NURSING
PRACTICE &
SKILL
ICD-9
998.31, 998.32, 998.33
ICD-10
T81.31, T81.32, T81.33
Authors
Suzan E. Jaffe, RN, PhD, ARNP
Cinahl Information Systems, Glendale, CA
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Reviewers
Darlene Strayer, RN, MBA
Cinahl Information Systems, Glendale, CA
Mary Woten, RN, BSN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
May 12, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Postoperative Complications: Preventing and Managing
Wound Dehiscence and Evisceration
What is Preventing and Managing Postoperative Wound
Dehiscence and Evisceration?
› Postoperative wound dehiscence and evisceration (PWDE) is a serious and potentially
life-threatening complication of surgery characterized by rupture of the suture line and
exposure or protrusion of internal organs. Careful patient monitoring, prompt recognition
of signs and symptoms indicating the development of this complication, and immediate,
appropriate intervention are necessary to minimize the consequences of PWDE and
support recovery (for more information on potential postoperative complications, see
Quick Lesson About … Surgical Wounds: Complications )
• What: Wound dehiscence is the rupture of a wound along the surgical suture line, which
can involve partial or complete separation of the joined sides of the incision; if there is
complete separation of the wound, the underlying viscera or organ may be exposed but
will remain intact within the body. Wound dehiscence is often accompanied by a sudden
gush of serosanguineous fluid, and can lead to wound evisceration. Wound evisceration,
an emergency postoperative complication, occurs when internal organs protrude through
the incisional site (e.g., protrusion of intestine from the abdominal cavity in cases of
abdominal surgery). The timing of PWDE is typically 5–8 days after the surgical event.
Intensive nursing assessment and initiation of prevention strategies can reduce patient
risk for PWDE
• How: Performing thorough preoperative screening (e.g., risk factor assessment,
including asking about a history of PWDE) and vigilant postoperative wound assessment
and care are essential to reduce the risk for PWDE. If PWDE develops, supportive
medical and nursing care is initiated and the patient is evaluated for immediate surgical
resolution. To manage evisceration, dressings saturated with normal saline (NS) are
applied to the wound using sterile technique to prevent further infection and drying of
the eviscerated organs
• Where: Prevention is initiated immediately following the surgical event when the patient
is in the post-anesthesia care unit (PACU), and continues through the inpatient stay
and after discharge from the facility (e.g., at home or in a rehabilitation center/facility).
Interventions and management for PWDE are initiated in any setting when PWDE
is identified, although typically a patient who develops PWDE while at home or in a
rehabilitation center/facility is readmitted to the acute care setting
• Who: Assessment of PWDE is the responsibility of the registered nurse and should not
be delegated to assistive healthcare personnel. Some facilities have specially trained
nurses certified in wound management who assess wounds that are not healing normally
or in patients who are considered at high risk for PWDE (e.g., patients with a history of
PWDE). Interventions (e.g., surgical resolution) for PWDE are performed by a physician
What is the Desired Outcome of Preventing and Managing
Postoperative Wound Dehiscence and Evisceration?
› The desired outcome of preventing and managing wound dehiscence and evisceration
is to decrease the serious consequences of this potentially life-threatening postoperative
complication
Why is Preventing and Managing Postoperative Wound Dehiscence and Evisceration
Important?
› Postoperative dehiscence is not just a cosmetic issue, although the patient can develop increased scarring following
dehiscence, but increases the risk for infection and evisceration. If evisceration occurs, the patient’s risk for infection,
peritonitis, and septic shock is substantially increased
› Because patients who experience evisceration have high rates of morbidity and mortality, intensive monitoring to reduce the
risk for PWDE and effective emergency intervention for patients who develop PWDE are often life-saving

Facts and Figures

› Post-laparotomy wound dehiscence occurs in 0.25–3% of cases; patients requiring surgical resolution are reported to have
death rates as high as 20% (Spiliotis et al., 2009)
› Preventing postoperative surgical site infection (SSI) appears to be one of the most significant strategies for preventing
wound dehiscence (Johnson, 2009)
› Investigators in Italy used a novel medical device called the Rigeneracons to manage patients with surgical wound
dehiscence. The Rigeneracons obtains autologous micro-grafts that are available for immediate clinical use, allowing for
the repair of damaged tissue. The investigators observed a complete remission of dehisced wounds in patients who received
treatment via the Rigeneracons (Marcarelli et al., 2016)

