Enterotomy risk in abdominal wall repair: a prospective study.

Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
Annals of surgery (Impact Factor: 7.19). 08/2012; 256(2):280-7. DOI: 10.1097/SLA.0b013e31826029a8
Source: PubMed

ABSTRACT To establish the incidence and predictive factors of enterotomy made during adhesiolysis in abdominal wall repair and to assess the impact of enterotomies and long-lasting adhesiolysis on postoperative morbidity such as sepsis, wound infection, abdominal complications and pneumonia, and socioeconomic costs.
Adhesions frequently complicate surgical repair of abdominal wall hernia. Enterotomies made during adhesiolysis specifically have a large impact on morbidity of patients, especially surgical site infections. Little is known on the incidence and burden of enterotomies and long-lasting adhesiolysis in abdominal wall repair.
Between June 2008 and June 2010 demographics, disease characteristics and perioperative data of all patients undergoing elective abdominal wall repair were included in a prospective cohort study that was focused on adhesiolysis-related problems. A trained researcher observed all surgeries and collected data on adhesion location, tenacity, adhesiolysis time, and inadvertent organ damage such as enterotomies. Primary outcome was the incidence of enterotomy, and predictive factors for enterotomy were assessed through univariate and multivariate analyses. In addition, we evaluated the impact of adhesiolysis and enterotomy on morbidity.
A cohort of 133 abdominal wall repairs was analyzed. Adhesiolysis was required in 124 (93.2%), with a mean adhesiolysis time of 35.7 ± 29.8 minutes. Thirty-three enterotomies were made in 17 patients (12.8%). Two patients had a delayed diagnosed bowel perforation. Adhesiolysis time, hernia size greater than 10 cm, and fistula were significant predictive factors in univariate analysis. In multivariate analysis, only adhesiolysis time was a significant and independent predictive factor for enterotomy (P = 0.004). Trends toward an increased risk were seen for patients with mesh in situ and hernia size greater than 10 cm. Patients with enterotomy had significantly more urgent reoperations (P = 0.029), and they more often required parenteral feeding (P = 0.037). Moreover, patients with extensive adhesiolysis (adhesiolysis time, >30 minutes) more often suffered from wound infection (9/63 vs 2/70; P = 0.025), abdominal complications (5/63 vs 0/70; P = 0.022), and sepsis (4/63 vs 0/70; P = 0.048).
One in 8 patients undergoing abdominal wall repair suffer inadvertent enterotomy following adhesiolysis. Adhesiolysis time predicts enterotomy. Morbidity in patients with extensive adhesiolysis and adhesiolysis complicated by enterotomy is high, inducing longer hospital stay and increased health care utilization.

  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Little evidence exists regarding the characteristics of intraoperative adverse events (iAEs). METHODS: Administrative data, the American College of Surgeons - National Surgical Quality Improvement Project, and systematic review of operative reports were used to confirm iAEs in abdominal surgery patients. Standard American College of Surgeons - National Surgical Quality Improvement Project data were supplemented with variables including injury type/organ, phase of operation, adhesions, repair type, and intraoperative consultations. RESULTS: Two hundred twenty-seven iAEs (187 patients) were confirmed in 9,292 patients. Most common injuries were enterotomies during intestinal surgery (68%) and vessel injuries during hepatopancreaticobiliary surgery (61%); 108 iAEs (48%) specifically occurred during adhesiolysis. A third of the iAEs required organ/tissue resection or complex reconstruction. Because of iAEs, 20 intraoperative consults (11%) were requested and 9 of the 66 (16%) laparoscopic cases were converted to open. Thirty-day mortality and morbidity were 6% and 58%, respectively. The complications included perioperative transfusions (36%), surgical site infection (19%), systemic sepsis (13%), and failure to wean off the ventilator (12%). CONCLUSIONS: iAEs commonly occur in reoperative cases requiring lysis of adhesions and possibly lead to increased patient morbidity. Understanding iAEs is essential to prevent their occurrence and mitigate their adverse effects.
    The American Journal of Surgery 05/2014; 208(4). DOI:10.1016/j.amjsurg.2014.02.014 · 2.41 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Key steps in managing patients with enterocutaneous fistulation and an abdominal wall defect include dealing effectively with abdominal sepsis and providing safe and effective nutritional support and skin care, then assessing intestinal and abdominal anatomy, before undertaking reconstructive surgery. The complexity, cost, and morbidity associated with such cases justifies creation of specialized centers in which gastroenterologic, hernia, and plastic surgical expertise, as well as experienced wound and stoma nursing and nutritional and psychological support, can be made available for patients with these challenging problems.
    Surgical Clinics of North America 10/2013; 93(5):1163-83. DOI:10.1016/j.suc.2013.06.006 · 1.93 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The operative report contains critical information for patient care, serves an educational purpose and is an important source for surgical research. Recent studies demonstrate that operative reports are unstructured and lack vital components. The accuracy of the operative notes has never been assessed. The aim of this study was to analyse the accuracy of operative reports by comparing notes with intraoperative observer-derived findings regarding adhesions and adhesiolysis-related complications. METHODS: The incidence of adhesions and adhesiolysis-induced injury were scored from the reports by a researcher blinded to operative findings obtained prospectively by direct observation. In addition, factors influencing correct reporting were analysed, including sex, surgical experience, delay in dictation, and the gradual introduction of a new report template with a focus on describing operative findings rather than actions taken. RESULTS: A total of 755 consecutive operative reports were analysed. Sensitivity and specificity for the incidence of adhesions was 85·1 and 72·4 per cent respectively. Six of 43 inadvertent enterotomies, and 17 of 48 other organ injuries, had not been reported. All missed bowel injuries were found in reports written in the old template. A median delay in dictating of 3 (range 1-226) working days was found for 56 reports (7·4 per cent). Documentation of inadvertent enterotomies was missing more often in delayed reports (2 of 3 versus 4 of 40 reports dictated with no delay; P = 0·022). CONCLUSION: The sensitivity and specificity of operative reports noting adhesions and adhesiolysis were low. One in seven enterotomies was not reported. Effort should be put into teaching timely, meaningful, structured and accurate reporting of surgical procedures. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
    British Journal of Surgery 02/2013; 100(3). DOI:10.1002/bjs.8994 · 5.21 Impact Factor