tailieunhanh - Improved Outcomes in Colon and Rectal Surgery part 38

Improved Outcomes in Colon and Rectal Surgery part 38. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | improved outcomes in colon and rectal surgery Figure Mercedes or triangular closure. A. Stoma site with fascia closed B. Initial approximation of skin and subcutaneous fat C. Completed closure with small area in center left open for drainage and secondary healing. stenosis or hernia. Experienced plastic surgeons can carefully use liposuction techniques to remove subcutaneous fat around the stoma. Obviously care must be taken to not injure the stoma during the procedure and to leave a flat smooth peristomal skin surface for the ostomy faceplate. Once the fatty tissue is removed it will not be redeposited despite additional weight gain. Ostomy Reversal Reversal of temporary stomas should be undertaken as soon as physiologically feasible to reestablish gastrointestinal continuity and for psychological improvement. This of course implies that the purposes of the stoma placement has been met and the patient is capable and a candidate for another operative procedure. There are two main operative approaches to ostomy reversal local or via a laparotomy. While both approaches are associated with inadvertent enterotomies bleeding wound infections and anastomotic complications the biggest advantages of the laparotomy approach is improved exposure and the ability to reexplore the abdomen. Certainly the type of ostomy is important to consider when planning the operative approach as loop ileostomies are technically the least challenging to reverse and often amenable to local reversal. Although a local approach is preferred patients with a prior Hartmann s procedure or those in which the distal remnant is not available via a local approach are obviously forced to undergo a repeat laparotomy. Surprisingly there is a paucity of recent data that highlights the potential perils of this seemingly benign operation. The most recent study published in 2005 was a retrospective review of 533 patients undergoing stoma closure at the University Hospital ofVienna. 70 The majority of the