Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIX: Wounds of the Abdomen

Postoperative Care

United States Department of Defense

Wound Closure

Reliability of the abdominal wound closure is of major importance. Patients are frequently moved in the early postoperative period. Generally speaking, a secure closure requires the use of a strong monofilament nonabsorbable suture which incorporates large "bites" of fascia. The closure may be interrupted or "running," but the latter is much more expeditious. Full-thickness retention sutures over bolsters are required in difficult closures and in most reoperative, complicated abdomens. When placed, they should be 2-3 cm apart and 3-4 cm from the edges of the wound. These sutures are usually left in place for three weeks. They may or may not be used in conjunction with a separate fascial closure. The skin and subcutaneous tissue in contaminated abdominal wounds should not be closed primarily. Delayed primary closure can be done in 4-5 days.

Stomas

Intestinal stomas require some care in the site selection. Anatomy and abdominal wall injuries will influence this choice. The future fitting of an appliance must be considered. Vascularity of the stoma must be preserved, since failure will require another laparotomy. The Brooke type of "turn-back" ileostomy stomas with 1.5-2 cm of elevation is preferred for stoma fitting and nursing management.

Colostomies for rectal injuries should always be a "diverting" type of end colostomy with a separate muscus fistula. The stomas may be flush, They should be matured at the primary operation by sewing the ends of the colon circumferentially to the skin. Loop colostomies are seldom needed in combat casualties, but they are simpler to construct and need not be opened for several days postoperatively. All stomas should have an adequate opening in the abdominal wall at all levels. They should be fixed to the fascia by several interrupted sutures superficially in the wall of the intestine or colon. A patient with a stoma should remain under the observation of the same surgeon to ensure the viability and satisfactory performance of the stoma. This also allows the surgeon the opportunity to explain to the patient the necessity for the procedure, the stoma's function, its care, and when the patient can expect the stoma to be closed.

Ileus

Postoperatively, the bowel undergoes a normal period of motor, but not secretory, inertia. This causes abdominal distention. The distention can be minimized by the use of nasogastric suction. Some patients may have a prolonged ileus. This may be due to contamination, bowel manipulation at operation, too rapid a resumption of feeding, an anastomotic leak, a missed injury, or intra-abdominal infection. Systemic nonabdominal sepsis and spinal cord injuries can also cause ileus. Treatment consists of nasogastric suction and parenteral fluid, and electrolyte and nutritional support. A search for the specific cause of the ileus should be ongoing, particularly if other findings are present.

Records

Accurate and complete documentation is essential; it need not be wordy. Legible handwritten operation notes and hospital summaries performed by the surgeons should be concise and cover the important points. Important points include the indications for operation, the findings, what was done, what was not done, technical points if they represent a deviation from the usual or if likely to be relevant in the future care of the patient, how the patient did postoperatively, and what the management plan would be if the physician were to continue caring for him. Liberal use of sketches and diagrams are of value.

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Operational Medicine 2001

Health Care in Military Settings

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