Smith P C, Tweddell J S, Bessey P Q
Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110.
J Trauma. 1992 Jan;32(1):16-20. doi: 10.1097/00005373-199201000-00004.
Excessive tension in an abdominal incision line may lead to fascial necrosis and wound sepsis. We utilized two alternative approaches to wound closure in 13 patients with severe abdominal trauma (2 blunt, 11 penetrating) whose midline incision could not be closed primarily without excessive tension at the initial operation because of massive visceral edema. In five patients synthetic mesh was used to bridge the fascial defect. Four patients survived the early postoperative period but had large open midline wounds that required one or more delayed procedures to close the wound or cover the visceral mass with skin graft. Two patients currently have large abdominal wall hernias. In the other eight patients the skin was reapproximated over the visceral mass utilizing towel clips at the initial operation. Six patients survived to be reexplored within 48-96 hours. Acute hemorrhage had stopped, the edema of the bowel and retroperitoneum had largely resolved, and the fascia could be closed primarily without excessive tension. All wounds went on to heal satisfactorily. When massive edema makes fascial closure at the initial operation difficult or impossible, closure of the skin over the visceral mass promotes resolution of the edema and often allows satisfactory primary closure within 48-96 hours. Synthetic mesh should be reserved for cases of abdominal wall tissue loss or dehiscence associated with wound sepsis.
腹部切口线张力过大可能导致筋膜坏死和伤口感染。我们对13例严重腹部创伤患者（2例钝性伤，11例穿透伤）采用了两种替代的伤口闭合方法，这些患者因大量内脏水肿，在初次手术时中线切口若不施加过大张力则无法一期闭合。5例患者使用合成网片修补筋膜缺损。4例患者度过了术后早期，但中线伤口较大且开放，需要进行一次或多次延期手术来闭合伤口或用皮肤移植覆盖内脏团块。2例患者目前患有巨大腹壁疝。另外8例患者在初次手术时利用巾钳将皮肤重新对合覆盖在内脏团块上。6例患者在48 - 96小时内接受再次探查，急性出血已停止，肠管和腹膜后水肿已基本消退，筋膜能够一期闭合且无过大张力，所有伤口均顺利愈合。当大量水肿使初次手术时筋膜闭合困难或无法进行时，将皮肤覆盖在内脏团块上可促进水肿消退，且通常能在48 - 96小时内实现满意的一期闭合。合成网片应保留用于腹壁组织缺失或与伤口感染相关的切口裂开病例。
