTE APPENDICITIS:
Appendicitis is inflammation of the appendix, located in the cecum, which is the portion where
the large intestine begins.Cases of acute appendicitis require a surgical procedure called
laparoscopic appendectomy or laparotomy it is no more than removal of the inflamed
appendix. Treatment is always surgical.In untreated cases, the morbidity rate is high, mainly
due to complications such as peritonitis and septic shock in particular when the inflamed
appendix ruptures. The mortality associated with the process is low except when it appears
free perforation and peritonitis associated with septic shock.
Etiology
The main theory of the pathophysiology of appendicitis, based on experimental evidence
points to a blockage of the lumen of the appendix by lymphoid hyperplasia, showing how one
of the first causes the second is the blockage of the appendix po an appendicolith.
Pathogeny
Inflammation of the appendix produces, over time, an obstruction of the lumen of the
organ. This obstruction leads to an accumulation of secretions of the mucosa with consequent
increase in intraluminal pressure. Proceeding the inflammation and obstruction, compress the

7. veins and arteries causing ischemia and bacterial invasion into the wall of the appendix with
necrosis, gangrene and rupture if not treated immediately.
Based on this sequence of evolutionary stages, the appendix with signs of mild inflammation
known as catarrhal or mucosa, phlegmonous, "purulent" then going to
gangrenosaperforandose and may evolve into an appendiceal abscess or appendicitis Plaston,
or a more serious stage of peritonitis acute diffuse.
Diagnostic signs
In 75% of cases there is the triad of Cope, the sequence consisting of abdominal pain
(described above), food vomiting and fever. The classic signs are located in the right iliac fossa,
where the abdominal wall becomes sensitive to slight pressure of palpation. Furthermore, with
the painful sudden decompression of the abdomen, a sign called Rebound sign, indicates a
reaction to irritation parietal peritoneum.
Other diseases of the gastrointestinal system and intestinal obstruction, colonic diverticular
disease, colorectal cancer, and ischemia and intestinal bleeding can be serious risks of surgical
treatment.
GASTRIC BYPASS SURGERY
It is an operation that helps you lose weight by changing how the stomach and small intestine
handle the food you eat.
After surgery, your stomach will be smaller and you will feel full with less food.
The food you eat and not go to certain parts of your stomach and small intestine break down
food. Because of this, your body will not absorb all the calories from the foods you eat.

8. Description
You will receive general anesthesia before this surgery and will be asleep and pain.
There are two basic steps during gastric bypass surgery:
• The first step makes the stomach smaller. The surgeon uses staples to divide the stomach
into a small upper section and a larger bottom section. The upper section of the stomach
called the pouch is where the food you eat. This bag is about the size of a walnut and stores
only one ounce of food.
• The second step is the derivation. The surgeon connects a portion of the small intestine
called the jejunum, a small hole in the bag. The food you eat will now travel from the pouch
into the new opening in the small intestine. Because of this, the body absorbs fewer calories.
Gastric bypass can be done in two ways. With open surgery, the surgeon makes a large surgical
cut open the abdomen and perform the derivation directly manipulating the stomach, small
intestine and other organs.
Another way to do this surgery using a tiny camera called a laparoscope, which is placed in the
abdomen. The surgery is called laparoscopy.
In this surgery:
• First, the surgeon will make 4 to 6 small incisions in her abdomen.
• The surgeon will then pass the laparoscope through one of these incisions and this will be
connected to a video monitor in the operating room. The surgeon will monitor to see inside
your abdomen.
• The surgeon will use thin surgical instruments to make the bypass, which are inserted
through the other incisions.
The advantages of laparoscopy over open surgery include:
• Shorter hospital stay and faster recovery
• Less pain
• Smaller scars and a lower risk of a hernia or infection

9. This surgery takes about 2 to 4 hours.
Why is the procedure
You do not usually perform surgery to lose weight, unless you can not lose a lot of weight and
keep it off with diet, changing their behavior and exercise alone.
Doctors often use body mass index (BMI) and conditions such as type 2 diabetes and
hypertension, to determine which patients are most likely to benefit from weight loss surgery.
Gastric bypass surgery is not a "quick fix" for obesity. You must diet and exercise after the
operation. Also need to know the risks of surgery and how will his life after the operation.
Risks
Gastric bypass is major surgery and has many risks, some of which are very serious. You must
be addressed with the surgeon.
Risks for any surgery or anesthesia include:
• Allergic reactions to medicines
• Blood clots in the legs that may travel to the lungs
• Bleeding
• Respiratory problems
• Heart attack or stroke during or after surgery
• Infection, including in the incision, lungs (pneumonia), bladder or kidney
There are many risks associated with any weight loss surgery.There are also risks that are more
likely after gastric bypass surgery.
Before the procedure
The surgeon will ask you to have tests and consult with other doctors before undergoing
surgery.
If you smoke, stop smoking several weeks before surgery and not start smoking again after
surgery. Smoking slows recovery and increases the risk of problems. Tell your doctor or nurse if
you need help quitting.
Always tell your doctor or nurse:

10. • If you are or might be pregnant.
• What drugs, vitamins, herbs and other supplements you are taking, including those bought
without a prescription.
During the week before surgery:
• You may be asked to stop taking aspirin (aspirin), ibuprofen (Advil, Motrin), vitamin E,
warfarin (Coumadin) and other drugs that affect blood clotting.
• Ask your doctor which drugs you should still take on the day of surgery.
• Prepare your home for after surgery.
After the procedure
Most people stay in the hospital for 3 to 5 days after surgery. In the hospital:
• You will be asked to sit on the side of the bed and walk around the same day you had
surgery.
• May have a catheter (tube) is passed through the mouth into the stomach for 1 or 2
days. This tube helps drain fluid from the abdomen.
• You may have a urinary catheter to drain urine.
• You can not eat during the first 1 to 3 days. After that, you can take liquids and pureed foods
or soft foods.
• You may have a catheter connected to the larger part of his stomach that was bypassed. It
will come out one side and drain fluids.
• Wear special stockings on your legs to help prevent blood clots.
• You will receive medication by injection to prevent blood clots.
• You will receive pain medication. Take pills for pain and given pain medication through an
intravenous catheter that goes into your veins.
You can go home when:
• Be able to eat liquid or pureed without vomiting.
• can be moved around without much pain.
• Do not need pain medicine through an IV or administered by injection.
Forecast

11. Most people lose 10 to 20 pounds about a month in the first year after surgery. Weight loss
will decrease with time, so persevere with diet and exercise will provide the largest early
thinning.
You can lose half or more of their extra weight in the first two years and will lose weight
quickly right after surgery, if he is still liquid or soft diet.
Losing enough weight after surgery can improve many conditions, such as:
• Asthma
• Gastroesophageal reflux disease (GERD)
• Hypertension
• High Cholesterol
• Obstructive sleep apnea
• Type 2 Diabetes
Weighing less should also make it much easier to move around and do everyday activities.
Bypass surgery itself is not a solution to losing weight. Can train you to eat less, but you still
have to do much of the work. To lose weight and avoid complications from the procedure, you
will need to follow the exercise and eating guidelines that your doctor and dietician will have.
Alternative Names
Bariatric surgery (gastric bypass) Bypass Gastric Bypass Roux en Y gastric, gastric bypass Roux
en Y

12. SURGERY IN THE ABDOMINAL CAVITY
Upon entering, the surgeon needs to roll the vessels of the subcutaneous tissue almost
immediately after making the incision, unless you use a unit Electrosurgical for this purpose.
Sutures are generally preferred absorbable.
When preparing the bonds, the instruments often prepares a thread a needle to use as suture
ligation if the surgeon desires transficción a large glass. Once in the abdominal cavity, the type
of selected suture depends on the nature of the operation and technology the surgeon.
Gastrointestinal tract
Leakage from the anastomosis or suture site are the main problem faced to close the wounds
of the gastrointestinal tract. This problem can lead to localized or generalized peritonitis. The
sutures be too tight knot at the anastomosis. Wounds of the stomach and intestine are rich in
blood supply and can be swollen and hard. Tight sutures may cut the tissue and cause leaks.
Can be achieved a leak-proof anastomosis with a closing single or double shots.
For a simple closure, interrupted sutures should be placed approximately 1 / 4 "(6 mm.) apart.
suture is placed through the submucosa, in the muscle and through the serosa. Because the
submucosa provides strength in the gastrointestinal tract, the effective closure involves
suturing the submucosal layers in apposition without penetrating the mucosa.
A continuous suture line provides a more secure seal the sutures interrupted. However, if one
suture breaks, the entire line can be separated.
Many surgeons prefer to use a closure in two planes, for safety placed a second layer of
interrupted sutures through the serosa. In closing single or double absorbable sutures may be
used VICRYL, MONOCRYL sutures, PDS II sutures or chromic catgut sutures. Surgical silk may
also be used in the background of a double closing.

