Jump to content
Sign in to follow this  
harris

ΧΕΙΡΟΥΡΓΙΚΑ VIDEO

Recommended Posts

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Γειά σου ρε Χάρη που θες να μας διδάξεις κιόλας! Αλήθεια εκείνες τις κατατακτήριες στην ιατρική τις έδωσες ή ακόμα;

:splats:

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

ΝΑ ΚΑΙ ΕΝΑΣ ΠΟΥ ΕΧΕΙ ΜΑΘΕΙ ΤΗΝ ΣΗΜΑΣΙΑ ΤΗΣ ΛΕΞΗΣ ΕΥΧΑΡΙΣΤΩ...

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Κ εγώ που τις έδωσα...... έπρεπε να το ξανασκεφτώ :))

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Και μην ξεχνάμε τα http://www.websurg.com (απαιτείται δωρεάν εγγραφή) για να μάθετε επιτέλους ποιοι είναι οι Leroy και Dallemagne και http://www.e-laparoscopy.com όπου μπορείτε να δείτε βίντεο με τον απίστευτο JL Dulucq να κάνει Whipple λαπαροσκοπικά...

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

ωραία πράγματα. Θενκς

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

πολύ καλό το site!Θενκς κι από εμένα, harris πάντως μη μασάς κομπλεξικούς θα συναντήσεις πολλούς αλλά αν το γουστάρεις κάντο για τί κακά τα ψέματα και παρά τις γκρίνιες, κάποιες εμπειρίες που αποκτάς ως φοιτητής ιατρικής είναι once in a lifetime.

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

ΣΕ ΚΑΘΕ ΧΕΙΡΟΥΡΓΕΙΟ ΔΕΝ ΠΡΕΠΕΙ ΝΑ ΚΛΕΙΝΟΥΜΕ ΠΕΡΙΤΟΝΑΙΟ!ΝΑ ΓΙΑΤΙ:

PERITONEAL CLOSURE

1. Introduction

Closure of the parietal peritoneum at lower abdominal surgery has long been advocated in

traditional surgical training. The reason for this is to establish normal anatomical relations, to

prevent adhesion formation between the intestines and fascia or between uterus and fascia, to

reduce the risk of infection and to reduce the risk of herniation or dehiscence.1 However, the

advantages of this technique have not been proved by prospective randomised trials.

Prior animal experiments and general surgery reports have shown that suture peritonealisation

tends to cause tissue ischaemia, necrosis, inflammation, and foreign body reactions to suture

material. These factors may slow down the healing process and are considered important

precursors for adhesion formation. Peritoneum is a mesothelial organ. In contrast to epidermal

repair, where healing occurs gradually from wound borders, peritoneum heals simultaneously

throughout the wound because mesothelial cells initiate multiple sites of repair.1 If the peritoneum

is left open, experimental studies have shown that a spontaneous reperitonealisation will appear

within 48–72 hours after injuring the peritoneum with complete healing after five to six days.2,4

2. Methodology

A review of literature was undertaken to establish the evidence for and against peritoneal closure.

Medical databases were searched for reports of published clinical trials comparing peritoneal

closure to non-closure in obstetric and gynaecological surgery (MeSH terms used were

‘peritoneum’, ‘caesarean section’, ‘hysterectomy’ and ‘laparotomy’). The trials were identified by

searching Embase (1988–2001), Medline (1966–2001), and the Cochrane Controlled Trials

Register database. All languages were included. References cited in all trials were searched

iteratively to identify any missing studies, in addition to a reference search from a review article.5

3. Peritoneal closure versus non-closure at caesarean section

3.1 Operative benefits of peritoneal non-closure at caesarean section

Non-closure of the parietal peritoneum is recommended during caesarean section because it

results in significantly shorter operating time.

Six randomised-controlled trials,6–11 involving 1615 patients undergoing caesarean

section, assessed operative complications in relation to closure or non-closure of the

parietal or parietal and visceral peritoneum. Four of these trials, involving 1194

Guideline No 15

Revised July 2002

RCOG Guideline No. 15 1 of 7

A

Evidence

level Ia

women,6–9 were included in a Cochrane systematic review.12 This review showed that

non-closure of the peritoneum during caesarean section saved operating time

(weighted mean difference of -6.1 minutes, 95% confidence interval -8.0 to -4.3).

