BURST

ABDOMEN

I Ketut Sudartana, MD., PhD. Heru Sutanto Koerniawan
Associate Professor – Consultant PGY-4 Surgical Resident
Department of Surgery Depaertment of Surgery
Digestive Surgery Sanglah General Hospital – Udayana
Sanglah General Hospital University School of Medicine
Denpasar Bali Denpasar Bali

INTRODUCTION
Burst Abdomen or Abdominal Wound Dehiscence is a severe post-surgical complication. It is
defined as post surgical separation of musculo-aponeurotic layers of abdomen and a serious
sequel of impaired of wound healing process .1 It is considered when intestine, omentum, or
other viscera’s are seen in the abdominal surgical wound following any abdominal surgery.
Despite the advance in asepsis method, anti microbial drugs, sterilization and operative
technique, burst Abdomen is a continuing problem for the general surgeon as the incidence
of such complication may reach 3% and mortality more than 25%.2
WOUND HEALING
During Surgery, when the incision made, It will initiate a complex cascade of
mechanism in cellular level, which aim at achieving healing at incision site.3 The healing may
occur in primary intention (wounds with opposed edges) or by secondary intention (wounds
with separated edges). Healing by secondary intention occurs whenever there is an extensive
loss of cells and tissue occurs in infarct, inflammatory, infection, ulceration, abscess
formation.
Wound healing is a mechanism wherein the body tries to re-establish the integrity of
the injured part. It requires energy and is an anabolic process. It is a continuous process with
four different stages: hemostasis, inflammation, proliferation and maturation.5,6

Figure 1. Sequential illustration of the stages involved in the wound healing process.8

The hemostasis occurs at the beginning of inflammatory stage. The injured blood
vessels contract and the leaked blood coagulates contributing to the maintenance of its
integrity. The fibrin will be forming a barrier against microorganism. In the late stage of
inflammatory there will be migration and proliferation of fibroblast. The aim of the
proliferative stage is to diminish the injured tissue area by contraction and fibroplasia,
establishing a viable epithelial barrier to activate keratinocytes. This stage is responsible for
the closure of the lesion itself, which includes angiogenesis, fibroplasia, and re-
epithelialization. These processes begin in the microenvironment of the lesion within the first
48 hours and can unfold up to the 14th day after the onset of the lesion.8 The third phase of
healing consists of remodeling, which begins two to three weeks after the onset of the lesion
and can last for one year or more. The core aim of the remodeling stage is to achieve the
maximum tensile strength through reorganization, degradation, and re-synthesis of the
extracellular matrix.8

If there is a failure in one of the stages due to any causes, such as lack of resource
needed for healing (malnutrition), or lack of energy due to infection fighting process, or not
ideal of environment such as sepsis, the wound would break apart. More over the
proliferation of bacteria leads to decrease collagen synthesis and weakening of fascial closure.
Gram negative bacteria are most common organism involved in abdominal wound
dehiscence.1

RISK FACTOR
Patient
Study by halaza found, there is no correlation of the increased incidence of Burst abdomen
with the increasing age.4 The presence of anemia, hyponatremia, hypoalbuminemia,
peritonitis, post operative complications, obesity, increased intra-abdominal pressure (severe
cough, vomiting, and distension), sepsis, post operative wound infection, delayed
presentation, and malignancy is a risk for burst abdomen.1,4,5 Increased intra-abdominal
pressure and inflammatory mediators lowers the tissue breaking strength and increase the
probability for dehiscence.5 Infection and sepsis increases metabolic rate. If it prolongs along
with the decrease of body mass such as in malignancy, catabolic metabolism would persist. It
will cause detrimental effect on wound healing.5 Diabetes Mellitus and Use of corticosteroid
can hinder the wound healing process that contribute in wound dehiscence or fascial
dehiscence that cause burst abdomen.13
Operative
Midline and vertical wounds apparently more likely to disrupt with hernia rate 5%-15% than
transverse.9,11 Transverse, oblique and paramedian incisions caused significantly less
incisional hernias and burst abdomen than midline incisions.10,11 Despite the apparent
benefits of the paramedian incision10, it has not gained widespread use. This is likely due to
the challenge of ostomy creation, slower entrance and closure, and decreased exposure
compared with a midline laparotomy.9 The midline incision is still preferred because of the
ease, speed, and excellent exposure but should be used with caution because of the high
incidence of incisional hernia.11