What You Need to Know Before Initiating Strategies to Prevent or Manage

Postoperative Wound Dehiscence and Evisceration
› The nurse should be familiar with
• the physiologic process of normal wound healing and factors that can interfere with this process
–The first 2 postoperative weeks are the most critical for normal wound healing because the wound is in the early phases of
healing and the suture line is fragile
- Observing the incision site and monitoring that sutures or staples are intact are simple strategies for preventing PWDE
• aseptic technique. Aseptic technique varies somewhat depending on the clinical situation and is generally distinguished as
either surgical aseptic technique (referred to as surgical asepsis or sterile technique; i.e., complete maintenance of asepsis
during all elements of the procedure) or general aseptic non-touch technique (ANTT; i.e., non-sterile surfaces/items do not
come in contact with sterile surfaces/items) (for more information, see Nursing Practice & Skill … Aseptic Technique and
Infection Prevention: Applying Principles )
› Risk for PWDE is increased in patients who
• develop SSIs; infection in the incisional wound delays healing and weakens newly formed tissue, making the surgical site
susceptible to injury (e.g., dehiscence) (for more information, see Evidence-Based Care Sheet: Infections, Surgical Site:
Prevention )
–Monitoring wound drainage is essential in assessing for SSIs; monitoring should include drainage consistency, color,
smell (e.g., foul odor suggests infection), and quantity (e.g., a larger amount of drainage than expected suggests infection)
• are malnourished prior to surgery or unable to eat adequately during the postoperative period
–To promote healing, it is essential that postoperative patients receive an adequate supply of protein, calories, and vitamins.
Referral to a dietitian or administration of parenteral nutrition may be indicated for patients who are malnourished or
otherwise at risk for PWDE
• are obese; the normal process of wound closure and healing is impeded in obese persons due to excess adipose tissue
(for more information, see Nursing Practice & Skill … Surgical Risk Factors: Obesity --Implementing Assessment and
Prevention Strategies )
• develop sudden increased abdominal pressure (e.g., due to vomiting, coughing, or heavy lifting), which can compromise
the integrity of the incisional wound; postoperative systemic infection (e.g., upper respiratory virus) and chronic
obstructive pulmonary disease (COPD) increase this risk
–Patients should not lift anything heavier than 5 lb (~ 2.3 kg) for at least two weeks following surgery
› Medical conditions that increase risk for PWDE include
• Ehlers-Danlos syndrome, which is a genetic disorder characterized by insufficient collagen production for normal scar
formation
• scurvy, which is caused by vitamin C deficiency; normally vitamin C strengthens the cross links of collagen fibers, and
without adequate vitamin C intake the scar tissue is weak
 • diabetes mellitus, because affected persons have poor circulation and decreased oxygenation and nutrition to the wound
site, resulting in the formation of weak scar tissue
• cardiovascular disease and hypertension
• neoplasm
• liver or renal disease
• chronic anemia
• immune deficiency syndromes (e.g., HIV/AIDS)
› Other factors that increase risk for PWDE include
• older age (> 65 years)
• alcoholism
• chemotherapy or radiation therapy
• hypoalbuminemia
• chronic tobacco use
• use of certain medications (e.g., aspirin, anticoagulants, systemic corticosteroids)
› The risk for dehiscence is reduced by regular inspection of the integrity of the wound closure and close monitoring for signs
of infection
› Preliminary steps that should be performed before initiating strategies to prevent or manage PWDE include the following:
• Review the facility/unit specific protocols for preventing and managing PWDE, if available
• Review the treating clinician’s orders regarding postoperative patient monitoring and care of the surgical site
• Review the manufacturer’s instructions for all equipment to be used and verify that the equipment is in good working order
• Verify completion of facility informed consent documents, as necessary
› The general consent for treatment executed by patients at the outset of admission to a healthcare facility typically contains
standard provisions that encompass wound care; additional informed consent documents will be necessary if emergent
surgery is performed to manage evisceration
• Review the patient’s medical history/medical record for
–the surgery performed
–any allergies (e.g., to latex, medications or other substances); use alternative materials, as appropriate
–any risk factors for PWDE (e.g., older age, chronic tobacco use)
› Gather the necessary supplies, which typically include the following:
• Sterile and nonsterile gloves; additional personal protective equipment (PPE; e.g., gown, mask, eye protection)will be
necessary if exposure to body fluids is anticipated
• Facility-approved pain assessment tool
• Vital signs monitoring equipment
• Prescribed medication (e.g., antibiotic, analgesic, anxiolytic, antiemetic), if applicable
• Sterile NS (1 L)
• Sterile irrigation set (including 50 mL catheter-tip syringe and sterile basin)
• Sterile towels
• Sterile abdominal dressings and/or gauze, and tape to secure dressings
• Sterile, waterproof drape to place over the abdominal dressings
• Absorbent “linen-saver” pads to protect bedding from fluids
• Intravenous (I.V.) therapy supplies (e.g., prescribed I.V. solution, needles, tubing)
• Nasogastric tube and suction equipment
• Written information, if available, to reinforce verbal education