Grundsell et al., in a randomised controlled trial involving 361 patients, also found

that operating time was significantly shorter, in the non-closure group, by 7.9

minutes (P < 0.01).10 In the study by Galaal and Krolikowski, the average duration

of operation for the peritoneal closure and non-closure groups were 61.9 minutes

(± 12.7) and 53.6 (± 11.2), respectively (P < 0.01).11

3.2 Early postoperative morbidity and peritoneal closure at caesarean section

Non-closure of the parietal peritoneum at caesarean section is recommended because it is

associated with lower postoperative febrile morbidity and postoperative use of analgesics.

Early postoperative complications assessed in studies include wound haematoma, postoperative

febrile morbidity, wound infection and postoperative pain and analgesia.

The Cochrane systematic review by Wilkinson and Enkin12 showed that there were

no statistically significant differences in postoperative morbidity, analgesic

requirements and length of hospital stay. However, there was a consistent, although

non-significant, trend for improved immediate postoperative outcome if the

peritoneum was not closed.

In a more recent randomised controlled trial,13 visual analogue scales showed no

difference in postoperative pain comparing closure and non-closure of parietal

peritoneum. However, the use of postoperative analgesia was significantly lower in

the non-closure group.

Grundsell et al.,10 in their randomised controlled trial, reported that febrile morbidity

and wound infection were significantly lower in the non-closure group (P < 0.001

and P < 0.05, respectively). In their study, hospital stay was one day less in the group

where the peritoneum was left open. These findings made them conclude that nonclosure

of the visceral and parietal peritoneum is associated with fewer postoperative

complications.

Recently, there have been a number of anecdotal reports of dehiscence of lower transverse

wounds, perhaps associated with non-closure of the parietal peritoneum. This particular

complication is infrequent and was not assessed in the above trials, but will be kept under review.

Non-closure of the visceral peritoneum at caesarean section is recommended because it is

associated with significantly shorter operating time and postoperative hospital stay, as well

as significantly lower postoperative febrile and infectious morbidity.

In a prospective trial, 549 women undergoing caesarean section were randomised to

either closure or non-closure of the visceral peritoneum.14 The mean operating time

(± SD) was significantly greater in the closed group (56.9 ± 17.9 minutes) than in the

open group (50.6 ± 16.8 minutes) (P < 0.001). Comparison of the operating times in

patients in whom caesarean section and tubal sterilisation were performed revealed

no significant difference between both groups. Postoperative hospitalisation was also

significantly longer in the closed group (7.9 ± 1.8 days) than in the open group (7.2

± 1.6 days) (P < 0.001). Both temperature ≥ 38ºC for more than two postoperative

days and the daily average temperature values during the first postoperative week

were significantly higher with closure of the peritoneum (P < 0.001).

RCOG Guideline No. 15 2 of 7

A

Evidence

level Ia

Evidence

level Ib

A

Evidence

level Ib

Evidence

level Ia

Non-closure of the peritoneum during caesarean section is recommended because it leads to

a quicker return of bowel activity.

In a retrospective study comparing closure versus non-closure of the visceral and

parietal peritoneum during caesarean section, in two groups of patients, with 50

women in each group, McNally et al.15 found that urinary tract infection,

endometritis, wound infection and respiratory infection occurred with similar

frequency. However, the return of full bowel activity occurred at a significantly later

time in the peritoneal closure group.

3.3 Peritoneal closure and adhesion formation

Peritoneal closure increases the incidence of bladder adhesions following caesarean section

and is therefore not recommended.

Buckman et al.16 showed that deperitonealised surfaces, which have not been otherwise

traumatised, heal without permanent adhesions because they retain their ability to lyse fibrinous

adhesions before organisation can occur. Peritoneum that has been made ischaemic by grafting or

tight suturing not only loses its ability to lyse fibrin, but also may actively inhibit fibrinolysis by

normal tissue.

In a retrospective analysis of the operative findings during the second lower-segment

caesarean section in a group of women who had the visceral and parietal peritoneum

closed and another group who had these left opened during their first caesarean

section, the incidence of adhesions was found to be 28% in the closed group,

compared with only 14% in the open group.15 The authors concluded that closure of

the peritoneum at lower-segment caesarean section does not appear to confer any

extra postoperative benefit and may increase morbidity because of prolonged

operative time and subsequent risk of visceral injury, in particular to the bladder, due

to adhesions.

