Plicatura de la bolsa Bogotá en cierre difícil de la pared abdominal / Bogotá Pouch Plication in Difficult Closure of the Abdominal Wall

Introducción: El cierre con pérdida masiva de tejido de la pared abdominal constituye un reto en la cirugía. Objetivo: Presentar un caso de cierre abdominal difícil donde se utilizó la técnica plicatura de la bolsa Bogotá hasta lograr aproximación de los planos cutáneo, muscular y aponeurótico. Caso clínico: Paciente recibido en emergencias con herida perforo-cortante en fosa lumbar izquierda. En la intervención se encontró hemoperitoneo por lesión esplénica, diafragmática y sección del ángulo esplénico del colon. Se le realizó esplenectomía, pleurostomía izquierda y rafia de lesión colónica. Pasadas cinco horas se reintervino por signos de choque y se encontró hematoma retroperitoneal y sección completa del polo superior del riñón izquierdo. Se le realizó nefrectomía izquierda. Al quinto día del posoperatorio mostró signos peritoneales y la exploración confirmó peritonitis fecaloidea por dehiscencia de sutura de colon. Se lavó cavidad y se le ejecutó colostomía tipo Devine. La pérdida masiva de pared abdominal obligó a emplear una plicatura de la bolsa Bogotá para aproximar ambos colgajos, se obtuvo aproximación paulatina hasta la síntesis de la pared. Conclusiones: El abdomen catastrófico es una condición grave y de difícil tratamiento. La bolsa Bogotá es una alternativa viable para esta condición y modificada con plicaturas paulatinas permite el acercamiento de los dos colgajos cutáneos y garantiza el cierre de la pared abdominal, además de ser una técnica fácil de usar y económica(AU)

Introduction: Closure with massive loss of abdominal wall tissue is a challenge in surgery. Objective: To report a case of difficult abdominal closure where the Bogotá bag technique was used until the approximation of the cutaneous, muscular and aponeurotic planes was achieved. Clinical case report: This patient was received in the emergency room with a perforating-cutting wound in the left lumbar fossa. In the intervention, hemoperitoneum was found due to splenic and diaphragmatic injury and section of the splenic flexure of the colon. Splenectomy, left pleurostomy and colonic injury raffia were performed. After five hours, the patient was operated again due to signs of shock. We found a retroperitoneal hematoma and a complete section of the upper pole of the left kidney. It was decided to perform left nephrectomy. On the fifth postoperative day, this patient showed peritoneal signs and examination confirmed fecal peritonitis due to dehiscence of the colon suture. Cavity was washed and a Devine-type colostomy was performed. The massive loss of the abdominal wall made it necessary to use a plication of the Bogotá bag to approximate both flaps, a gradual approximation was obtained until the synthesis of the wall. Conclusions: The catastrophic abdomen is a serious condition that is difficult to treat. The Bogotá bag is a viable alternative for this condition and modified with gradual plications, it allows the two skin flaps to approach each other and guarantees the closure of the abdominal wall, in addition to being an easy-to-use and economical technique(AU)

Terapia asistida con vacío y estoma flotante (floating stoma): una nueva forma de tratar un absceso periostomal / Vacuum assisted therapy and floating stoma: S new way to treat a periostomal abscess

Resumen Introducción: Los estomas flotantes se definen como un estoma que no está fijado a la piel de la pared abdominal, esta técnica se ha descrito en cirugía para fístulas entero-atmosféricas y de control de daños. Caso Clínico: Presentamos un reporte de caso de manejo de absceso paraostomal en paciente con antecedente de laparotomía por abdomen agudo, por lo que se decide uso de terapia de presión negativa asociada a estoma flotante, demostrando su utilidad en este tipo complejo de pacientes.

Introduction: Floating stomata are defined as a stoma that is not attached to the skin of the abdominal wall, this technique is described in surgery for entero-atmospheric fistulas and damage control. Clinical Case: We present a case report of the management of paraostomal abscess in a patient with a history of laparotomy due to acute abdomen, it was decided to use negative pressure therapy associated with a floating stoma, demonstrating its usefulness in this complex type of patient.

