Re: peritoneum
From: Gordon Goldman (obgyndoc@swbell.net)
Thu Mar 6 16:42:52 2008
Sorry about the split infinitive. No offense intended ;).
I am admittedly a 'creature of habit' and my habit with regard to
both peritoneal closure and 3/0 plain gut for skin has served me well
for the past 34 years. So, I continue to do so until they outlaw it.
I had used staples as noted in an earlier post with removal at three
days and steristrip, but still got tracks. May be more my technique
than the staples, but I got what I got and so quit it. That sort of
reminds me of the breach classification of 'awfully simple or simply
awful' with regard to wound complications, though I have not
experienced the latter as yet. I find even Rapide lasts longer than
I like. The plain gut is tied external to the wound edge and usually
drops off in 7-10 days, by which time the skin holds itself together.
Just what works for me.
--
Gordon M. Goldman, M.D., FACOG
Private Practice, St. Louis, Mo.
On Mar 6, 2008, at 5:03 PM, Raymond Stephen wrote:
> The evidence is clear that closing peritoneum increases adhesions.
> The study that showed a better result by closing parietal
> peritoneum really only applies to cases which get infection.
> Closing the bladder peritoneum still goes against the evidence.
>
> "..to not.." is a split infinitive and drives me mad. The correct
> construction is "...refusing not to close...". By closing
> peritoneum, you may not feel like an outcast, but to me you still
> are if you split your infinitives! ;)
>
> However, you redeemed yourself by advocating skin closure with
> subcuticular 3/0 rather than staples. Staples hurt, need removing
> and leave marks. I would suggest using Monocryl or Vicryl Rapide
> though, as plain c/g seems to be out of fashion now - BSE and all
> that! Subcuticular closure does have one disadvantage though, and
> that is that it is waterproof and if there should be a collection
> in the wound there is no way for it to drain. The result is
> chronic sinuses and granulation formation with a long slow healing
> process. I tell my residents that subcuticular closure is like the
> "little girl with the curl" - when it is good it is very, very
> good, but when it is bad it is horrid!
>
> Steve
>
> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
> Gordon Goldman
> Sent: Friday, 7 March 2008 8:41 AM
> To: Multiple recipients of list OB-GYN-L
> Subject: Re: peritoneum
>
> Frances,
>
> For years I was the 'outcast', refusing to not close the peritoneum
> at laparotomy/section. I have a general surgical background and
> had always felt a careful/clean peritoneal closure was better with
> regard to adhesion formation than simply leaving it up to 'natural'
> biologic processes. Ditto for the bladder flap, as long as you
> don't 'advance' it as they did in the early days. It just does not
> take that much extra time and my experience with others who have
> gone before me did not justify any change. The same sequence of
> events you have experienced is also occurring at our hospitals.
>
> I also continue to close transverse incisions with subcuticular 3/0
> plain catgut, not staples. I think the wound looks better and
> heals better and doesn't leave 'staple tracks'.
>
> Gordon M. Goldman, M.D., FACOG
> Private Practice, St. Louis, Mo.
>
> On Mar 6, 2008, at 1:43 PM, FRANCES WREN wrote:
>
>> for years I neatly sewed up the parietal peritoneum at C/S (25 yrs+)
>> then within the last 1-2 years started , as it seemed the
>> literature had been advocating for some time , to leave it open
>> and just sew up the fascia.
>> this am I did a C/S ..I am doing a locum, and my assistant said
>> he'd heard that the'y revised the opinion of leaving the
>> peritoneum open and it was now...again...felt better to close
>> it ..in terms of adhesion formation.
>> certainly looks neater at the time when one closes it....but
>> quicker to not (besides I am now used to NOT closing it)
>>
>> I have not read anything recently saying to close it ..
>> any evidence re better to close or leave open????
>> opinions please.
>>
>> frances wrenMD FRCS.
>
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