Stark et al.17 compared non-closure with closure of the visceral and parietal

peritoneal layers. Adhesion formation was less during repeat operations in the nonclosure

than closure groups (6.3 versus 38.8%, P < 0.05), although the number of

repeat operations was not described. These findings were also confirmed more

recently by other investigators.18

The CAESARean Section Surgical Techniques (CAESAR) study19 is a 2x2x2 factorial design

randomised controlled trial evaluating three alternative caesarean section operative techniques.

One of the aspects evaluated in the trial is closure versus non-closure of the pelvic peritoneum.

The trial is currently in progress and should provide further valuable evidence regarding the

management of the peritoneum at caesarean section.

3.4 Economic benefits of peritoneal non-closure at caesarean section

Closure of the peritoneum during caesarean section is not recommended as it is not costeffective.

Cost analysis to determine possible savings with omission of peritoneal closure was

performed in two randomised trials.9,10 The first trial, which involved 248 women

and was reported in 1991, calculated that possible savings, to their unit, would

amount to US$100,286 per year. This calculation was based on cost of a single suture

used for peritoneal closure, 6800 deliveries per annum and a 15.1% caesarean

section rate. The authors took into account operating room time and anaesthesia

RCOG Guideline No. 15 3 of 7

B

Evidence

level III

B

Evidence

level III

A

Evidence

level Ib

expenses. Grundsell et al.,10 in 1998, estimated that the cost saving for each caesarean

section when the visceral and parietal peritoneum was not closed would amount to

US$330. In their calculation, the authors took into account that the hospital stay was

one day less in the non-closure group.

4. Peritoneal closure versus non-closure at hysterectomy

4.1 Peritoneal closure at abdominal hysterectomy

Visceral and/or parietal peritoneal closure at abdominal hysterectomy is not recommended

as it lengthens the surgical time and anaesthesia exposure without providing immediate

postoperative benefits.

The question of whether peritoneal non-closure alters the operative or postoperative

course at abdominal hysterectomy was addressed by two randomised clinical

trials.20,21 In the study carried out by Nagele et al.,20 211 patients were randomised to

closure or non-closure of the visceral peritoneum. Although there was no significant

difference between the two groups in the temperature curves in the first week after

surgery, the number of patients requiring antibiotics for various complications was

significantly higher in patients of the closed group (P = 0.03). The authors concluded

that non-closure of the visceral peritoneum simplifies the surgical technique and

results in a smaller number of postoperative complications.

Gupta et al.21 randomised 144 women, who underwent abdominal hysterectomy

with or without salpingo-oophorectomy, to two groups, depending on whether the

visceral and parietal peritoneum was closed or left open. The mean operative

time was ten minutes shorter (P < 0.001) and there was a 45 ml reduction in the

estimated blood loss in the non-closure group (P = 0.03). In their study, there were

no differences in postoperative pain in the two groups.

4.2. Peritoneal closure at vaginal hysterectomy

Peritoneal closure during vaginal hysterectomy is not recommended.

The clinical outcomes of 106 patients who underwent vaginal hysterectomy with or

without peritoneal closure were assessed in a randomised controlled trial.22

Postoperative complications were similar in both groups. The incidence of deepthrust

dyspareunia at 6 and 12 months was also similar. In this study, there was no

statistical difference between the two groups in the ovary-to-vaginal-cuff distances

either overall or when patients with dyspareunia were considered separately. The

authors concluded that the data from the study do not support routine closure of the

peritoneum during vaginal hysterectomy. However, because of the small sample size

and the lack of statistical power, the conclusion was considered to be a grade B

recommendation, despite the study being a randomised controlled trial.

5. Peritoneal closure at radical abdominal surgery for gynaecological cancers

Closure of the peritoneum at radical abdominal hysterectomy and node dissection is not

recommended.

Effects of peritoneal non-closure during radical surgery for gynaecological cancers

were assessed in randomised controlled trials. Kadanali et al.23 and Than et al.24

assessed this in ovarian cancer surgery and cervical cancer surgery, respectively. They

found improved outcomes (reduced adhesions and reduced fever) where the visceral

RCOG Guideline No. 15 4 of 7

A

Evidence

level Ib

B

Evidence

level Ib

A

Evidence

level Ib

Evidence

level Ib

peritoneum was left to heal on its own. In a randomised controlled study of 120

patients, Franchi and associates25 found that the amount of drainage was significantly

higher in the closed group (median of 740 ml versus 340 ml; P < 0.005). There was

no difference between the two groups in the incidence of symptomatic or

asymptomatic lymphocysts, wound and pelvic infection, febrile morbidity and

obstruction.

