Wound Dehiscence From A Surgical Perspective

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1 Wound Dehiscence (Surgical Perspective)

Wound Dehiscence
(Surgical Perspective)

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2 Wound Dehiscence (Surgical Perspective)

Table of Contents
What is it?...................................................................................................................................................3
Incidence.....................................................................................................................................................3
Mortality......................................................................................................................................................4
Causes.........................................................................................................................................................4
Frequency of Burst Abdomen by Age and Sex.............................................................................................7
Mechanisms for Wound Dehiscence...........................................................................................................8
Intervals between Day of operation and Bursting of abdomen...................................................................8
Diagnostic Pointer.......................................................................................................................................9
Recommendations.......................................................................................................................................9
Technique of Abdominal Closure...............................................................................................................10
Mathematical Model of Closure................................................................................................................14
Incision Type and Recommendations........................................................................................................16
Risk Score for abdominal wound dehiscence............................................................................................17
Treatment..................................................................................................................................................18
References.................................................................................................................................................22

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3 Wound Dehiscence (Surgical Perspective)

Burst Abdomen

What is it?
Also known as abdominal wound dehiscence, wound failure, wound
disruption, evisceration and eventration. May be partial or complete.

Wound dehiscence before cutaneous healing is burst abdomen while


dehiscence after cutaneous healing is incisional hernia.

Incidence:

 The incidence varies in reported series of cases, but it is


somewhere between 0.5 and 5%.

 The incidence of wound dehiscence/burst abdomen varies from


center to another worldwide. While it is recorded to be 1-3 % in
most centers

 Incidence of wound dehiscence before 1940 (>71000 incisions):


0.24-3.0%

 Incidence of wound dehiscence between 1950 and 1984 (>320,000


incisions): 0.24 - 5.8%

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4 Wound Dehiscence (Surgical Perspective)

 Incidence of dehiscence between 1985-1996 (18,133 incisions):


1.2%

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5 Wound Dehiscence (Surgical Perspective)

Mortality:

 A consistently higher mortality was found in the patients who had


burst than in the controls

 35% according to studies

Causes:

Preoperative Factors:

 (Chronic pulmonary disease) Cough present pre-operatively and


post-operatively

 Being treated with Corticosteroids

 Ascites, Jaundice or Depletion of protein or vitamin C or uraemia

 Obesity

 Malignant Disease

 Peritonitis

 Haemoglobin < 11g/dl

 Diabetes

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6 Wound Dehiscence (Surgical Perspective)

 Zinc Deficiency

Nature of Primary - Disease and Operation:

Main groups of operations after which burst abdomens occurred are


those on the Gastroduodenum (mainly for peptic ulcer) and Large Bowel

The Operation

 Most burst abdomens occur in Upper abdominal incisions and


vertical incisions

 Almost no burst abdomen occurred in Lower abdomen oblique or


transverse incision according to few studies

 The inclusion of too little rather than too much of tissue leads to
trouble

 Using Catgut 11% Dehiscence occurred in one study

 Incisions greater than 18 cm

 Emergency Operations carry more risk than elective

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7 Wound Dehiscence (Surgical Perspective)

Post-Operative Complications:

 Cough

 Distention

 Vomiting

 Ascites

 Hiccup

 Wound Inflammation Infected wounds are significantly weaker


than controls almost certainly due to decreased fibroblast
concentration and activity

 Pancreatic or intestinal digestion of the suture line from a fistula

 Ileus

 Radiation Therapy

 Antineoplastic Therapy: Delay the treatment till 2-3 weeks

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8 Wound Dehiscence (Surgical Perspective)

Frequency of Burst Abdomen by Age and


Sex:

Frequency of Burst Abdomen by Age and Sex

1.6

1.4
1.2

1
Frequency

Male
0.8
Female
0.6
0.4
0.2
0
<30 40 50 60 70
Age

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9 Wound Dehiscence (Surgical Perspective)

Mechanisms for Wound Dehiscence:


 Tearing of sutures through tissues (29%)
 Infection (9%)
 Broken suture (8%)
 Facial necrosis (6%)
 Loose knots (4%)
 No explanation (44%)

Intervals between Day of operation and


Bursting of abdomen:
Intervals between Day of operation and Bursting of abdomen

70

60

50
% Bursts

40 Male
30 Female

20

10

0
0-4 5-8 9-12 13-16 17-
Post-operative Day

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10 Wound Dehiscence (Surgical Perspective)

Mean presentation of abdominal wound dehiscence was at


postoperative day 9 (range: 0–32 days), with 90% of all cases presenting
before the 15th postoperative day

Diagnostic Pointer:
Appearance of a pink, watery discharge through the wound a week or so
after operation. This is blood-tinged peritoneal exudate escaping
through the deeper layers of the wound, and its appearance is strong
evidence of imminent complete dehiscence. Recognition of the
significance of this discharge should make it possible to resuture the
abdominal wound before the frightening and potentially dangerous
complication of complete rupture is allowed to occur.

