Wound Dehiscence

Burst abdomen
By
R.V.Kalyani
Gen Surgery V unit
Wound healing
 Wound Dehiscence

* It is a rupture of the wound along the surgical incision.

Incidence; 1 to 3% of all abdominal operations.

* Develops 7 to 10 days Post-op.

Anytime after Surgery, D1 to D20

* It's a morbid complication,

* Mortality rate -10 to 40 %
* Male to Female ratio: 2:1
Age > 45 yrs - 5.4%
 Factors for wound breakdown
A. Local factors ; hematoma, seroma
B. Regional factors ; Bowel oedema, abdominal distension, infections,
haemorrage, trauma, pre op obstruction

C. Systemic - Advanced age

-Malnutrition ,Vit c deficiency
- Pulmonary, Cardiac diseases, Renal Failure
-Obesity ,DM
- Jaundice, Alcoholism
-Hypoproteinaemia

D.Raised Intra abdominal pressure

, sneezing, coughing
- Repeated urinary retention
- Prolonged Paralytic Ileus
E. Surgical

- Emergency Procedure or Imperfect techniques of closure

- Imperfect incision
- Prolonged OT time
- Trauma to wound post.op

Failure of the suture to remain anchored in the fascia can be due to

1. Suture Breakage
2. Knot failure , poor knotting technique
3. Excessive stitch interval allowing protrusion of viscera
4. Suture pulled through the fascia {when sutures are placed to close to
the edge or under too much tension it causes fascial necrosis }
 Clinical manifestations

Dehiscence usually declares itself 7-14 days post.op and may

occur without warning.
May manifest following straining or removal of sutures.
Patient often notes a " ripping sensation" or a feeling that"
something has given way".
Impending dehiscence is often preceded by the appearance of
salmon pink serous discharge from the wound.
 Symptoms
The patient may present with one or more of the following:

• Bleeding • Unexplained fever • Broken sutures

• Swelling • Unexplained tachycardia • The wound opening spontaneously

• Redness • Pus and /or frothy drainage

• Unusual wound pain
• Paralytic ileus
• Pain
 Operative factors
Incision type

Closure
-Mass versus Layered Closure?

- Interrupted versus Continuous Sutures?

- Peritoneal Closure or not?
Suture Materials: Absorbable versus non-absorbable?

- Stitch interval and Size of Tissue Bite?

- Suture Length-to-Wound Length Ratio?
Incision type

- The rate of dehiscence is higher in

midline incisions than in transverse
incisions.

Midline incision cuts across the

aponeurotic fibres, as opposed to the
transverse incision which cuts parallel to
the fibres.

- Contraction of the abdominal wall causes

laterally directed tension on
the closure, suture material cut through by
separation of the
transversely orientated fibres,
Mass versus Layered Closure?
- Closure of the abdominal wall in layers has seen higher rate
of dehiscence than mass closure.

Interrupted versus Continuous Sutures?

Interrupted sutures and using Non absorbable sutures have
less chance of wound dehiscence.

The peritoneal defects heal by simultaneous regeneration of

the layer over the entire defect, therefore suturing the
peritoneum is not vital to prevent dehiscence.
Stitch interval and tissue bite size

• Should be I cm. average with a range between 1-2 cm.

• - Suture Length-to-Wound Length Ratio?
• - Should be 4:1 or greater for continuous mass closure.
• - A ratio < 4:1 is associated with an increased risk of abdominal
dehiscence and the later development of incisional hernia.
 Burst abdomen

• Describes partial or complete postoperative

separation of an abdominal wound closure with
protrusion or evisceration of the abdominal
contents
• Most commonly occurs from the 5th to the 8th
postoperative day when the strength of wound
is at its weakest
• Usually sutures opposing the deep layers, i.e,
peritoneum. and rectus sheath tear through
causing burst abdomen
Factors leading to burst abdomen

1. Failure to use non-absorbable sutures

2.Failure to control persistent leakage of pancreatic enzymes in cases
of pancreatic trauma, pancreatitis or. duodenal blowout
3. Failure to avoid factors which predispose to wound. infection
Failure to decompress grossly distended bowel in the presence of
obstruction
5. Damage to motor nerves after a subcostal or para-
rectal incision
6. Inadequate or poor closure of the wound
 Treatment
Treatment depends on
Extent of fascial separation
Presence of evisceration
Intraabdominal pathology like peritonitis

For most patients of wound dehiscence immediate resuturing with mass closure with
deep retention sutures is done.

Conservative management involves either saline-moistened gauze packing of the

wound or covering it with a sterile occlusive dressing along with antibiotic coverage if
patient is unstable.
Abdominal binder may be used to support disrupted abdominal wound
Wound may subsequently contract to closure, or if the patient's condition improves,
delayed operative closure may be performed.
 Large dehiscence with evisceration

• Pre operative broad spectrum antibiotic.

• Resuscitation, iv fluids, ngt suction followed by exploratory laparotomy must be done.
• Each protruding coil of intestine is gently washed with saline and returned to abd cavity.
• Protruding omentum is also treated similarly and spread over intestines.
• Mass closure of abdominal layers using monofilament nylon passed through soft rubber
tube collar is done.
• Adhesive plaster encircling the anterior 2/3 rd of the circumferance of trunk is placed for
additional support.
• Superficial wound drain is placed.
 Retention sutures

Use No. I monofilament Nylon. NA

Wide interrupted bites of at least 3
cm from the wound edge.
Stitch interval of 3 cm or less.
External retention sutures
(incorporating all layer] -3wks
Internal retention sutures;
Thread each suture through a short
length (5-6cm) of plastic or rubber
tubing to prevent suture erosion into
the skin.
Do not tie too tightly.
The Uncloseable Abdomen:
In a small number of patients it is impossible to close the abdomen .
Conditions which may predispose to an uncloseable abdomen include:
1. major abdominal trauma
2 gross abdominal sepsis,
3. retroperitoneal hematoma €-g. post ruptured AAA
4. loss of abdominal wall tisgue e.p. Necrotizing fasciitis

Attempted closure can cause abdominal compartment syndrome.

- Mesh closure of the abdominal incision is usually indicated.
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 the abdominal wall.
- Dressing changes and subsequent granulation tissue formation ultimately
result in a surface that can be covered with a split-skin graft.
 Bagota bag
• It is a sterile plastic bag used for
wound closure . It is sewn to the to
the skin or fascia of the anterior
abdominal wall.
• It is a tension free closure used most
commonly for abdominal
compartment syndrome in which
decompressive laparotomy is
necessary to reduce the IAP.
Abdominal compartment syndrome

• ACS is the consequence of acute severe abdominal distension with

sustained IAH [ > 12 mm hg ] along with organ dysfunction,
hypotension, oliguria, or respiratory insufficiency.
• Primary acs-blunt/penetrating trauma rupture of AAA /intestinal
obstruction.
• Secondary acs-severe burn injury & septic shock
• Tt; emergency abdominal decompression
• Temporary abdominal closure with bagota bag can be done
Prevention

Preoperative
• Correct the precipitating factors
• Manage causes of increased intra-abdominal
pressure
• Omit medications like steroids if possible
• Prophylactic antibiotics
• Gl decompression (Ryle's tube suction) in case of
intestinal obstruction
Perioperative prevention
• 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}
Suture should be FOUR times the length of the incision and bites
should be taken 1cm from the wound edge at 1cm intervals
Burst abdomen - A preventable
morbidity

Thank you