Closure of the peritoneum after pelvic lymphadenectomy is not recommended, as it may

increase the incidence of lymphocysts.

The incidence of lymphocysts following pelvic lymphadenectomies in women who

had peritoneal closure and those who did not were compared in two retrospective

studies.26–27 The first study analysed 226 iliac lymphadenectomies.26 The incidence of

lymphocysts in the peritoneal closure versus the non-closure group was 35.9% versus

17.4%, respectively. The other study analysed 157 patients who had external iliac

lymphadenectomy with either closure or non-closure of the visceral peritoneum.27

Lymphoceles occurred in 23.1% of the cases in the peritonealisation group compared

to 6.1% in the non-peritonealisation group.

It is essential that operative details are clearly documented, including the time of onset of

the procedure, details of any adhesions or operative difficulties, operative technique and

suture materials used.

References

1. Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet Gynecol Surv

1994;49:817–22.

2. Elkins TE, Stovall TG, Warren J, Ling FW, Meyer NL. A histologic evaluation of peritoneal

injury and repair: implications for adhesion formation. Obstet Gynecol 1987;70:225–8.

3. McDonald MN, Elkins TE, Wortham GF, Stovall TG, Ling FW, McNeeley SG. Adhesion

formation and prevention after peritoneal injury and repair in the rabbit. J Reprod Med

1988;33:436–9.

4. Hubbard TB, Khan MZ, Carag VR, Albites VE, Hricko GM. The pathology of peritoneal

repair: its relation to the formation of adhesions. Ann Surg 1967;165:908–16.

5. Hema KR, Johanson R. Techniques for performing caesarean section. Best Practice &

Research in Clinical Obstetrics & Gynaecology 2001;15:17–47.

6. Hull D, Varner M. A randomized study of closure of the peritoneum at Cesarean delivery.

Obstet Gynecol 1991;77:818–21.

7. Irion O, Luzuy F, Beguin F. Non-closure of the visceral and parietal peritoneum at caesarean

section: a randomised controlled trial. Br J Obstet Gynaecol 1996;103:690–4.

8. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or non-closure

of the visceral peritoneum at caesarean delivery. Am J Obstet Gynecol 1996;174:1366–70.

9. Pietrantoni M, Parsons MT, O’Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal

closure or non-closure at cesarean. Obstet Gynecol 1991;77:293–6.

10. Grundsell HS, Rizk DEE, Kumar RM. Randomized study of non-closure of peritoneum in

lower segment cesarean section. Acta Obstet Gynecol Scand 1998;77:110–15.

11. Galaal KA, Krolikowski A. A randomized controlled study of peritoneal closure at cesarean

section. Saudi Med J 2000;21:759–61.

12. Wilkinson CS, Enkin MW. Peritoneal non-closure at caesarean section. Cochrane Database

Syst Rev 2001;(3).

13. Hojberg KE, Aagaard J, Laursen H, Diab L, Secher NJ. Closure versus non-closure of

peritoneum at cesarean section – evaluation of pain. Acta Obstet Gynecol Scand

1998;77:741–5.

14. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or nonclosure

of the visceral peritoneum at caesarean delivery. Am J Obstet Gynecol 1996;174:1366–70.

RCOG Guideline No. 15 5 of 7

B

Evidence

level III

Evidence

level Ib

15. McNally OM, Curtain AC. Does closure of the peritoneum during caesarean section

influence postoperative morbidity and subsequent bladder adhesion formation? J Obstet

Gynaecol 1997;17:239–41.

16. Buckman RF Jr, Buckman PD, Hufnagel HV, Gervin AS. A physiological basis for the

adhesion-free healing of deperitonealized surfaces. J Surg Res 1976;21:67–76.

17. Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of combinations of

procedures in cesarean section. Int J Obstet Gynecol 1995;48:273–6.

18. Joura EA, Nather A, Husslein P. Non-closure of peritoneum and adhesions: the repeat

cesarean section. Acta Obstet Gynecol Scand 2001;80:286.