Lateral radiograph of the abdomen may confirm the diagnosis by


showing bowel shadows very close to the skin of the wound area.

Recommendations:
 Tension free Single Layered: “Mass Closure” of midline incisions
 monofilament nonabsorbable suture
 (suture length)SL: WL(wound length) between 4: 1 and 6: 1 with
big loose bites gives conditions in the wound so that the effect of
30% wound lengthening leads to a rise in tension of less than 2%
 Wide bites of the rectus sheath at least 1 cm from the edge of the
incision. Drains are inserted through a separate stab away from
the incision and a colostomy or ileostomy is always fashioned
through a separate incision

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11 Wound Dehiscence (Surgical Perspective)

 Continous Closure or Interrupted closure

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12 Wound Dehiscence (Surgical Perspective)

Technique of Abdominal Closure:

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13 Wound Dehiscence (Surgical Perspective)

Braided Silk at 70 Days:

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14 Wound Dehiscence (Surgical Perspective)

Multifilament Nylon (non-absorbable) at 10 days:

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15 Wound Dehiscence (Surgical Perspective)

Braided Silk at 70 days (Non-infected)

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16 Wound Dehiscence (Surgical Perspective)

Mathematical Model of Closure:

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17 Wound Dehiscence (Surgical Perspective)

Another Similar Mathematical Model:

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18 Wound Dehiscence (Surgical Perspective)

Incision Type and Recommendations:

 No advantage or disadvantage of a transverse over a vertical


abdominal incision or of a paramedian over a median incision
could be shown in a study.
 When reviewing all data, the transverse incision seems to cause
less wound dehiscence than the midline and paramedian incisions,
but numbers are too small to speak of an actual trend
 Unilateral transverse incision should be the preferred incision for
small unilateral operations
 Lateral paramedian incision should be used for most major
elective laparotomies

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19 Wound Dehiscence (Surgical Perspective)

 Midline incision limited to emergency surgery in which unlimited


access to the entire abdominal cavity is necessary or useful.

Risk Score for abdominal wound


dehiscence:
On the basis of risk factors a risk score for abdominal wound dehiscence
has been proposed in 2009. This score can be entered into a formula to
calculate the probability of developing abdominal wound dehiscence for
individual patients

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20 Wound Dehiscence (Surgical Perspective)

Treatment:

Non-Operative:

Patient very unstable and there has been no evisceration. Preferably to


treat non-operatively:

 Guaze packing of the wound or covering it with a sterile occlusive


dressing

 Abdominal binder may be used to support disrupted abdominal


wound

 Wound may subsequently contact to closure, or if the patient's


condition improves, delayed operative closure may be performed.

 Hernia is a common sequela

Operative Treatment:

 For most patients immediate re-operation is indicated

 Most common technique is immediate resuture with retention


sutures

 Pre-operative broad spectrum antibiotics should be given

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21 Wound Dehiscence (Surgical Perspective)

Technique:
1. Free the omentum and bowel for a short distance on a deep surface
of the wound on both sides
2. Insert deep retention sutures, and then proceed with mass closure
of the abdominal wall. Be certain to take deep bites of tissues,
using plenty of suture material, and avoid excessive tension on the
wound.
3. Close the skin fairly loosely and consider using a superficial wound
drain.
4. In the presence of gross wound sepsis, leave the skin open and
pack

Retention Sutures: Basic Principles:


1. Use heavy non-absorbable suture e.g. No.1 monofilament nylon
2. wide interrupted bites of at least 3cm from the wound edge and a
stitch interval of 3cm or less
3. either external (incorporating all layers peritoneum through to
skin) or internal (all layers except skin) may be used.
4. Internal retention sutures avoid producing an unsightly ladder-
pattern scar, however they are unable to be removed subsequently
(increased infection risk) a buttress device is used to prevent
suture erosion into the skin e.g. thread each suture through a short
length (5-6 cm) of plastic or rubber tubing do not tie too tightly
external retention sutures area usually left in for at least 3 weeks

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22 Wound Dehiscence (Surgical Perspective)

The Uncloseable:
 major abdominal trauma
 grosss abdominal sepsis
 retroperitoneum hematoma e.g. post ruptured AAA
 Loss of abdominal wall tissue e.g. necrotizing fasciitis
 attempted closure may lead abdominal compartment syndrome

Options:

Temporarily close abdomen by packing the wound and taking a further


look in 24-48 hours.