Intra-abdominal hypertension secondary to chronic diaphragmatic rupture in a dog / Hipertensão intra-abdominal secundária à ruptura diafragmática crônica em um cão

ABSTRACT: Intra-abdominal hypertension (IAH) is the persistent increase of intra-abdominal pressure (IAP) that could be caused by several pathologies. It is capable of promoting organ dysfunction, thereby increasing the mortality rate of human patients. As for cats and dogs, there are still few reports on how this pressure can be monitored and treated as a routine for admitted and hospitalized animals and on its relationship with the mortality of the patients. Therefore, the objective of this paper was to report a case of IAH secondary to chronic diaphragmatic rupture in a dog, which was treated with a temporary abdominal closure (TAC). A bitch was admitted to the veterinary hospital to undergo an elective ovariohysterectomy when it was diagnosed with a diaphragmatic rupture and displacement of the liver and intestinal loops in the chest. After repositioning these structures in the abdominal cavity, tension was observed in the abdomen. A temporary abdominal closure was then performed with a Bogota bag. Immediately after the surgery, the IAP was measured, presenting a value of 15 mmHg, indicating that there was an increase in intra-abdominal pressure. The animal was hospitalized, and IAP was monitored. After 24 hours, IAP was 5.8 mmHg when the Bogota bag was removed, and definitive celiorraphy was performed. The patient showed satisfactory clinical progress and was discharged 72 hours after the surgical procedure. The treatment used for IAH proved to be effective and contributed to the quick and satisfactory recovery of the patient.

RESUMO: A hipertensão intra-abdominal (HIA) é o aumento persistente da pressão intra-abdominal (PIA), podendo ser causada por diversas afecções e caraterizada por promover disfunções orgânicas, aumentando a taxa de mortalidade no homem. Em cães e gatos, ainda há poucos relatos da monitoração dessa pressão e do seu tratamento na rotina dos animais admitidos e internados, e sua relação com a mortalidade dos pacientes. Assim, objetivou-se relatar um caso de HIA secundária à ruptura diafragmática crônica em cão, a qual foi tratada com o fechamento abdominal temporário (FAT). Uma cadela foi admitida no hospital veterinário para realização de uma cirurgia de ovário-histerectomia eletiva, quando foi diagnosticada com ruptura diafragmática com fígado e alças intestinais deslocadas para o interior do tórax. Após reposicionamento dessas estruturas na cavidade abdominal, observou-se tensão no abdômen. Realizou-se então o fechamento abdominal temporário com bolsa de Bogotá. Imediatamente após o término da cirurgia, a PIA foi aferida e seu valor era de 15 mmHg, indicando aumento da mesma. O animal foi mantido internado e sua PIA monitorada. Após 24 horas seu valor era de 5,8 mmHg, quando a bolsa de Bogotá foi removida e realizada a celiorrafia definitiva. O paciente teve evolução clínica satisfatória e 72h após a cirurgia recebeu alta hospitalar. O tratamento utilizado para a HIA se mostrou eficaz, contribuindo para a rápida e satisfatória recuperação da paciente.

Fístula de alto gasto / High output fistula

Se presenta a un paciente de 37 años de edad que acude a nuestro Cuerpo de Guardia politraumatizado, con lesiones torácicas y abdominales, con síntomas y signos sugestivos de fracturas costales múltiples, con hemotórax derecho y hemoperitoneo, corroborado imaginológicamente y en la punción abdominal. Se realiza pleurostomía mínima intermedia y laparotomía exploratoria. Se le encuentran lesiones hepáticas de los segmentos VI, V, VIII y IV, con una profundidad mayor de 3 cm, además, deserosamientos en las asas delgadas intestinales y colon. Se realiza hepatorrafia y empaquetamiento hepático. Posteriormente van apareciendo complicaciones, por lo que tiene que ser reintervenido en máqs de 60 ocasiones. Entre ellas, la aparición de una fístula de alto gasto, que lo llevó a la desnutrición y a la permanencia con el abdomen expuesto durante 7 meses hasta el egreso. Se revisa la literatura correspondiente a estas entidades(AU)

A 37 years-old multi-traumatized male patient went to our emergency service. He had many injures in the thorax and the abdomen, together with symptoms and signs suggestive of multiple costal fractures, with right hemothorax and hemoperitoneum, all of which was confirmed by imaging techniques and by abdominal puncture. Minimal intermediate pleurostomy and exploratory laparoscopy were performed. We found hepatic lesions in the 6th, 5th, 8th and 4th segments, over 3 cm deep; additionally, the loss of serosa from the intestinal ansae and from the colon. Hepatorrhaphy and hepatic packing were also performed. Later on, more complications appeared, so he had to be re-operated more than 60 times. The occurrence of a high output fistula led him to malnutrition and his abdomen remained exposed for 7 months until he was finally discharged from hospital. This paper also presented a literature review on this topic(AU)

