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Flashcards in Plastics 2 Deck (24):
1

What is a difficult about abdominal hernia
1. What is more significant than size?

2. Complication?

1. Presence or absence of components is more significant than size

2. Damage to abdominal wall components compromises future repair efforts

2

1. 36 (80%) had what?
2. 11 (24%) had a what?
3. 13 (29%) had a what?

1. incisional hernias
2. trauma history
3. history of gynecologic surgery

3

Comorbid Conditions
for difficult hernia? 4

1. Obese (>30% over ideal wt) 25 (56%)
2. Cigarette smoking 15 (33%)
3. Hypertension 12 (27%)
4. Diabetes 11 (24%)

4

Complaints
for difficult hernia? 5

1. Back pain
2. Abdominal pain
3. Gastrointestinal symptoms
4. Inability to perform ADL or work
5. Dissatisfaction with appearance

5

Preoperative Evaluation
3

1. Physical Examination
2. CT Scanning
3. General Surgery Consultation

6

General Surgery Consultation
includes? 3

1. Stoma takedown
2. Extensive enterolysis
3. Other conditions (diaphragmatic hernia)

7

Hernia Closure Strategy 4


Additonal manuevers? 2

1. Reduction of hernia with lysis of adhesions

2. Mobilization of skin and subcutaneous tissues to axillary line and costal margin

3. Incision of of external oblique from costal margin to iliac spine

4. Incision of rectus fascia along costal margin


Additional maneuvers
1. Incise anterior rectus sheath bringing medial edges together in midline
2. Incise transversalis fascia as needed

8

Repair Techniques for hernia?
1. Most common?
2. Other options? 4

1. Components separation (89%)

2.
-Rectus release 73%
-External oblique release 73%
-Both external and internal 58%
-Mesh augmentation (13%)

9

Hernia Postoperative Data
Complications?
4

Postop stay mean 11.5 days—range 2 to 60
1. One death
2. Wound infection 29%
3. Sepsis 4%
4. Dehiscence 4%

10

Hernia Postoperative Followup
1. ranges from what to what?
2. PE how often?
3. Intervention for abdominal wall?
4. When would we do a CT scan?

1. Followup ranges from 8 to 52 months

2. Monthly clinic appointments with physical examination

3. Postoperative physical therapy for abdominal wall strengthening at 6-8 weeks

4. CT scanning in cases of unclear clinical findings of recurrence

11

Management of Recurrences of hernias? 3

1. Prosthetic mesh--absorbable
2. Local flaps
3. Primary closure

12

Presence of what is a much more significant factor than the size of a hernia?

abdominal wall components

13

1. What is a major risk factor for recurrence?

2. _____ patients have significantly more problems

1. Prior procedures, especially more than one prior procedure,

2. Obese

14

Lower Extremity Soft Tissue Reconstruction
-The First Decisions?
6

1 Is this a salvageable limb?
2. Nerve loss,
3. vascular damage,
4. extensive bone or
5. soft tissue loss
6. Look at patient--associated injuries and setting of injury

15

General Guidelines: Lower Extremity Soft Tissue Reconstruction?
5

1. Two or more vessels out
2. Need for fasciotomies
3. Failed initial vascular repair
4. Insensate plantar surface--posterior tibial nerve
5. Extensive bone loss

16

Patient Variables that will affect healing? 5

1. Look at nutritional numbers--prealbumin, transferrin
2. Sugars need to be tightly controlled
3. Oxygenation, acidosis, perfusion should be optimized
4. Smokers do very poorly
5. Control of infection

17

Skin Grafts:
1. What do you need?
2. What can work but may be unstable?
3. Prepping wound bed with what can be useful?

1. Need vascularized bed

2. Paratenon, periosteum can work but may be unstable

3. Prepping wound bed with VAC can be useful

18

Skin Graft Technique:

-Prep bed well
-1.___________ for donor site
-Cover donor with 2.________then let dry out Mepilex border also OK
-3.____ thousandths for depth
-VAC makes great dressing--leave on for 4. how long?
-Then dress with 5. ______

1. Marcaine with epi

2. xeroform--

3. 16

4. 5 days

5. xeroform

19

Fasciocutaneous flaps
Advantages? 3

1. Very durable, reliable
2. No muscle donor (can have that as a backup if available)
3. Quick dissection

20

Muscle Flaps
1. Use what for proximal defects?
2. What for the middle third?
3. Distal third of lower extremity?

1. Gastrocnemius for proximal defects
2. Soleus for middle third
3. Distal third of lower extremity may require free tissue transfer

21

MOA for V.A.C.
1. Mechanical? 2
2. Vascular? 3
3. Chemical? 2
4. Infection control? 2

1. MECHANICAL
-Recruitment
-Increased Mitosis

2. VASCULAR
-Neovascularization
-Decreased Edema
-Decreased Afterload

3. CHEMICAL
-Removal of Inhibitory Factors
-Promotion of Growth Factors

4. INFECTION CONTROL
-Hostile Medium
-Increased Vascularity

22

Indications for VAC Therapy
12

1. Pressure ulcers
2. Dehisced incisions
3. Traumatic wounds
4. Meshed grafts: Expanded & 5. Non-expanded
6. Flaps
7. Arterial insufficiency ulcers
8. Venous stasis ulcers
9. Diabetic ulcers
10. Radiation ulcers
11. Burns
12. Compromised flaps

23

Precautions for VAC therapy?
4

1. Patients on anticoagulants

2. Patients with difficult hemostasis after debridement

3. Universal precautions should be observed

4. Dressing should be removed if therapy is interrupted for more than 2 hours per day

24

Free Tissue Transfer
1. Usually for what?
2. Requires what?
3. What are the typical donors?
4. Need to be sure about what?

1. Usually for large coverage problems more distally
2. Requires vascular supply--need angiogram
3. Donors typically rectus, latissimus, gracilis, lateral arm
4. Need to pretty sure the limb will be worth the cost