OR

Mesh closure of the abdomen

The defect is bridged with one or two layers of a prosthetic mesh

The mesh is sutured in place with sutures that penetrate the full
thickness of wound

Desirable Result:

Granulation tissue formation ultimately result in a surface that can be


covered with a split-skin graft

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23 Wound Dehiscence (Surgical Perspective)

Prosthetic Mesh:

Absorbable mesh (polyglycolic acid eg. Dexon)

 temporary closure

 good for infected abdomen

 subsequent incision hernia inevitable

Polypropylene mesh (eg. Prolene, Marlex):

 erosion into bowel and fistula formation

 dense adhesion formation

 quite tolerant of infection

PTFE (Polytetrafluoroethylene) (eg. Goretex):

 Soft and pliable

 less adhesions to bowel

 tolerates infection poorly

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24 Wound Dehiscence (Surgical Perspective)

 Once well enough and intestinal edema has resolved, usually


return to operating theatre for attempt at abdominal wall closure

References:
1. Hampton J. R., B.M. The Burst Abdomen. British Medical Journal
1963 Oct 1032-35

2. Bucknall T E, Cox P J, Ellis Harold. Burst abdomen and incisional


hernia: a prospective study of 1129 major laparotomies. British
Medical Journal 1982 284:931-33

3. Ramshorst G. Abdominal Wound Dehiscence in Adults:


Development and Validation of a Risk Model. World J Surg 2010
34:20–27 [PMID: 19898894 ]

4. Bucknall T. E. Factors influencing wound complications: A clinical


and experimental study. Annals of the Royal College of Surgeons of
England 1983 65:71-77

5. Lotfy, Wael. Burst Abdomen: Is it a Preventable Complication.


Egyptian Journal of Surgery 2009 July 28(3):128-32

6. Carlson MA. Acute Wound Failure. Surgical Clinics of North


America 1997 77:607- 636

7. Keill RH, Keitzer WF, Nichols WK, Henzel J and De Weese MS.
Abdominal wound dehiscence. Arch Surg 1973 106:573-7

8. Reitamo J., and Moller C. Acta Chirurgica Scandinavica 1972


138:170

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25 Wound Dehiscence (Surgical Perspective)

9. Alexander, H. C. and Prudden, J. F. The causes of abdominal wound


disruption. Surg., Gynec g: Obst. 1966 122:1223-1229

10. Goligher, J C, et al. British Journal of Surgery 1975 62:823

11. Standeven, A. Lancet 1955 1:533

12. Haxton, H A. British Journal of Surgery 1963 50:534

13. Spiliotis John. Wound dehiscence: is still a problem in the 21th


century: a retrospective study. World Journal of Emergency
Surgery. 2009 4:12

14. Kirk R.M. The Incidence of Burst Abdomen: Comparison of Layered


Opening and Closing with Straight-through One-layered Closure.
Lancet 1972 ii 352

15. Jenkins, T P N. British Journal of Surgery 1976 63:873

16. Dudley HAF. Layered and mass closure of the abdominal wall - a
theoretical and experimental analysis. Br J Surg 1970 57:664-7

17. Gupta Himanshu et al. Comparison of Interrupted Versus


Continuous Closure in Abdominal Wound Repair: A Meta-analysis
of 23 Trials. Asian Journal of Surgery 2008 July 31(3):104 - 114

18. Varshney Subodh, Manekt Parimal, Johnsont CD. Six-fold


suture:wound length ratio for abdominal closure. Ann R Coll Surg
Engl 1999 81:333-336

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26 Wound Dehiscence (Surgical Perspective)

19. Weiland DE, Bay RC, Del Sordi S. Choosing the Best Abdominal
Closure by Meta-analysis. American Journal of Surgery 1998
176:666-670

20. Hodgson N. C. F., Malthaner R. A. The Search for an Ideal Method of


Abdominal Fascial Closure: A Meta-Analysis. Annals of Surgery.
2000 231(3):436–442

21. Varshney Subodh, Manekt Parimal, Johnsont CD. Six-fold


suture:wound length ratio for abdominal closure. Ann R Coll Surg
Engl 1999 81:333-336

22. Cengiz Yucel, Blomquist Peter, Israelsson Leif A. Small Tissue Bites
and Wound Strength: An Experimental Study. Arch Surg. 2001 136:
272-275

23. Ellis Harold, Coleridge-Smith Philip D., Joyce Adrian D. Abdominal


incisions-vertical or transverse?. Postgraduate Medical Journal
1984 june 60:407-410

24. Burger J. W. A., Riet M. van ‘t, Jeekel J. Abdominal incisions:


techniques and postoperative complications. Scandinavian Journal
of Surgery. 2002 91:315–321

25. Nagy KK, Fildes JJ, Mahr C, et al. Experience with three Prosthetic
Materials in Temporary Abdominal Wall Closure. American
Surgeon 1996 62:331-335

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