Abdominal wound dehiscence

ABDOMINAL WOUND DEHISCENCE

Dr Umar Muh’d AminuDepartment of Surgery

ATBUTH Bauchi

Outline• Introduction-

– Definition– Epidemiology

• Causes– Pre-operative– Operative– Post-operative

• Classification• Clinical features• Treatment

– Non-operative– Operative

• Prevention• Conclusion

Introduction

• Important cause of morbidity and mortality among surgical patients

• Affects patients by increasing distress and mortality; the attendants by increasing cost of treatment; the surgeon for whom it is a disturbing reality ; and the hospital resources by increasing health care cost due to prolonged hospital stay

Definition

• separation of the layers of an abdominal wound before complete healing has taken place

• occurs when a wound fails to gain sufficientstrength to withstand stresses placed upon it. The separation may occur when overwhelming forces break sutures, when absorbable sutures dissolve too quickly or when tight sutures cut through tissues.

Epidemiology• Occurs in 2% of

Laparatomies• M:F=2:1• All ages->>over 50yrs• Commonest time of

disruption= 7-12 days post operatively

• Emergency>>Elective• Vertical

incisions>>>transverse incisions

Epidemiology Closure• Mass vs. Layered Closure?

Incidence of burst – layered closure > mass closure

• Interrupted vs. Continuous Sutures? Interrupted suturing – low

incidence of bursts• Peritoneal Closure or not?

Suturing the peritoneal - not vital to prevent Burst Abdomen

Cause of Disruption

• Increased Intra-abdominal Pressure vs. Weakness of Wound

• Pre-operatively vs. Operatively vs. Post-operatively

• Patient factors vs. Physician factors

Pre-operatively

Causes of ↑ed IAP• Chronic cough• Vomiting• Abdominal distension• 4Bladder outflow

obstruction

Causes of Wound weakness• Hypoprotienamia• Vitamin C Deficiency• Malignancy• Anaemia• Uraemia• Prolonged Steroid Therapy• Jaundice• Radiation

Operatively

Causes of ↑ed IAP• Excessive tissue

handling• Failure to decompress

grossly distends bowel

Causes of Wound Weakness• Vertical vs. Transverse incision• Damage to nerves after

subcostal or para-rectal incision

• Use of absorbable sutures to close rectus

• Poor suturing technique• Persistent leakage of

pancreatic enzymes• Failure of asepsis

Post-operatively

• Persistence of pre-operative factors• Wound haematoma• Wound infection• Post-op ileus

Classification

• Superficial and Revealed-– When skin and stitches are removed with

separation of skin and subcutaneous layers only• Deep and Concealed– There is separation of all layers of the abdominal

wall with exception of skin• Complete and Revealed (Burst abdomen)– Protrusion of loop of bowel or portion of

omentum

Clinical Features

Symptoms• Nausea• Fever• Local pain/Discomfort

Signs• Serosanguinous (pink)

or blood stained discharge

• Bowel or omentum protruding through the wound spontaneously after removal of sutures

Burst Abdomen

Treatment options

• Non-operative

• Operative

Non-operative treatment

• If patient is unstable and there has been no evisceration

• Involves either gauze packing of the wound or covering it with a sterile occlusive dressing

Non-operative treatment(cont’d)

• Abdominal binder may be used to support disrupted abdominal wound

Non-operative treatment(cont’d)

• Vacuum Assisted Closure (VAC)– Used in 10% of total patients– Significantly reduces post operative infection– Reduces the uses of antibiotics prescriptions– Can be safely used in patients using anti-

coagulants

Non-operative treatment(cont’d)

• Wound may subsequently contract to closure or if the patient’s condition improves, delayed operative closure may be performed

Operative Treatment

• Resuscitation if shock (+)• Reassurance• Appropriate analgesics• Nothing by mouth• Nasogastric tube insertion and suction• Antibiotic• Cover the wound with saline soaked sterile towel and

transfer to OT• Emergency operation for replacement of bowel and

re-suturing of wound

Operative Procedure• Each coils of intestine are washed with normal saline gently

and thoroughly• Return to abdominal cavity• Clean the abdominal wall

• Re-approximated with through and through monofilament nylon

• Buttressed by tension suture• Abdominal wall is supported by many-tail bandage, Adhesive

plaster• Post-operative -General build-up

-Treat/Avoid predisposing factors

Prevention

Preoperative• Correct the precipitating factors• Manage causes of increased intra-abdominal

pressure• Omit medications like steroids if possible• Prophylactic antibiotics• GI decompression (Ryle’s tube suction) in case of

intestinal obstruction

Per-operative• Reduce septic load –peritoneal toilet• Choice of suture –non-absorbable suture for wound

closure• Tension free closure• Follow Jenkin’s rule in closing midline laparotomy

wound– Mass closure technique (include peritoneum +

rectus sheath in closure)– Continuous suture– Suture should be FOUR times the length of the

incision and bites should be taken 1cm from the wound edge at 1cm intervals

• Good surgical technique and principles

Post-operative• Prevention of wound sepsis• Manage causes of increased intra-abdominal

pressure and GI distension• Urgent recognition and treatment of wound

dehiscence• Follow-up

Conclusion

• Abdominal wound high mortality rate and no single cause being responsible: rather it is a multi factorial problem

Reference• Principles and Practice of Surgery including Pathology in the Tropics; 4th

Edition; E A Badoe, E Q Archampong, J T da Rocha-Afodu• S H Waqar, Zafar Iqbal Malik, Asma Razzaq, M Tariq Abdullah, Aliya

Shaima, M A Zahid; Frequency And Risk Factors For Wound Dehiscence/Burst Abdomen In Midline Laparotomies; J Ayub Med Coll Abbottabad 2005;17(4)

• Kusum Meena, Shadan Ali, Awneet Singh Chawla, Lalit Aggarwal, Suhani Suhani,Sanjay Kumar, Rehan Nabi Khan; A Prospective Study of Factors Influencing Wound Dehiscence after Midline Laparotomy; Surgical Science, 2013, 4, 354-358 http://dx.doi.org/10.4236/ss.2013.48070 Published Online August 2013 (http://www.scirp.org/journal/ss)

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