13. Have been used successfully in this area invested closure techniques, everted, or end
conextremo, but all have drawbacks. The surgeon must take meticulous care to place the
sutures in the submucosa. Even with the best technique leakage can occur. Fortunately, the
omentum generally limits the area, and the body's natural defenses control the problem.
Stomach - To be an organ that contains free hydrochloric acid and potent proteolytic enzymes,
the stomach heals remarkably quickly. Stomach wounds attain maximum strength 14 to 21
days after the operation, and have a maximum rate of collagen synthesis in five days.
Absorbable sutures are generally accepted in the stomach, although they may produce a mild
reaction in both the wounded and in normal tissue. Sutures VICRYL are the most frequently
used. PROLENE sutures can also be used to close the stomach.

14. Small Intestine - The closure of the small intestine has the same considerations as the
stomach. The proximal bowel contents, primarily bile or pancreatic juice, can cause severe
chemical peritonitis (rather than bacterial).
If using an inverted closure technique, care must be taken to minimize the amount of tissue
that protrudes into the intestinal lumen to avoid partial or complete obstruction.
Generally preferred because it absorbable sutures to permanently limit the lumen diameter.
You can use a non-absorbable suture in the serosa layer for added security.
The small intestine heals very quickly and reaches its maximum strength in about 14 days.
Colon - The high microbial content of the colon that once made the biggest concern fura
pollution. Absorbable sutures But once you have absorbed, leaving no bacterial migration
channels. Still concerned about the output of the large intestine content as it is potentially
more severe consequences that the leak in other areas of the gastrointestinal tract.
The colon is a strong body about twice in the sigmoid region in the cecum.
However, the wounds of the colon regain strength with the same speed, regardless of location.
This lets you use the same size suture at either end of the colon. The colon heals at a rate
similar to that of the stomach or small intestine. Maintain a high rate of collagen synthesis for
a prolonged period (over 120 days). Entire gastrointestinal tract shows loss of collagen and
collagen activity increased immediately after the anastomosis of the colon.
Can be used for closing the colon both absorbable and nonabsorbable sutures. Helps prevent
complications placing sutures in the submucosa and prevent penetration of the mucosa.
Rectum - The rectum heals very slowly. Because the lower portion is located below the pelvic
peritoneum has no serosa. It should include a portion of muscle at the anastomosis, and
sutures should be cut carefully to avoid tying the tissues. Monofilament sutures reduce the risk
of bacterial proliferation in the rectum.
Closing The Abdomen
When closing the abdomen, may be more important than the type of technical material
suturaempleado.
Peritoneum - The peritoneum, the thin membrane of the abdominal cavity is located below
the rear fascia. Heal quickly. Some think that the peritoneum does not require sutures, while
others disagree. If the fascia is closed tightly after the suture of the peritoneum may or may
not help prevent an incisional hernia. The surgeons closed the peritoneum, usually prefer a
continuous line with absorbable suture. You can also use separate points.
Fascia - This layer of firm, strong connective tissue covering the muscles is the main support
structure of the body. By closing the abdominal incision, the fascia sutures hold the wound
closed and help to resist changes in intraabdominal pressure. Occasionally synthetic material
may be used when the fascia graft is absent or weak. You can use a polypropylene mesh
PROLENE to replace and repair abdominal wall hernias, whenever there is great tension in the

15. suture line during healing. Nonabsorbable sutures may be used as suture PROLENE to suture
the graft tissue.
The fascia recovers approximately 40% of its original strength in two months. It may take up to
a year or more to regain full strength. The full original strength is never recovered.
The anatomical location and type of abdominal incision influence the fascia layers to be
sutured.
The posterior layer of the fascia is always closed. The previous layer can be cut and required
stitches. Closing techniques with full-thickness sutures are becoming more popular.
Most suture materials have some degree of inherent elasticity. If you are not tied tightly, the
suture "give" to accommodate the postoperative edema. Stainless steel sutures, if tied too
tight, cut like a knife to the swollen tissue or increasing the tension on the suture line. In view
of slow healing and suturing the fascia must withstand the maximum voltage of the wound,
you can use a gauge nonabsorbable suture moderate. It can also provide adequate support an
absorbable suture with longer tensile strength, such as PDS II sutures.
PDS II sutures are particularly suitable for young, healthy patients. Many surgeons use an
interrupted technique to close the fascia. In the absence of obvious infection or
contamination, the surgeon can choose monofilament or multifilament sutures. In the
presence of infection can use a monofilament absorbable material like PDS II sutures or inert
nonabsorbable sutures like stainless steel, or sutures PROLENE .
Muscle - Muscle does not tolerate well the suture. However, there are several options in this
area. The abdominal muscles can be cut, paragraphs (separated), or withdrawn, depending on
the location and type of incision chosen. Whenever possible, the surgeon prefers to avoid
interfering with the blood supply and innervation by making an incision to separate the
muscle, or retracting the entire muscle to its innervation.
During the closure, muscles handled in this way need not be sutured. Fascia is sutured rather
than muscle.