Bolsa de Bogotá resistente en abdomen abierto / Bogota bag, resistant in open abdomen

Objetivo: Presentar una modificación a la colocación de la bolsa de Bogotá, que además de mantener las útiles características de esta técnica, adiciona más fuerza de sostén o resistencia a la capa de polivinilo en los pacientes con abdomen abierto. Sede: Hospital de segundo nivel de atención. Hospital General de Zona 53 Instituto Mexicano del Seguro Social. Diseño: Estudio piloto. Análisis estadístico: Porcentaje como medida de resumen para variables cualitativas. Pacientes y métodos: En el periodo de diciembre 2008 a marzo 2010 se trataron seis pacientes con esta técnica modificada de la bolsa de Bogotá. Edades comprendidas de 40 a 78 años, tres hombres, cinco pacientes con sepsis abdominal y el restante con pérdida de pared abdominal. Se incluyeron pacientes en quienes hubiera indicación de abdomen abierto y consecuente posibilidad de reintervención. Con nuestra técnica se buscó movilización y deambulación temprana de los pacientes y una forma segura de soporte del contenido abdominal, sin el uso de vendaje abdominal compresivo necesario para evitar evisceración, como suele pasar en la colocación de la bolsa de Bogotá tradicional, además el prevenir evisceración en un caso con apoyo ventilatorio. Resultados: En cinco pacientes se tuvo antecedente de 1 ó 2 cirugías previas. Sólo en un paciente se aplicó esta modificación en la primera cirugía. Hubo una muerte no relacionada al procedimiento debido a insuficiencia hepática. Este caso tuvo apoyo ventilatorio, soportado por la bolsa de Bogotá modificada sin evisceración. En los cinco pacientes restantes esta modificación permitió la movilización y deambulación temprana sin requerir vendaje abdominal. No se reintervino a ningún paciente, y el cierre de pared se realizó como hernia ventral planeada. El 100% de los pacientes toleraron la movilización temprana y/o uso de apoyo ventilatorio sin evisceración. Conclusiones: Esta modificación logra mayor funcionalidad de la bolsa de Bogotá, destacando la mayor resistencia y, en consecuencia, la movilización y deambulación temprana y sin riesgo de evisceración.

Empleo de la presión negativa en el tratamiento de heridas complicadas: Reporte de seis casos / Use of negative pressure for the treatment of complicated wounds: Report of six cases

Objetivo: Conocer la utilidad de un sistema de terapia basado en presión negativa tópica, aplicado en la herida quirúrgica complicada. Sede: Servicio de Cirugía General, hospital de tercer nivel de atención. Diseño: Estudio piloto, prospectivo, longitudinal y descriptivo. Análisis estadístico: Medidas de tendencia central. Pacientes y métodos: Se presentan seis pacientes postoperados, con herida quirúrgica abierta, complicada. Todos con infección demostrada por cultivo y con salida de material purulento, tres pacientes con abdomen abierto por sepsis abdominal, uno con lesión torácica postraumática, uno con muñón de amputación supracondílea infectado y el último paciente con herida quirúrgica complicada posterior a dermolipectomía; todos ellos con tratamientos previos sobre la herida quirúrgica antes de aplicar la presión negativa. Se incluyeron pacientes consecutivos que presentaban: herida complicada, infectada, con estancia hospitalaria prolongada, quienes no presentaban progreso con el tratamiento médico tradicional. Resultados: El tiempo de aplicación de la presión negativa para los seis pacientes estuvo entre 6 y 26 días, con evolución satisfactoria, obteniéndose la mejoría deseada de la herida quirúrgica y de la cavidad abdominal. En los tres pacientes con abdomen abierto y tratamiento previo con bolsa de Bogotá, se pudo cerrar la cavidad abdominal entre los 14 y los 26 días posteriores al tratamiento con presión negativa; en los otros tres pacientes, con lesiones más superficiales, el cierre de la herida se logró entre el sexto y el décimo cuarto día. En todos hubo seguimiento mayor a cinco meses, conservándose la herida cerrada, sin alteraciones. Conclusión: La terapia de presión negativa fue útil en el tratamiento de pacientes con heridas quirúrgicas complicadas y/o en el tratamiento de pacientes con abdomen abierto en sustitución de la bolsa de Bogotá. Del 100% de días de estancia hospitalaria, el 30% fue con terapia basado en presión negativa tópica.

