Wound Dehiscence from a Surgical Perspective

1 Wound Dehiscence (Surgical Perspective)

Wound Dehiscence

(Surgical Perspective)

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Table of ContentsWhat 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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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%

Incidence of dehiscence between 1985-1996 (18,133 incisions): 1.2%

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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

Zinc Deficiency

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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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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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Frequency of Burst Abdomen by Age and Sex:

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Frequency of Burst Abdomen by Age and Sex

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

<30 40 50 60 70

Age

Fre

qu

ency

Male

Female


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:

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Intervals between Day of operation and Bursting of abdomen

0

10

20

30

40

50

60

70

0-4 5-8 9-12 13-16 17-

Post-operative Day

% B

urs

ts

Male

Female


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

Continous Closure or Interrupted closure

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Technique of Abdominal Closure:

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Braided Silk at 70 Days:

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Multifilament Nylon (non-absorbable) at 10 days:

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Braided Silk at 70 days (Non-infected)

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Mathematical Model of Closure:

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Another Similar Mathematical Model:

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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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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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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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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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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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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

Once well enough and intestinal edema has resolved, usually return to operating theatre for attempt at abdominal wall closure

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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

9. Alexander, H. C. and Prudden, J. F. The causes of abdominal wound disruption. Surg., Gynec g: Obst. 1966 122:1223-1229

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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

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

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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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Wound Dehiscence from a Surgical Perspective