How to Initiate Strategies to Prevent or Manage Postoperative Wound Dehiscence

and Evisceration
› Perform hand hygiene and don PPE as appropriate
› Identify the patient according to facility protocol
› Establish privacy by closing the door to the patient’s room and/or drawing the curtain surrounding the patient’s bed
› Introduce yourself to the patient and family member(s), if present; explain your clinical role; assess the coping ability of the
patient/family and for knowledge deficits and anxiety regarding PWDE and related patient care procedures
• Determine whether the patient/family requires special considerations regarding communication (e.g., due to illiteracy,
language barriers, or deafness); make arrangements to meet these needs, if present
 –Use professional certified medical interpreters, either in person or via telephone, if language barriers exist
• Explain the procedure (including the expected length of time it will take) and the purpose of care; answer any questions and
provide emotional support as needed
• As necessary, ask family members and other visitors to leave the patient’s room to promote privacy and/or for infection
control purposes during wound care
› Assess the patient’s general health status and the incision site
• Assess the patient’s pain level using a facility-approved pain assessment tool
• Assess vital signs
• Examine the wound carefully according to facility protocol, noting wound location, type, and size, and the presence and
characteristics of any wound drainage
–Report to the treating clinician if the sutures or staples are very close together (if still present), or if the edges of the
incision appear tight and binding
- Unnecessarily tight sutures or staples can cause tissue necrosis due to strangulation of the wound edges (i.e., lack of
oxygen perfusion to new tissue)
–Note the initial characteristics of wound drainage and monitor for changes in drainage consistency, quantity, odor, and
color (e.g., blood tinged, purulent)
–Palpate immediately under the incision
- By the fifth postoperative day, a healing ridge of granulation tissue should be palpable; the ridge should extend
approximately 1 cm on both sides of the surgical wound
- Any deviations from normal healing, including poor ridge formation, suggest increased risk for PWDE, especially
between postoperative days 5 and 8
–Monitor for an open wound and exposed and/or protruding internal organs
• If abnormalities are assessed in the surgical incision, immediately notify the treating clinician and document in the patient’s
medical record that the abnormalities were assessed and the treating clinician notified
–The treating clinician may be able to fill in any gaps in the suture line by adding more sutures or applying sterile adhesive
strips to secure the wound at the bedside
• Confirm that the patient is receiving adequate nutrition to promote healing; request referral to the facility dietitian or
discuss with the physician the possibility of providing parenteral nutrition if there are any concerns regarding the patient’s
nutritional status
› Perform/assist with performing the following interventions if the patient develops wound dehiscence:
• Call for assistance from additional personnel, as needed
• Call the treating clinician; if the treating clinician is not available, follow facility protocol for notifying the on-callphysician
• Perform hand hygiene and apply nonsterile gloves
• Use ANTT to apply a sterile nonadherent dressing over the wound or use sterile technique to apply a wet NS dressing over
the wound as follows:
–Create a sterile field and arrange supplies
–Pour sterile NS into the sterile basin/container of the irrigation set
–Perform hand hygiene and don sterile gloves
–Saturate the dressings by placing in the basin with NS
–Place the moistened dressing over the wound and secure with a dry outer dressing and tape, as ordered
• Remain with the patient and provide emotional support to reduce anxiety
• Monitor vital signs frequently, noting any increase in body temperature as a sign of potential infection
• Assess for pain and administer prescribed analgesic; if prescribed analgesic is not adequate to relieve pain, notify the
treating clinician and administer other dosage or drug, as ordered
• Administer other prescribed medications (e.g., antibiotics, antiemetics), as ordered
• Maintain the patient in a supine position with the hips and knees bent and the head of the bed elevated no more than 20°
until the treating clinician arrives and/or initiates other orders
• If the treating clinician orders the wound to be left open (i.e., not surgically closed) and packed with gauze, repeat the
above sterile dressing procedure using sterile NS-moistened gauze, placing a dry dressing external to the wet gauze and
securing with tape
–Note that in some cases, the treating clinician orders that the wound be exposed to air because it may accelerate healing,
allow for drainage (e.g., of pus), and enhance new tissue growth
 • When dehiscence is resolved, another nurse takes over care of the patient, or the patient is transferred for surgical
resolution, discard used procedure materials appropriately and perform hand hygiene
› If evisceration occurs, follow facility protocols for patient care, which generally include the following:
• Call for assistance from additional personnel, as needed
• Immediately call the treating clinician; if the treating clinician is not available, follow facility protocol for notifying the
on-callphysician
• Do not attempt to push any protruding viscera into the abdomen
