Wound Dehiscence From A Surgical Perspective
Wound Dehiscence From A Surgical Perspective
Wound Dehiscence From A 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.
Incidence:
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Mortality:
Causes:
Preoperative Factors:
Obesity
Malignant Disease
Peritonitis
Diabetes
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Zinc Deficiency
The Operation
The inclusion of too little rather than too much of tissue leads to
trouble
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Post-Operative Complications:
Cough
Distention
Vomiting
Ascites
Hiccup
Ileus
Radiation Therapy
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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)
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)
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.
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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Treatment:
Non-Operative:
Operative Treatment:
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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
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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:
OR
The mesh is sutured in place with sutures that penetrate the full
thickness of wound
Desirable Result:
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Prosthetic Mesh:
temporary closure
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References:
1. Hampton J. R., B.M. The Burst Abdomen. British Medical Journal
1963 Oct 1032-35
7. Keill RH, Keitzer WF, Nichols WK, Henzel J and De Weese MS.
Abdominal wound dehiscence. Arch Surg 1973 106:573-7
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16. Dudley HAF. Layered and mass closure of the abdominal wall - a
theoretical and experimental analysis. Br J Surg 1970 57:664-7
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19. Weiland DE, Bay RC, Del Sordi S. Choosing the Best Abdominal
Closure by Meta-analysis. American Journal of Surgery 1998
176:666-670
22. Cengiz Yucel, Blomquist Peter, Israelsson Leif A. Small Tissue Bites
and Wound Strength: An Experimental Study. Arch Surg. 2001 136:
272-275
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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