Figure 2. Incisions.11
Method of closure affects the risk of burst abdomen as continuous suture more likely
to disrupt than interrupted suture.9 The interrupted sutures were preferred over continuous
sutures in the present study, as it was feared that continuous mass suture might produce
strangulation of the tissues included in the bite. But in some study recommend that
Continuous closure over interrupted closure since it is faster and less costly. Dehiscence,
wound complication rates, and incisional hernia rates are similar between interrupted and
continuous closures.9 There is a theoretical benefit of even distribution of tension across the
entire incision with continuous sutures.9 A potential disadvantage of a continuous closure is
the risk that the entire suture line can be disrupted if a single knot or strand of suture breaks;
however, this has proven to be an extremely rare cause of wound dehiscence.
The amount of suture used also appears to be important in reducing hernia formation. A
suture-to-wound-length ratio of at least 4:1 is thought to be the minimum amount of suture
needed to provide a strong closure and reduce hernia formation.9 It is not clear with what
frequency a 4:1 suture-to-wound-length ratio is obtained in clinical practice, since most
surgeons do not routinely measure their exact suture usage. One factor that affects the
suture-to-wound-length ratio is the size and distance between the fascial bites. Some have
questioned the traditional teaching that fascial bites should be 1 cm from the fascial edges
and have 1 cm advances.9 Israelsson et al have reported that a 4:1 ratio for suture-to-wound
length and smaller fascial bites (,1 cm) result in less hernia formation.9 Millbourn et al and
Deerenberg et al comparing fascial closure using smaller bites (5–8 mm) to larger bites (10
mm) demonstrated decreased incisional hernias when smaller fascial bites were used.12,13
The suture material was reported influence the risk of burst abdomen as well.6,7 Meta-
analyses by Diener et al and Van’t Riet et al demonstrated no difference in incisional hernia
incidence between slowly absorbable and non absorbable sutures; however, more wound
pain and more suture sinuses occurred with the use of non absorbable sutures.14,15
CLOSURE OF BURST ABDOMEN
Many different methods have been used to close the dehiscence, ranging from simply closing
the skin over the defect and leaving the fascia and peritoneum wide open to doing relaxing
incisions of both fascia and skin well away from the wound, closing the primary wound and
skin grafting the resulting defect. More recently (figure 3), the bogota bag technique (1984),
the barker technique (1997) , and the vacuum pack technique (1995),17 as well as mesh, has
been used, including Prolene, Marlex, PTFE and Vicryl, or more complex closures using
pedicled or rotation flaps are being used. None of these methods proved to be ideal or
without a significant hazard, and certain disadvantages inherent in each technique require
departure from the ideal: primary tension-free parietal closure without use of prosthetic
material.
Esmat reported a new technique called TI, TIE and TIES incision.2 The lateral incision is done
from inside the abdomen along a line between the costal margin above to the iliac crest below
in the area between the mid and anterior axillary line. According to the depth of the incision,
the incision may either involve the transversus abdominis muscle and internal oblique
muscles (TI incision), or include in addition the external oblique muscle (TIE incision), or it may
also involve the Scarpa’s fascia (TIES incision). Such incisions would give an extra length on
each side towards medial advancement.2

Figure 3. Left. Bogota Bag; Middle. Barker Technique; Right. Vacuum assisted closure.17

2
Figure 4. a closure of burst abdomen with TIES incision.
CONCLUSION
Burst abdomen is a serious sequel of impaired wound healing. Eliminating local wound
complications (burst abdomen) after abdominal wound closure remains a persistent
challenge. Presence of anaemia hipoproteinemia, hipoalbuminemia, infection, and sepsis
favors high incidence of burst abdomen.
Yet there is a considerable amount of evidence regarding the optimal closure
technique. While the type of incision seems to play a role in hernia formation, surgeons are
unlikely to change their practice. The primary closure sometimes not possible, the “bridge” in
doing delayed sometimes need to be done as the infection and the soiling of the wound are
severe so there are some technique such as Bogota Bag, Bakers Technique, and Vacuum
Assisted Closure can be an alternative to administered.
To decrease local wound complications and hernia formation after laparotomy
closure, fascial closure with a size 1 or 2 slowly absorbable monofilament suture is
recommended. The suture length - to- wound-length ratio should be greater than 4:1. Closure
should be accomplished with small fascial bites (5–8 mm). Excessive tension has to be
avoided. A recent study by Hope et al evaluating surgery residents found that only 10% of
residents knew the correct suture-to-wound-length ratio, and only 40% were familiar with
literature on the proper technique of abdominal closure.16


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