Plastics 2

Question 1

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

2. Complication?

Answer 1

1. Presence or absence of components is more significant than size
2. Damage to abdominal wall components compromises future repair efforts

Question 2

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

Answer 2

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

Question 3

Comorbid Conditions

for difficult hernia? 4

Answer 3

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

Question 4

Complaints

for difficult hernia? 5

Answer 4

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

Question 5

Preoperative Evaluation

3

Answer 5

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

Question 6

General Surgery Consultation

includes? 3

Answer 6

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

Question 7

Hernia Closure Strategy 4

Additonal manuevers? 2

Answer 7

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

Question 8

Repair Techniques for hernia?

1. Most common?
2. Other options? 4

Answer 8

1. Components separation (89%)
2. • Rectus release 73%
   • External oblique release 73%
   • Both external and internal 58%
   • Mesh augmentation (13%)

Question 9

Hernia Postoperative Data
Complications?
4

Answer 9

Postop stay mean 11.5 days—range 2 to 60

1. One death
2. Wound infection 29%
3. Sepsis 4%
4. Dehiscence 4%

Question 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?

Answer 10

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

Question 11

Management of Recurrences of hernias? 3

Answer 11

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

Question 12

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

Answer 12

abdominal wall components

Question 13

1. What is a major risk factor for recurrence?

2. _____ patients have significantly more problems

Answer 13

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

Question 14

Lower Extremity Soft Tissue Reconstruction
-The First Decisions?
6

Answer 14

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

Question 15

General Guidelines: Lower Extremity Soft Tissue Reconstruction?
5

Answer 15

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

Question 16

Patient Variables that will affect healing? 5

Answer 16

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

Question 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?

Answer 17

1. Need vascularized bed
2. Paratenon, periosteum can work but may be unstable
3. Prepping wound bed with VAC can be useful

Question 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. ______

Answer 18

1. Marcaine with epi
2. xeroform–
3. 16
4. 5 days
5. xeroform

Question 19

Fasciocutaneous flaps

Advantages? 3

Answer 19

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

Question 20

Muscle Flaps

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

Answer 20

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

Question 21

MOA for V.A.C.

1. Mechanical? 2
2. Vascular? 3
3. Chemical? 2
4. Infection control? 2

Answer 21

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

Question 22

Indications for VAC Therapy

12

Answer 22

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

Question 23

Precautions for VAC therapy?

4

Answer 23

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

Question 24

Free Tissue Transfer

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

Answer 24

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