Objective: To know the usefulness of a therapy system based on negative pressure topically applied on a complicated surgical wound. Setting: General Surgery Service, third level health care hospital. Design: Pilot study, prospective, longitudinal and descriptive. Statistical analysis: Central tendency measures. Patients and methods: We present six post-operated patients with open complicated surgical wounds. All with infection demonstrated by culture and output of purulent material: three patients with open abdomen due to abdominal sepsis, one with post-traumatic thoracic injury, one with an supracondyle infected stump, and the last with complicated surgical wound due to dermolipectomy, all of them with treatments of the surgical wound before applying negative pressure. We included consecutive patients coursing with complicated infected wounds, prolonged in-hospital stay, and who did not improve with traditional medical treatment. Results: The time of negative pressure application for the six patients ranged from 6 to 26 days, with satisfactory evolution, obtaining the expected improvement of the surgical wound and the abdominal cavity. In the three patients with open abdomen and previous treatment with Bogota pouch, the abdominal cavity could be closed between 14 and 26 days of negative pressure treatment; in the other three patients with more superficial wounds, closure of the wound was achieved between the 6th and 14th day. All patients were followed for more than 5 months, the wound remained closed and without any alterations. Conclusion: Negative pressure therapy was useful in the treatment of patients with complicated surgical wounds and/or treatment of open abdomen substituting the Bogota pouch. Of the 100% of in-hospital stay days, 30% corresponded to topically applied negative pressure therapy.

Fechamento de laparostomia com descolamento cutâneo-adiposo: uma técnica simples e eficaz para um problema complexo / Skin-adipose tissue detachment for laparostomy closure: a simple and effective technique for a complex problem

OBJETIVO: Descrever uma técnica de fechamento de laparostomia através de descolamento cutâneo-adiposo e os resultados obtidos. MÉTODOS: Entre janeiro de 2003 a outubro de 2008 quarenta pacientes laparostomizados com silo plástico (bolsa de Bogotá) foram fechados usando-se a técnica descrita neste trabalho. Dados foram coletados dos prontuários e da busca ativa após alta hospitalar. RESULTADOS: A maioria dos pacientes eram homens (95 por cento), com trauma por arma de fogo (70 por cento). As médias de ISS e APACHE II foram de 28,78 e 20, respectivamente. Hérnia ventral ocorreu em 81,5 por cento dos pacientes, num intervalo médio de seguimento de 9,2 meses. Aproximadamente 1/3 dos pacientes apresentavam hérnias pequenas e não desejavam corrigi-las quando questionados. Somente dois pacientes estavam insatisfeitos com o procedimento em relação a atividades cotidianas e aspectos estéticos. Não houve óbitos ou fístulas intestinais em decorrência do fechamento. CONCLUSÃO: Embora não represente uma técnica de fechamento mioaponeurótico, o descolamento cutâneo-adiposo é simples, seguro e de baixo custo. É uma boa opção terapêutica para os pacientes laparostomizados, principalmente quando o fechamento da aponeurose não for possível nos primeiros 7 a 10 dias.

OBJECTIVE: To describe a technique of laparostomy closure through cutaneous-adipose tissues detachment and its results. METHODS: From January 2003 to october 2008 forty patients in laparostomy (Bogota bag) were engaged in surgical procedures for closing their open abdomens according to the technique described here. Data were collected from patient records and during active search. RESULTS: The majority of patients was men (95 percent) with gunshot wounds (70 percent). The average ISS and APACHE II scores were 28.78 and 20, respectively. Ventral hernias were found in 81.5 percent of patients with a mean follow-up time of 9.2 months. Approximately 1/3 of patients had small hernias and didn't want to have their hernias closed because they didn't feel any functional or anatomic impediment to support the closure at that time. Only two patients were dissatisfied in relation to daily activities and to the surgical procedure itself. There were neither deaths nor intestinal fistula with this type of closure. CONCLUSION: Although it doesn't represent a technique for fascial closure, it is simple to perform, safe, and with low cost. It is a therapeutic option for patients with open abdomen, especially if closure of the aponeurosis was not possible in the first 7 to 10 days.