ORIGINAL ARTICLE Management of abdominal wound dehiscence: still a challenge 84

84
ORIGINAL ARTICLE
Management of abdominal wound dehiscence: still a
challenge
Abdul Qaiyoume Amini, Naveed Ali Khan, Javed Ahmad, Amjad Siraj Memon
Abstract:
Objective: To find out the effective way of management of abdominal wound dehiscence after
emergency and elective laparotomies.
Materials and methods: The study was carried out in Surgical Unit 5, Civil Hospital Karachi
during January 2011 to April 2012. One hundred and thirty consecutive patients undergoing
laparotomy through a midline incision either in emergency or elective setup were included in
the study. They were followed by wound examination from second post operative day onwards
to see normal or otherwise healing and findings were recorded. The cases of wound dehiscence were divided into two groups i.e. group A, managed with thorough abdominal wash and
deep tension sutures and group B, managed with thorough abdominal wash and Bogota bag
application.
Results: 15 out of 130 (11.5%) patients developed complete wound dehiscence (burst abdomen). Frequency of burst abdomen was significantly higher after emergency laparotomies
(14/94 i.e. 14.89%) while 1 patient undergoing elective laparotomy developed burst abdomen
(1/36 i.e. 2.7%). Group A (n=8) was managed with deep tension sutures and group B (n=7)
was managed with Bogotá bag. The outcome of deep tension sutures was associated with less
morbidity, less number of further surgeries and low mortality.
Conclusion: Thorough abdominal wash with copious amount of normal saline and closure
with deep tension sutures is still an effective way of management of patients with complete
wound dehiscence while Bogotá bag application is useful in cases abdominal closure is difficult due to generalized gut edema or need of further re-operations.
Keywords: Abdominal wound dehiscence, midline laparotomy, deep tension suture, Bogota
bag, burst abdomen
Civil Hospital Karachi
AQ Amini
NA Khan
J Ahmad
AS Memon
Correspondence:
Abdul Qaiyoume Amini
Resident year 4, Surgical
Unit 5, Civil Hospital
Karachi,
Postal Address: House
No. A-141, Behind Jama
Masjid Afzal, Gulistan-eJauhar block 14, Karachi.
email: [email protected]
com, Cell: 0345-2340172
Pak J Surg 2013; 29(2):84-87
Introduction:
Abdominal wound dehiscence (burst abdomen) is a severe post operative complication
experienced by surgeons who do a significant
volume of surgery. The incidence as described
in the international literature range from 0.4 to
3.5%1-7 and is associated with a mortality rate
as high as 45%8-10 while our local data showed
still higher frequency of wound dehiscence
with overall rate of 4.8 and 6.6%11,12. Abdominal
wound dehiscence can result in evisceration, requiring immediate treatment.
Despite increased knowledge about wound
healing, advances in perioperative care and suture materials, wound dehiscence continues to
be a significant problem which prolongs hospital stay and is associated with patients’ morbidity, subsequent re-operations, high incidence of
incisional hernia and increased mortality. This
may be attributable to increasing rates of emergency laparotomies in high risk patients with
multiple comorbids outweighing the benefits of
technical achievements.2,7,13
The management of wound dehiscence ranges
from simple dressing to further surgery for abdominal wash and subsequent closure of burst
85
AQ Amini, NA Khan, J Ahmad, AS Memon
abdomen followed by a period of intensive
care.14 We compared two management strategies
for burst abdomen: Deep tension suture (DTS)
which has been used for long time by many surgeons and Bogotá bag which are often used for
temporary abdominal closure after damage control or staged laparotomy for trauma or release
of abdominal compartment syndrome21, 22.
Materials and methods:
This comparative cross-sectional study was conducted at Surgical Unit 5, Civil Hospital Karachi
from January 2011 to March 2012. A total of one
hundred and thirty consecutive cases, irrespective of the age and sex, undergoing laparotomies
through a midline incision, were included in the
study. Patients under 12 years of age or operated
through other incisions were excluded from the
study.
A detailed history and clinical examination was
conducted. The data was noted on a proforma
which also included all the major risk factors
for wound dehiscence like age, gender, nature
of disease, emergency surgery, nutritional status of patient, anemia, jaundice and presence
of comorbids (diabetes mellitus, hypertension,
chronic obstructive pulmonary disease, steroid
use, immunodeficiency states etc). Baseline investigations and total protein, albumin/globulin
ratio were noted in all cases as well as abdominal radiographs and ultrasonography. CT scan
abdomen was also done where required. After
optimization of patient and anesthesia clearance
every patient underwent laparotomy through a
midline incision.
Postoperatively, abdominal wounds were examined from third postoperative day onwards on
daily basis to see the signs of wound infection,
dehiscence including redness (erythema), seroma formation, discharge of serosanguinous fluid
or pus from one or more sites and subsequently
partial or complete wound dehiscence.