19. The CAESAR Study [www.npeu.ox.ac.uk/trials/Caesar.html].

20. Nagele F, Kurz C, Staudach A, Steiner H, Grünberger W, Beck A, et al. Closure or

nonclosure of the visceral peritoneum in abdominal hysterectomy. J Gynecol Surg

1995;11:133–9.

21. Gupta JK, Dinas K, Khan KS. To peritonealize or not to peritonealize? A randomised trial

at abdominal hysterectomy. Am J Obstet Gynecol 1998;178:796–800.

22. Lipscomb GH, Ling FW, Stovall TG, Summitt RL. Peritoneal closure at vaginal

hysterectomy: a reassessment. Obstet Gynecol 1996;87:40–3.

23. Kadanali S, Erten O, Kucukozkan T. Pelvic and periaortic peritoneal closure or non-closure

at lymphadenectomy in ovarian cancer: effects on morbidity and adhesion formation. Eur J

Surg Oncol 1996;22:282–5.

24. Than GN, Arany AA, Schunk E, Vizer M, Krommer KF. Closure or non-closure of visceral

peritoneums after abdominal hysterectomies and Wertheim-Meigs radical abdominal

hysterectomies. Acta Chir Hung 1994;34:79–86.

25. Franchi M, Ghezzi F, Zanaboni F, Scarabelli C, Beretta P, Donadello N. Nonclosure of the

peritoneum at radical abdominal hysterectomy and pelvic node dissection: A randomised

study. Obstet Gynecol 1997;90:622–7.

26. Pennehouat G, Mosseri V, Durand JC, Hamelin JP, Asselain B, Pilleron JP, et al.

Lymphoceles et peritonisation après lymphadenectomies pour cancers de l’uterus. J Gynecol

Obstet Biol Reprod 1988;17:373–8.

27. Thome Saint Paul M, Bremond A, Rochet Y. Absence de peritonisation après la chirurgie

pelvienne carcinologique. J Gynecol Obstet Biol Reprod 1991;20:957–60

RCOG Guideline No. 15 6 of 7

APPENDIX

Clinical guidelines are: ‘systematically developed statements which assist clinicians and patients in

making decisions about appropriate treatment for specific conditions’. Each guideline is

systematically developed using a standardised methodology. Exact details of this process can be

found in Clinical Governance Advice No 1: Guidance for the Development of RCOG Green-top

Guidelines (available on the RCOG website http://www.rcog.org.uk/medical/greentopguide.html).

These recommendations are not intended to dictate an exclusive course of management or

treatment. They must be evaluated with reference to individual patient needs, resources and

limitations unique to the institution and variations in local populations. It is hoped that this

process of local ownership will help to incorporate these guidelines into routine practice. Attention

is drawn to areas of clinical uncertainty where further research may be indicated.

The evidence used in this guideline was graded using the scheme below and the recommendations

formulated in a similar fashion with a standardised grading scheme.

Classification of evidence levels

Ia Evidence obtained from meta-analysis of randomised controlled trials.

Ib Evidence obtained from at least one randomised controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomisation.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.

III Evidence obtained from well-designed non-experimental descriptive studies, such as

comparative studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/or clinical experience

of respected authorities.

Grades of recommendations

Requires at least one randomised controlled trial as part of a body of literature of overall

good quality and consistency addressing the specific recommendation. (Evidence levels Ia, Ib)

Requires the availability of well-controlled clinical studies but no randomised clinical trials

on the topic of recommendations. (Evidence levels IIa, IIb, III)

Requires evidence obtained from expert committee reports or opinions and/or clinical

experiences of respected authorities. Indicates an absence of directly applicable clinical

studies of good quality. (Evidence level IV)

Good practice point

Recommended best practice based on the clinical experience of the guideline development

group.

GUIDELINE OF THE ROYAL COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS.

ΕΧΕΙ ΝΟΜΙΚΗ ΑΞΙΑ!

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Είσαι θεός! Thanksssssssssss

Μοιράσου αυτή τη δημοσίευση


Σύνδεσμος στη δημοσίευση
Μοιράσου σε άλλους δικτυακούς τόπους

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Επισκέπτης
Απάντησε σε αυτό το θέμα...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Sign in to follow this  

×
×
  • Δημιουργία νέας...