Abdominal Wound Dehiscence

Presenter: T Mohammed Moderator: Dr H Pienaar

Introduction
• Wound Dehiscence is the premature "bursting" open of a wound along surgical suture. It is a surgical complication that results from poor wound healing. Risk factors in general are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery. Sometimes a pink (serosanguinous) fluid may leak out.

Introduction
• Abdominal wound dehiscence (burst abdomen, fascial dehiscence) is a severe postoperative complication, with mortality rates reported as high as 45%. The incidence as described in the literature ranges from 0.4% to 3.5%.

high incidence of incision hernia. Prolonged hospital stay. requiring immediate treatment.Introduction • Abdominal wound dehiscence can result in evisceration. . and subsequent reoperations underline the severity of this complication.

incidence and mortality rates in regard to abdominal wound dehiscence have not significantly changed over the past decades. This may be attributable to increasing incidences of risk factors within patient populations outweighing the benefits of technical achievements.Introduction • Despite advances in perioperative care and suture materials. .

Types of Wounds .

Recent Literature • In this study by Van Ramshorst et al (World J of Surg 2010. Erasmus University Medical Center. The study was conducted at the department of surgery. Netherlands.34:20-27) the objective was to develop a risk model to recognize high risk patients and identify independent risk factors for abdominal wound dehiscence. Rotterdam. .

Major independent risk factors were: age. . jaundice. postoperative coughing. gender. and wound infection. anemia. chronic pulmonary disease. emergency surgery. ascites.089 controls were analyzed.Recent Literature • A total of 363 cases and 1. type of surgery.

001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). risk scores were significantly higher (P<0. Resulting scores ranged from 0 to 8.Recent Literature • In the validation population.1%.02% to 70. and the risk for abdominal wound dehiscence over this range increased exponentially from 0.5. .

.Risk Formula • The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk. The calculation of the probability of abdominal wound dehiscence for an individual surgical patient is performed in two steps.

. the probability of developing abdominal wound dehiscence.37 + (1.085 x calculated total risk score)’. P. the total risk score is calculated by adding the weights of the various variables shown in Table 1. In the second step. is calculated according to the logistic formula: P= eх/ (1+ex )x100%.Risk Formula • First.where ‘ex’ represents the exponential function and ‘x’ represents ‘-8.

.

for a total of 3. P.6)) x100%= 1.6)) /1+e (-8.Risk Calculation • For example.37+(1.6.7 (score for chronic pulmonary disease). of this patient’s developing abdominal wound dehiscence is: e(-8.37+(1.7 (score for male gender) ? 1. the risk score for a 67-year-old man who undergoes an elective reconstruction of the abdominal aorta and is known to have a history of chronic pulmonary disease is 0.3 (score for vascular surgery) + 0.085x3.1% .085x3. The probability.9 (score for age 60– 69 years) + 0.

Thus. subtotal of 3. the absolute risk rises to 4.7 anemia).6 emergency + 0.Risk Calculation • An emergency repair in a similar patient with a ruptured aneurysm and subsequent anemia results in a total score of 4.6 points + 0.9 (i..5%.e. .

Risk Score Intepretation .

and the chance of contamination of the surgical field is higher than in elective surgery. the performance of the surgeon might be affected at night.Risk factors • Patients who undergo emergency surgery are generally in worse condition and nutritional state. Moreover. which could lead to suboptimal closure of the abdomen at the end of the operation. .

Especially during the first few days of the wound healing process. The explanation for this might lie in deterioration of the tissue repair mechanism in the elderly. Age has also been reported as a risk factor in other studies.Risk factors • Old age is another independent risk factor for abdominal wound dehiscence. the immune system plays a key role. .

Risk Factors • One of the interesting risk factors found in this Rotterdam study. This was attributed to smoking as a possible confounder and its effect on tissue repair. . In previous studies. is gender. males have been reported to have a higher risk of developing abdominal wound dehiscence.

causing the sutures to cut through the muscles and fascia. An increase in intra-abdominal pressure results in higher strain on the wound edges. .Risk Factors • Another explanation may be that men build up higher abdominal wall tension than females.

