Presentación del Residente Walter Robles en la reunión de los residentes de cirugía del Hospital Rebagliati EsSLUD. Lima Perú. Ivan Vojvodic Jefe del Departamento

1. MR2 ROBLES VALVERDE, WALTER . HOSPITAL EDGARDO REBAGLIATI MARTINS EsSALUD DEPARTAMENTO DE CIRUGÌA GENERAL Y DIGESTIVA DR. IVÀN VOJVODIC HERNÀNDEZ JEFE HIPERTENSIÒN ABDOMINAL Y MANEJO QUIRÙRGICO

7. DEFINICIONES: MEDICION PIA Castellanos G et al. La hipertensión intraabdominal y el síndrome Compartimental abdominal: ¿qué debe saber y cómo debe tratarlos el cirujano?. Cir Esp. 2007;81(1):4-11

17. CONSECUENCIAS FISIOPATOLÓGICAS DE LA HIA: Is it wise not to think about intraabdominal hypertension in the ICU? Manu LNG Malbrain. Curr Opin Crit Care 10:132–145. 2004

18. CONSECUENCIAS EN LA CIRCULACIÓN ESPLÁCNICA Castellanos G et al. La hipertensión intraabdominal y el síndrome Compartimental abdominal: ¿qué debe saber y cómo debe tratarlos el cirujano?. Cir Esp. 2007;81(1):4-11

19. CONSECUENCIAS EN LA CIRCULACIÓN ESPLÁCNICA Castellanos G et al. La hipertensión intraabdominal y el síndrome Compartimental abdominal: ¿qué debe saber y cómo debe tratarlos el cirujano?. Cir Esp. 2007;81(1):4-11

21. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations. Intensive Care Med DOI 10.1007/s00134-007-0592-4 grade 1B

32. CIERRE TEMPORAL DE LA PARED: TIPOS Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close. Closure Technique Description Advantages Disadvantages Skin only (towel clip closure, running suture of skin) Serial application of towel clips or suture Rapid Does not prevent IAH; damage to clips may interfere with subsequent radiography (e.g., angiography) Bogota bag 3-L IV bag, Steri-drape (3M, St. Paul, MN), Silastic bag, plastic bag rapidly sutured to skin Inexpensive, inert, nonadherent Risk of evisceration, loss of abdominal domain, risk for IAH Dexon mesh (Davis & Geck, Danbury, CT) ; Vicryl mesh (Ethicon, Somerville, NJ) Suturing of absorbable mesh to skin or fascial edges Can be applied directly over bowel; allows for drainage of peritoneal fluid Rapid loss of tensile strength (in the setting of infection), potentially large-volume losses Later ventral hernia development risk for bowel fistula when mesh is absorbed

33. CIERRE TEMPORAL DE LA PARED: TIPOS Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close. Closure Technique Description Advantages Disadvantages Polypropylene mesh Suturing of the mesh to the fascial edges Good tensile strength, allows for drainage of peritoneal fluid Risk of intestinal erosion when applied directly over bowel, potentially large-volume losses, high risk of mesh infection and hernias, difficult to remove Polytetrafluoroethylene (PTFE) mesh Suturing of the mesh to the fascial edges Good tensile strength Potential fluid accumulation underneath the mesh, limited tissue integration and granulation tissue formation over the mesh, risk of mesh infection, expensive

34. CIERRE TEMPORAL DE LA PARED: Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close. Closure Technique Description Advantages Disadvantages Wittmann patch, (Star Surgical, Burlington, WI) Suturing of artificial burr (i.e., Velcro) to fascia, staged abdominal closure by application of controlled tension Good tensile strength, allows for easy reexploration and eventual primary fascial closure Poor control of third-space fluid, adherence of bowel to abdominal wall, potential for fistulae Human acellular dermal graft (Alloderm; LifeCell, Branchburg, NJ) Effective and safe in contaminated wounds. Limited experience, long-term results not yet known; may require multiple pieces sown together Can be used as a permanent prosthesis.

35. CIERRE TEMPORAL DE LA PARED: Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close. Closure Technique Description Advantages Disadvantages Vacuum-pack closure Bowel covered with plastic sheet and towel or Kerlix (KCI, San Antonio, TX) rolls; flat drains attached to wall suction Inexpensive, uses material found in operating rooms, moderate control of fluid, high success in fascial closure Inability to quantify suction

36. CIERRE TEMPORAL DE LA PARED: Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close. Closure Technique Description Advantages Disadvantages Negative pressure therapy; V.A.C. Abdominal Dressing System (KCI, San Antonio, TX) (vacuum-assisted closure device) Reticulated polyurethane foam dressing over the plastic covering of the bowel. The negative pressure is controlled with a computer-controlled vacuum pump that applies a constant, regulated pressure to the wound surface and a sensing device to prevent uncontrolled fluid (e.g., blood) drainage. Increase in blood flow, a reduction on abdominal wall tension, reduction in size of the abdominal wall defect, decreased bowel edema, and potential removal of inflammatory substances that accumulate in the abdomen during inflammatory states. Edema and third-space losses can be controlled and abdomen closed in a timelier manner. Expensive

44. Algorritmo de manejo del abdomen abierto Current Surgical Therapy, 9na edición. 2008 – The Abdomen that won’t close.

48. GRACIAS POR LA ATENCION