16. The technique of Smead-Jones far-and-close for abdominal closure is strong and fast, provides
good support during the early healing with low incidence of wound separation, and has a low
frequency of late incisional problems. It's a close in a plane through both layers of the
abdominal wall fascia, abdominal muscles, peritoneum, and anterior layer of the fascia.
Shaped interrupted sutures of 8 when placed. Absorbable sutures are usually used Vicryl or
PDS II.
Can also be used stainless steel sutures. Monofilament sutures PROLENE also provide all the
advantages of steel sutures: strength, minimal tissue reaction, and resistance to bacterial
contamination. M'as are tolerated by patients than steel sutures in the late months of the
operation and are easier to handle and tying by the surgeon. However, both stainless steel
sutures as PROLENE can be detected under the skin in thin patients. To avoid this problem, the
knots should be buried in the fascia and subcutaneous space.
Subcutaneous fat - not muscle or fat is well tolerated by suture. Some surgeons question the
appropriateness of placing sutures in the fat tissue because it has little tensile strength due to
its composition, which is mostly water. However, others think it is necessary to place at least a
few stitches in a thick layer of subcutaneous tissue to avoid dead spaces, especially in obese
patients. The dead spaces are more likely to occur in this type of tissue, so that the edges of
the wound must approach carefully. Tissue fluids can accumulate in these spaces, delaying
healing and predisposing to infection. Usually you select absorbable sutures for the
subcutaneous plane. The suture VICRYL is especially suitable for use in fatty tissue, avascular,
since it is absorbed by hydrolysis. The surgeon may use the same type and size of material
used earlier to tie the vessels in this plane.
Closing the abdomen
Subcuticular tissue - To minimize scarring, suturing the subcuticular plane of connective tissue
keeps the wound edges in close approximation. At one end of a single plane can be seen
subcuticular smaller scar after a period of 6 to 9 months when performing a simple skin
closure. The surgeon places short side continued below the plane of the skin epithelium. You
can use absorbable or nonabsorbable sutures. If you choose non-absorbable material, the

17. suture protruding at each end of the incision, the surgeon can be knotted together to form a
loop or knot the ends out of the incision. To be only one line of scar as a hair (on the face, for
example), you can keep the skin in very close approximation with strips of skin closure in
addition to the subcuticular suture. Depending on the location of the tape can be left in the
wound a long time. When there is great tension in the wound, as in facial surgery or neck, you
can use very fine sizes in subcuticular sutures. Abdominal wounds they bear more tension
sutures require a larger caliber. Some surgeons prefer to close both the subcuticular plane as
the skin to have a minimal scar. The chromic surgical gut sutures and polymeric materials such
as sutures MONOCRYL are acceptable in the dermis. They are able to maintain sufficient
tensile strength in collagen synthesis phase, which lasts about six weeks. Sutures should not be
placed too close to the epidermal surface to reduce the extrusion. If the skin is thin and non-
pigmented, clear or white suture as the suture monofilament MONOCRYL invisible. After
closing this plane can be approximated skin edges.
Skin - The skin is composed of epithelium and underlying dermis. It is so strong that it takes a
sharp needle at each point to minimize tissue trauma. (See the section on Selection of
Needles).
The wounds of the skin regain tensile strength slowly. However, surgeons usually remove the
sutures between 3 and 10 days after the operation, when the wound has recovered
approximately 5% to 10% of its strength. This is possible because the fascia absorbs the
increased tension on the wound, the surgeon relies on it to keep the wound closed. The skin
sutures or subcuticular need to support only the natural tension of the skin and keep the edges
in apposition.
The suture technique for skin closure can be continuous or interrupted nonabsorbable suture
material. The skin edges are everted. Preferably, each suture is passed through the skin once,
reducing the likelihood of contamination along the suture line. Technique is generally
preferred interrupted.
The skin sutures are exposed to the external environment, thus become a serious threat of
pollution and abscesses. The interstices of multifilament sutures may provide a shelter for
microorganisms. Therefore, to close the skin usually prefer monofilament absorbable sutures.
Monofilament sutures also induce less tissue reaction than multifilament sutures. May be
preferred for cosmetic reasons or monofilament nylon sutures of polypropylene.
Many skin wounds closed well with silk and polyester multifilament. The tissue reaction to
nonabsorbable sutures decreases and remains relatively acellular fibrous tissue to grow and
form a thick capsule around the suture. (It is known that surgical catgut produces an intense
tissue reaction. However, surgical gut is absorbed quickly tends to be less reactive due to its
rapid absorption profile). The key to success is early suture removal occurs before
epithelialization of the suture and before contamination becomes infection.
A word about the scar (epithelialization) - When a wound is kept on the skin - either
accidentally or during a surgical procedure - the epithelial cells of the basal layer of the wound