Risk Factors • In the Rotterdam study. Its importance has been confirmed by virtually every study on this topic. . wound infection proved to be the risk factor with the highest relative weight. Continued presence of bacteria causes influx and activation of neutrophils and increases in levels of degradative matrix metalloproteinases (MMPs).

which degrades collagen fibers. wound degradation will occur. Infection thereby causes a prolongation of the inflammatory phase and negatively affects deposition of collagen and fibroblast activity. .Risk Factors • In the absence of sufficient tissue inhibitors of MMPs. The release of endotoxins by bacteria leads to the production of collagenase.

it has been observed that degradation of collagen exceeds the synthesis of collagen. which adversely affects breaking strength. Adequate tissue breaking strength is necessary.Risk factors • In wounds of patients with abdominal wound dehiscence. . however. to provide support for the sutures that hold the wound edges together.

. especially in the presence of increased intra-abdominal pressure and abnormal inflammatory response.Risk Factors Low breaking strength can therefore amount to abdominal wound dehiscence.

. creating the need for the use of mesh or acceptance of the high risk of recurrent abdominal wound dehiscence.Risk factors • Primary repair can be difficult or impossible when tissue has low breaking strength.

Risk factors • Risk factors that did not have independent effects in the Rotterdam study included: 1. corticosteroid use.uremia 3.hypertension 2. .

sepsis. but no significant effects were found in the present study. . Malignancy.Risk Factors • The Rotterdam study found no significant effect on the occurrence of abdominal wound dehiscence for diabetes mellitus and previous laparotomy. and postoperative vomiting have been identified as risk factors by several authors.

. microvascular changes due to hypertension and diabetes. would be risk factors.Risk factors • This was surprising because it was suspected that the presence of scar tissue. associated with sepsis and malignancy. and poor overall condition of the patient. poor tissue perfusion.

.e.. was found to be an independent risk factor. The conclusion of The Rotterdam study was that wound healing is affected in jaundiced patients due to the association with low hematocrit and albumin levels and malignancy (i.Risk factors • Jaundice. on the other hand. poor nutritional status) and not to raised bilirubin levels.

Risk Factors • Low protein and albumin levels and deficiencies of several vitamins and minerals such as vitamins A. B1. selenium and copper have been associated with poor wound repair. C and zinc. B2. B6. .

and decreased tissue oxygenation. blood transfusions. all of which can affect the immune system and the wound healing process. .Risk Factors • Anemia is a risk factor that is related to increased perioperative stress.

American Risk Model • A similar validation model of risk of dehiscence index was developed by an American group in Salt Lake City Utah in 2003 using data from the Veterans Affairs National Surgical Quality Improvement Program but lacks a formula for calculating the probability of developing dehiscence as in the Rotterdam Study. .

our results may not be generalizable to the public at large.American Risk Model • There are several limitations to this study. . Because the veterans carry more comorbidities than the general population.

Abdominal Wall Closure For secure abdominal wall closures. . the reduced tissue integrity along the border of the acute wound led to development of the concept of an optimal suture length–to– wound length (Suture Length-to-Wound Length) ratio for the primary closure of midline laparotomies .

large. this is where the surgical training dictum of 1-cm ‘‘bites’’ followed by 1 cm of progress originated.Abdominal Wall Closure Well-done. prospective studies with the best follow-up found that a SL-to-WL ratio of approximately 4:1 minimized the incidence of fascial dehiscence and incisional hernia formation. .

chronic pulmonary disease. type of surgery. jaundice. gender • 3. and wound infection. emergency surgery.Conclusion • Important risk factors for abdominal wound dehiscence have been identified in the Rotterdam case-control study 2010 including: • 1. age. • 4. . • 2. anemia. coughing.ascites.

Conclusion • • • • • • 5.emergency surgery 8.wound infection .jaundice 6.anemia 7.type of surgery 9.coughing 10.

Conclusion • A number of factors for abdominal wound dehiscence have been identified but the risk of developing abdominal wound dehiscence can be reduced by preventing pneumonia and wound infection. . and by applying optimal surgical technique in every patient.

Surg Clin North Am 2003. • The biology of acute wound failure.34:2027. Dubay et al.References • Abdominal wound dehiscence in adults. 109: 130137. World J of Surg 2010. Webster et al. • Prognostic models of wound dehiscence. J Surg Research 2003. Van Ramshorst et al.83:464-481 .

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