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ABDOMINAL

WOUND
MANAGEMENT
(Menejemen Penutupan Luka Operasi
Abdomen disertai Penyulit yang Komplex)

Basrul Hanafi
Departemen Ilmu Bedah FK
Unpad /
RS Hasan Sadikin
Bandung
Source : Basrul Hanafi, Asia Pacific Wound Healing
Society, 2013

Bandung Adventist
Hospital Wound

Center Team

Severe Abdominal
Wound Complications
High incidence of :
I. Abdominal Wound Sepsis
II. Fascitis Necroticans
III. Burst Abdomen
IV. Opened Abdomen
Management

Space SSI
Consultation of SBCH HS, Male, 50 yo, day 5 after
Distal Gastrectomy

Source : Basrul Hanafi, Asia Pacific Wound Healing


Society, 2013

Cross-section of abdomen depicting


Classification of surgical site
infection (SSI)

Source : WHO Guideline for Safe


Surgery 2009

Case I : Deep
abdominal surgical
infection (Deep SSI)
Male 45 Year, consultation of home

surgeon (RS Santosa Bandung), day 5 after


Celiotomy due to Acute Appendicitis with
Perforation.
After all stitch was taken out, the fascia in
the base of wound was necrotic
debridement of necrotic fascia
Wound treated 2 days with Alginate +Ag,
applied secondary dressing ; Hydrocolloid
and Polyurethane Foam R/
R/ Suprasorb : A, G, X + PHMB, H and
5 days using
only alginate
P , M healthy

After all skin stitch was


taken out, opened
wound treatment

In Vitro Study : Bacterial


reduction after using Alginate
+ Ag

Day 7 : debridement of necrotic


fascia

Day 10 : Healthy granulation


tissue

Day 14 : Using Native Collagen R/


Secundair Suture but 3 month later
; Ventral Hernia Repair

Case II : Burst Abdomen


Consultation from home surgeon

(SBCH): Male, 60 Years ; Day 5


Surgery of General peritonitis due to
leak of Ileo-colon anastomosis +
Severe sepsis + EGDT
Second Laparatomy was done : Total
Colectomy and Ileostomy.
During surgery the patient has had
Septic Shock EGDT in ICU
suffered 6 organ dysfunction, but the

Days 5 : Wound was opened


due to Deep Abdominal wound
SSI burst

Days 7 Burst Abdomen


and
Compartment
Syndrome
Laparotomy on demand
Using TACD (Temporary Abdominal

Closing Device ) of Prolene Mesh.


Using Modern Wound Dressing R/
After 7 days : Compartment Syndrome
was negative Prolene mesh was taken
out
Abdominal fascia was closed, skin
interrupted
Suprasorb : A, G, X + PHMB, H and
6 months R/
: Ileostomy was
P , Mclosed

Abdominal incision and


ileostomy

bag vs Bogota bag or


others bag
1. Good material ; Polypropylene with
zipper
2. Better ; Composite Mesh
3. Best material ; Whitman Mesh with
zipper
All of ; 1, 2, 3 material are not
available in Indonesia
Good alternative for TACD using
Bogota bag (blood transfusion bag)

Source : Stuart Chow ; Grand


Medical Center

Cost Comparison of
TACD

Sorce : Stuart Chow ; Grand Medical


Center

Bogota bag ; saline or


blood bag

Source : Stuart Chow ; Grand


Medical Center

Source : Stuart Chow ; Grand


Medical Center

VAC THERAPY
VAC Kinetic TEXAS

VAC Daewoong

Vacuum Assisted
Abdominal Wound
Treatment
Basrul Hanafi
Digestive Surgery Division of Medical
Faculty Padjadjaran University,
Hasan Sadikin Hospital, Bandung

Case III : Opened


Abdomen, using Vacuumassisted closure device
F, 29 yo, Burst abdomen post sc Deep

SSI. + Abdominal Compartment Syndrome


Using TACD (Temporary Abdominal Closure
Device) Urinal bag (modified Bogota bag)
by OBGN Consultant
Day 10 : Referred to Digestive Surgery
Consultant after growing a thick
granulation fibrous tissue Skin graft
Using Vaccum Assisted Closure (VAC)
day 20 healthy granulation tissue Spit
Skin graf

Modified VAC (Bandung)

F, 29 yo
0929
Burst
abdomen1001
post sc
(D+0)

(D+3)

1005
(D+7)

1009
(D+11)

1018 (D+20)
OP STSG

1022 (D+4
II)

VAC on ACS (Abd


Comp Synd)

Post-injury day (PID) 1, after massive


volume resuscitation and correction of
coagulopathy. Extensive visceral edema
is noted with inability to close abdomen

Abdominal Compartment Syndrome and Management of the Open


Abdomen ; Joseph F. Sucher , TRAUMA A ND EMERGENCY CARE

Cost Effective of TACD


& VAC

Guidelines for the Management of the Open Abdomen


Mark Kaplan, MD, FACS, S U P P L E M E N T T O WO U N D S ;O C T O B

Treatment of open
abdomen in patients
with abdominal sepsis
using the vacuum pack
system
Leobaldo Lpez et al
2010;78:317-321

Cir Cir

The choice for TACD should be a matter of


clinical circumstances and the institutional
preference, as well as that of the individual
surgeon

Placing the first


multiperforated polyethylene
sheet

Leobaldo Lpez et al
Cir Cir
2010;78:317-321

below the parietal


peritoneum

Leobaldo Lpez et al
Cir Cir
2010;78:317-321

catheters to the first


dressing

Leobaldo Lpez et al
Cir Cir
2010;78:317-321

compress over suction


catheters

Leobaldo Lpez et al
Cir Cir
2010;78:317-321

sheet placed with the


system under
negative pressure

Leobaldo Lpez et al
Cir Cir
2010;78:317-321

Take Home Messages


New concept of management of
wound treatment should be practised
Contaminated or dirty wound are
always accompanied with mild to
moderate SSI, and may be fatal
Early prevention may avoid unwanted
complication of necrotizing fascitis or
burst abdomen
Management of Opened Abdomen
should be trained on IKABDI
Abdominal Wound care Workshop

Hopefully it will be benefit for :


Patients, Hospitals & All of Us

Thank You