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Improved Outcomes in Colon and Rectal Surgery part 24

Improved Outcomes in Colon and Rectal Surgery part 24. 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 21.4 Marsupialization. A The diseased tissue is excised with electocautery. B The cavity is debrided. C The edges of the wound are then sutured down to the base of the wound using absorbable suture. D Resulting in a small open wound. wound closure reported less infectious complications 13 vs. 30 and recurrences 5 vs. 10 with the open technique but more overall wound complications. Slightly more patients in the open group were not satisfied with the outcome of treatment 8 vs. 5 . However a larger series of 493 patients 25 treated with midline excision and primary closure via an oblique elliptical incision which crossed the midline showed recurrence rate of 5.6 at 18 months with very low incidence of wound infection 1.2 hematoma 0.4 or wound dehiscence 1 postoperatively. The benefit of faster healing time and smaller final scar slightly outweighs the possible increase in infection or wound dehiscence. Recurrence is related more to inadequate excision of diseased tissue rather than to closure technique. Excision or Unroofing with Marsupialization Another option to leave a smaller wound is marsupialization. The excision of tissue is carried out as described above. Then the skin edges are tacked down to the base of the wound using absorbable suture. This leaves a smaller and more shallow wound which is easier to pack. Figures 21.4a-d By not completely closing the wound there is a theoretical decrease in wound complications and the duration of healing is less than for a fully open wound. Simply unroofing the wound versus excision also results in a smaller wound. A study of 26 patients who underwent wide local excision and 42 who had unroofing and marsupialization reported significantly longer healing times 21 vs. 6 weeks and wound complications requiring reoperation 35 vs. 2 in the wide local excision group. 26 Simple unroofing without marsupialization has become the preferred initial operation for pilonidal disease .