Partial wound dehiscence was managed conservatively by laying open the wound, daily wound
wash and dressing along with intravenous antibiotics according to culture and sensitivity.
Cases of complete wound dehiscence (burst abdomen) were divided randomly into two groups
i.e. group A, managed with thorough abdominal wash and deep tension sutures and group B,
managed with thorough abdominal wash and
application of Bogotá bag. In group A patients,
deep tension sutures applied using 1.0 prolene
with suture 2 cm from wound edges and 3 cm
apart with a plastic tube of 4 cm length to avoid
cutting of skin. Interrupted mattress sutures also
applied in between the deep tension sutures.
In Group B, Bogotá bag applied, made from
transparent side of a urine bag and sutured on
all sides of open wound at least 3 cm apart from
wound edges. Patients of both groups received
broad spectrum antibiotics and daily sterilized
dressing by a doctor.
Results:
A total of 130 patients underwent laparotomy
through a midline incision during the study
period. Mean age of patients was 34.22 years
(standard deviation: 14.9) including 86 males
(66.2%) and 44 females (33.8%). Male to female ratio was 2:1. Emergency laparotomies for
various pathologies were done in 94 patients
(72.3%) while elective laparotomies were performed on 36 patients (27.7%).
Out of 130 patients undergoing a midline
laparotomy, 15 developed complete wound
dehiscence (burst abdomen) giving an overall frequency of 11.5% although emergency
laparotomies showed a much higher frequency
(14/94 i.e. 14.89%) while 1 patient developed
burst abdomen after an elective laparotomy
(1/36 i.e. 2.7%). Majority of cases were dirty
having gut perforations and a fecal peritonitis
(11/15 i.e. 73.3%). [Table 1]
Group A patients (n=8) were managed with
thorough abdominal wash and deep tension
sutures while group B patients (n=7) were managed with abdominal wash and application of
Bogotá bag.
The mean length of stay was longer in group
B (39.14 ± 12.95) with patients requiring 2 or
more abdominal washes and later development
Pak J Surg 2013; 29(2): 84-87
86
Management of abdominal wound dehiscence: still a challenge
Table 1: Frequency of burst abdomen in different pathologies
40
Group B (Bogotá)
Diagnosis
Frequency
No of Burst Abdomen
35
Group A (DTS)
TB Abdomen
21
4
30
Gunshot Abdomen
19
0
25
Obst due to post-op bands/adhesions
17
0
20
Typhoid Ileal Perforation
16
3
15
Perf DU
10
2
10
Colorectal tumor
6
2
5
Perforated Apendix
5
0
0
Sigmoid Volvulus
5
1
Biliary perotonitis
5
1
Gangrenous Bowel
4
0
Iatrogenic injuries during Obs procedures
4
1
Stab Wound
4
1
Blunt Abdominal Trauma
4
0
Pancreatitis
3
0
Others
7
0
Total
130
15
Incisional
hernia
Mortality (%)
Figure 1: Outcome of both groups
Table 2: Comparison of Management Groups
Groups
Mean Length
of stay in days
Abdominal
washes
Incisional
hernia
Mortality
(%)
Group A (DTS)
18.5
4
0
25
Group B (Bogotá)
39.14
25
5
28.6
of incisional hernias. The mean length of stay in
group A was 18.5 (± 5.3). 4 patients died giving
an overall mortality of 26.6%. It included 1patient from group A (2/8 i.e. 25%%) and 2 from
group B (2/7 i.e. 28.6%). [See Table 2 and Figure 1]
Discussion:
A burst abdomen is considered present when
intestine, omentum or other visceras are seen
through the abdominal wound following surgery. It occurs mostly on 6th to 8th day post
operatively. Factors relating to the incidence
of burst abdomen are suture material, closure
technique, postoperative coughing and vomiting, distention, obesity, malignancy, hypoproteinemia, anaemia, immunocompromised states
and contaminated surgeries15. The frequency of
burst abdomen in our study was 11.5% which
is higher than other local data which showed a
frequency ranging from 5.3 to 8.3%11, 16-18. The
higher frequency of burst abdomen is in contrast with many Western studies which showed
Pak J Surg 2013; 29(2): 84-87
Mean Length Abdominal
of stay in days
washes
an incidence of 0.4 to 3.5% but is in accordance
with the study done by Mathur19 which showed
that the problem of wound dehiscence is much
more prevalent in South East Asia than the
Western world. This may be attributable to poor
nutritional state of patients, delayed presentation to the tertiary care hospitals, poor quality
of suture material, disease like tuberculous abdomen which is endemic to countries of South
East Asia and higher load of emergency surgeries. Our study also showed a significantly higher
frequency of burst abdomen in emergency laparotomies i.e. 14.89% as compared to elective laparotomies i.e. 2.7%. This is also reflected in many
other studies 7, 11-18,20. This may be because of the
fact that patients who undergo emergency surgery are generally in suboptimal condition and
nutritional state and the chances of contamination of the surgical field is higher than in elective
surgery. Moreover the performance of the surgeon might be affected at night which could lead
to suboptimal closure of the abdomen at the end
of operation.
