Dr Enja Amarnath Reddy

4
th
May 2011
Post-operative separation of the abdominal
musculo-aponeurotic layers.

Mean time for dehiscence
8 to 10 days

Burst abdomen
Fascial dehiscence
Evisceration




Incidence
Historical 10%
< 1 %
Recent study Veterens Affairs Quality programme
3.2%



6S

Surgery
Surgeon
Sutures
Sepsis
Straining
Sick patient


6S
Surgery
Grossly contaminated surgery
Peritonitis
Biliary-fistula
Faecal-fistula
Surgeon
Technique
Meticulous dissection
Hemostasis
Gentle tissue handling
Tensionless sutures
incision
Midline incision better than para-median


Sutures
Prefer non-absorbable sutures
Sepsis
Uncontrolled sepsis
Straining
Violent cough
Persistent vomiting
Distension
Paralytic ileus


Sick patient
Malignancy
Jaundice
Obesity
Anaemia
Hypo-proteinemia
Uremia






Pre-operative
Cough
Anaemia
Hypo-proteinemia
Malnutrition
Steroid
Post-operative
Cough
Abdominal distension
Ascitis
Vomiting
Bowel leakage
Wound infection
Haematoma
Uraemia
Jaundice
Electrolyte imbalance




Risk Factor Score
CVA/ Stroke without deficit 4
H/o COPD 4
Current Pneumonia 4
Emergency proceudre 6
Operative time > 2.5 hrs 2
Postgraduate yeasr 4 as
surgeon
3
Clean wound classification -3
Superficial wound infection 5
Deep wound infection 17
Failure to wean 6
One or more complications 7
Return to OR -11



Risk Category Total Score Predicted Rate
of Dehiscence
Low 3 or <3 1.47 %
Medium 4 to 10 2.70 %
High 11 to 14 4.53 %
Very High >14 10.90 %
Range
9 to 43 %
Recent study
16 %

Prevention is the cornerstone
With meticulous surgical technique




Pathognomonic feature
Sudden rush of copious serosanguinous
discharge for the wound

? Large subcutaneous hematoma
Herniated bowel under the skin
Tympanic boggy swelling

Basic principle
Resuture the wound edges

Replace the eviscerated organs
Prevent
recurrent dehiscence
Later development of ventral hernias
As soon as recognized
Protruding viscera - Warm NS bath
cover with large sterile dressing
Shift to OR




seepage of serosanguineous fluid through a closed abdominal
wound

remove one or two sutures in the skin and explore the wound
manually, using a sterile glove.

If there is separation of the rectus fascia

operating room for primary closure.

Wound dehiscence may or may not be associated with intestinal
evisceration.

When evisceration is present, the mortality rate is dramatically
increased and may reach 30%.

Small deficit
Conservative management
Packing with moist sterile dressing
Transverse elastic dressing
Abdominal binder
Avoid strenous activities
Vaccum-assisted wound closure devices
Secondary suturing/ natural healing
Incisional hernia dealt later



GA
NG tube
Lift up edges
Replace prolapsed bowel
Extract fragments of suture
Freshen the edges
Notice retracted facial edges
Suture
Strong monofilament non-absorbable
Continuous/ interrupted



If only very small area of the wound disrupted
That portion alone sutured

If > half of the incision disrupted
Suture whole wound afresh



No reduction in future incisional hernia
Reduce chance of evisceration
Pain, discomfort
Types
Internal
External
Strong monofilament Nylon
Thread through protective rubber tubing
2.5 cm apart, 2.5 cm from margim
All layers of the abdomen
2 to 4 weeks



Despite all measures
Repaired dehisced wound incisional hernia
risk over 10 yr
69%
Majority within 2 yr

? Non-absorbable mesh reapir


Technical
Non-technical

Technical
Incision
Upper-midline
Technique
Mass closure best for midline
Suture material
Rupture 0/ 1
Distance from edge 1 cm
Frequent error improper knot tying



GASTROENTEROLOGY 2003;124:11111134