18. margins flatten and move into the area wound. Migrate down the edge until they find living
tissue is not damaged at the base of the wound. Then move along the wound bed to make
contact with similar cells that are migrating from the opposite side. They move down the
suture after it has been embedded in the skin. When the suture is removed, it is the path of
epithelial cells. May eventually disappear, but may be slightly and form keratin. Usually you
see a dotted scar the skin and can lead to the appearance of "railroad" or "grid" of the wound.
This is relatively rare if the skin sutures are placed with excessive tension and are pulled
towards the seventh day after the operation.
The forces that create the distance between the edges of the wound remain long after you
have removed the sutures. There is significant collagen synthesis between 5 and 42 days after
surgery. After this time, any additional gain in tensile strength is due to remodeling or
crosslinking of collagen fibers rather than synthesis. The tensile strength increases continue
until two years, but the tissue never regains its original strength.
Closing the abdomen
Retention suture closure - We have already discussed the techniques for placing retention
sutures, and use them in a secondary suture. (See section Suturing Techniques.) Generally
used high rating (0 to 5) of nonabsorbable material, not by force, but because larger sizes are
less likely to cut tissue when there is a sudden increase in intraabdominal pressure as
coughing, vomiting, straining, or distention. To avoid cutting the suture material to tension the
skin can pass one end of the retention suture through a plastic or rubber tube of short length
as a support or protection before tying. You can also use a plastic clip bridge to protect the skin
and primary suture line and allow a comfortable postoperative wound management for the
patient.

19. The properly placed retention sutures provide strong reinforcement of abdominal wounds, but
also cause more pain to the patient that the closure plans. The best technique is to use a
needle suture material assembled at each end (double armed). They should be placed from the
inside out of the skin to avoid passing potentially contaminated epithelial cells through the
abdominal wall.
The suture line ETHICON retention suture includes ETHILON, MERSILENE, Ethibond
Extra PROLENE and PERMA-HAND . You can also use steel surgical sutures. Retention sutures
may be left 14 to 21 days after the operation. The average is three weeks.
The factor in deciding when to remove retention sutures is the evaluation of the patient.
Sutures Drain - If a drainage tube placed in an organ or inserted deep bladder drainage, you
can make the wall of the body with absorbable sutures. The surgeon may prefer to minimize
the distance between the body and the abdominal wall using sutures to attach the body that
drains into the peritoneum and fascia. Sutures may be placed around the circumference of the
drain, either two sutures at 12 and 6 o'clock, or four sutures at 12, 3, 6, and 9 o'clock and
secured to the skin with temporary handles. When drainage is no longer necessary, the skin
sutures can be removed easily for removal. You can leave the opening to allow additional
drainage until it closes naturally.
A drainage tube inserted into the peritoneal cavity through a puncture in the abdominal wall
usually is anchored to the skin with one or two nonabsorbable sutures. This prevents the drain
from slipping into or out of the wound.
The importance of repairing the mesentery - When closing, the surgeon should know how
important it is to repair any defect created in the mesentery during the surgical procedure to
avoid a possible hernia. The mesentery is a fold membrane that holds the different organs to
the abdominal wall. Technique can be used continuously or interrupted catgut sutures or
surgical VICRYL.

20. BIBLIOGRAPHY
http://www.nlm.nih.gov/medlineplus/spanish/ency/article/007199.htm
http://librosvip.blogspot.com/2011/08/lecciones-de-cirugia.html
http://es.wikipedia.org/wiki/Apendicitis