Our study showed that deep tension suturing
(DTS) is a simple an effective way of managing burst abdomen which is associated with less
morbidity and mortality. The mean length of
stay was significantly higher in Bogota bag group
(39.14) than DTS group and later development
of incisional hernia was also a problem which
was seen in Bogotá bag group which increased
he frequency of re-explorations and further surgeries on patients. The mortality in group B was
28.6% % which was similar to group A (25%)
and is also similar to another study by Krishtein
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AQ Amini, NA Khan, J Ahmad, AS Memon
et al21. which showed a mortality of 24% associated with Bogota bag.
Conclusion:
Deep tension suture is an effective way of managing patients with burst abdomen and associated with less morbidity in terms of length of stay,
further need of re-operations and later development of incisional hernia as compared to Bogotá
bag. The mortality of both is almost comparable
and owes more to the condition of the patient
rather than the modality of management.
References:
1. Swaroop M, Williams M, Greene WR et al. Multiple laparotomies are a predictor of fascial dehiscence in the setting of severe trauma. Am Surg 2005;71:402–405
2. Gislason H, Grønbech JE, Søreide O. Burst abdomen
and incisional hernia after major gastrointestinal operations—comparison of three closure techniques. Eur J Surg
1995;161:349–354
3. Penninckx FM, Poelmans SV, Kerremans RP et al. Abdominal
wound dehiscence in gastroenterological surgery. Ann Surg
1979;189:345–352
4. Pavlidis TE, Galatianos IN, Papaziogas BT et al. Complete dehiscence of the abdominal wound and incriminating factors.
Eur J Surg 2001;167:351–354
5. Ma¨kela¨ JT, Kiviniemi H, Juvonen T et al. Factors influencing wound dehiscence after midline laparotomy. Am J Surg
1995;170:387–390
6. Keill RH, Keitzer WF, Nichols WK et al. Abdominal wound
dehiscence. Arch Surg 1973;106:573–577
7. Co¨l C, Soran A, Co¨l M. Can postoperative abdominal
wound dehiscence be predicted? Tokai J Exp Clin Med 1998
;23:123–127
8. . Fleischer GM, Rennert A, Ru¨hmer M. Die infizierte Bauchdecke und der Platzbauch. Chirurg 2000;71:754–762
9. Poole GV Jr. Mechanical factors in abdominal wound closure:
the prevention of fascial dehiscence. Surgery 1985; 97:631–
640
10. Carlson MA. Acute wound failure. Surg Clin North Am
1997;77:607–636
11. Adnan A, Shams NA, Irfan S, Manzar S. Abdominal wound dehiscence: An ongoing dilemma. Pak J Surg 2009;25(3):204-8
12. Badar M, Saira S, Muhammad AS. Post operative Complications in emergency versus elective laparotomies at a peripheral hospital. J Ayub Med Coll Abottabad 2010;22(3):42-7
13. Riou JP, Cohen JR, Johnson H Jr (1992) Factors influencing
wound dehiscence. Am J Surg 163:324–330
14. David CB, Andrew NK. Abdominal wound ehiscence and incisional hernia. Surg 2006;24(7):234-8
15. Begum B, Zaman R, Ahmed M, Ali S. Burst abdomen: A preventable morbidity. Mymensingh Med J 2008;17(1):63-6
16. Lodhi F, Ayyaz M, Majeed HJ etal. Etiological factors responsible for abdominal wound dehiscence and their management.
Ann King Edward Med Coll 1999;5(3-4):312-4
17. Khan MNS, Naqvi AH, Irshad K et al. Frequency and risk factors of abdominal wound dehiscence. J Coll Physicians Surg
Pak 204;14(6):355-7
18. Shaikh MS, Shaikh SA, Shaikh BA. Abdominal wound dehiscence: Frequency and risk factors. J Surg Pak 2005;10(4):30-3
19. Mathur SK. Burst abdomen: A preventable complication,
monolayer closure of the abdominal incision with monofilament nylon. J Postgrad Med 1983;29
20. Waqar SH, Zafar IM, Asma R et al. Frequency and risk factors
for wound dehiscence/ burst abdomen in midline laparotomies. J Ayub Med Coll Abbottabad 2005;17(4):
21. Kirshtein B, Roy-Shapira A, Lantsberg L, Mizrahi S. Use of the
“Bogota bag” for temporary abdominal closure in patients with
secondary peritonitis. Am Surg. 2007 Mar;73(3):249-52.
22. Myers JA, Latenser BA Nonoperative progressive “Bogota
bag” closure after abdominal decompression. Am Surg. 2002
Nov;68(11):1029-30
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