Page 39 - PlasticosVol4

V O L 4 2019 I S S U E

FRUGAL FUNDAS FRUGAL FUNDAS

A 5-year-old girl was operated for bilateral end-
A CHALLENGING CASE stage renal disease secondary to congenital
dysplastic kidney and received a live related
renal transplant from her mother. But
OF PAEDIATRIC OPEN unfortunately, due to limited intraabdominal
space following transplant, the surgeons were
unable to close the abdomen and the intestines
ABDOMEN CLOSED were managed extraperitoneally using a mesh
and gradually reduced over multiple session.

USING DERMAL At the end of 1 month, the skin edges were 17

cm apart horizontally and 24 cm in the vertical
TRACTION plane and the muscle defect was bridged
with the mesh. On attempting approximation
manually, the edges moved not more than 1-2
cm on either side. At the time of referral, the
child had daily fever spikes and deranged renal
functions with anemia. The immediate priority
was to achieve closure with the following
challenges:

• Prolonged anesthesia was difficult, but
possible in view of deranged renal function
(S. Creatinine – 2.4 mg/dl) and anaemia (Hb Child was posted for the application of custom
- 7.4 gms). made dermal traction straps and a reticulate
• The child had received almost all the foam was placed over the mesh. A Ryle’s tube
higher antibiotics (Cefuroxime, Piptaz, was used to provide a suction pressure of
Vancomycin, Colistin, Meropenem, 100 mm Hg using wall suction. The skin was
Teicoplanin, Capsiofungin) and nothing left undermined for 2 cm all around. On table,
if she went into sepsis. the final gap after maximum approximation
• Limited size of donor area for free flap. was 8 cm. Following this the subsequent
• Low hemoglobin levels, blood transfusion approximation was done bedside in 2 sessions
contraindicated fearing transplant until the skin edges were 2 cm apart at the end
rejection. of 5 days.
• Immunosuppression post renal transplant.
• Mesh looked infected and needed removal After 9 days from the initial application, the child
as soon as possible. was posted again under short GA for the final
closure. The dual mesh which was infected was
With the above points in mind, it was decided removed and the skin edges were closed with
to attempt gradual approximation along with minimal tension on the wound edges. A new
vacuum assisted closure which was inspired by set of straps were applied to keep the suture
Dr Deevich N.D 2 devices in the market – Top closure TM (IVT line tension free. Soon after the procedure, the

Fellowship in Biodesign Medical Ltd) and ABTHERA TM (KCI Acelity). fever spikes subsided and the renal parameters
Senior Resident, ESIC & PGIMSR & Model Hospital, returned to normal levels.

38 Rajajinagar, Bangalore 39