• Perform hand hygiene and don nonsterile gloves
• Place an absorbent “linen-saver” pad under the patient
• Create a sterile field
• Pour sterile NS (approximately 400 mL) into the sterile basin/container of the irrigation set
• Perform hand hygiene and don sterile gloves
• Saturate one or two sterile abdominal dressings by placing them in the basin with the sterile NS
• Place the moistened dressings over the patient’s exposed viscera
• Check the dressings at least every hour and use a syringe to squirt sterile NS over the dressings to resaturate them
• Observe the color of the exposed viscera while performing dressing checks
–If viscera is black or dusky in appearance, notify the treating clinician immediately that the patient may be developing
tissue hypoxemia and necrosis
• Maintain the patient on complete bed rest in a low Fowler’s position with head elevated no more than 20° and knees flexed
• Keep the patient NPO until further orders are obtained to reduce the risk for aspiration if surgery is to be performed
• Monitor vital signs every 15 minutes and intensively monitor for the development of peritonitis and septic shock
• Assess for pain and administer prescribed analgesics, as ordered; if prescribed analgesic does not provide adequate pain
relief, notify the treating clinician and administer other dosage or drug, as ordered
• Administer other prescribed medications (e.g., antibiotics, antiemetics), as ordered
› If surgical resolution is ordered (e.g., for organ repositioning and resuturing, placement of surgical mesh, debridement of
necrotic tissue, or resolution of other complicating conditions such as bowel edema), prepare the patient for returning to the
operating room
• Start an I.V. line if one is not already running, and insert a nasogastric tube attached to low suction, if ordered
• Remain with the patient and/or family and provide emotional support to reduce anxiety
• Verify completion of facility informed consent documents for surgery
• Administer prescribed preoperative medications (e.g., antibiotics, anxiolytics)
• Keep the head of the bed elevated at a low Fowler’s position
• Frequently assess the patient’s vital signs and level of consciousness; report status changes immediately to the treating
clinician
• Assess for pain and other discomfort and administer analgesics, as ordered. If medication is inadequate to relieve
symptoms, immediately consult with the treating clinician and administer additional medication dose or another agent as
ordered
• Maintain wound status per facility protocols or orders of the treating clinician (e.g., wound and organs covered with wet
dressings, packed with gauze, or exposed to air)
• Assist with transporting the patient to the surgical suite, as appropriate
› Update the patient’s plan of care, as appropriate, and document the following information in the patient’s medical record:
• Date and time patient care was provided
• Description of the care provided to prevent or manage PWDE, including wound care procedures, any medications
administered, insertion of a nasogastric tube, and/or initiation or maintenance of I.V. therapy
• Patient assessment information, such as
–vital signs
–pain level
–level of consciousness
–wound assessment findings and details of the development of dehiscence or evisceration, as applicable
–the patient’s activity level and mobility before the development of PWDE, if applicable
• Date and time of surgery and if the patient has a coexisting condition (e.g., bowel edema) that requires surgical repair
• Patient/family education, including topics presented, response to education provided/discussed, plan for follow-up
education, and details regarding any barriers to communication and/or techniques that promoted successful communication
Other Tests, Treatments, or Procedures That May be Necessary Before or After
Initiating Strategies to Prevent or Manage Postoperative Wound Dehiscence and
Evisceration
› PWDE is typically an unexpected event, but the treating clinician may order ultrasound, CT scan, or MRI to evaluate for
infection and/or pockets of fluid below the suture site in patients at risk for PWDE
› Stool softeners may be prescribed to prevent constipation
› Routine preoperative chemistry, including glucose and albumin, is usual
› Other laboratory tests are ordered based on the patient’s physiologic status, the presence of coexisting medical conditions,
and previous abnormal test findings
› Temporary or permanent surgical mesh may be surgically placed to bridge the opening at a gaping incision
› Negative pressure wound therapy (NPWT; see Nursing Practice & Skill … Wound Therapy, Performing: Applying Negative
Pressure ) is approved by the U.S. Food and Drug Administration (FDA) for treatment of dehisced wounds. NPWT induces
healing by
• mechanically drawing wound tissue together
• decreasing the wound size
• promoting granulation tissue formation
• increasing local tissue perfusion
• reducing bacterial colonization
• removing interstitial fluid
• reducing tissue edema
• promoting the absorption of intra-abdominal fluid

What to Expect After Initiating Strategies to Prevent or Manage Postoperative Wound

Dehiscence and Evisceration
› PWDE will be prevented and patient’s postoperative wound will heal normally
› If PWDE occurs, wound management and interventions will be initiated that reduce patient morbidity and mortality risk and
the patient will be stabilized within a short period of time
› If surgery is necessary, all patient information will be documented in the patient’s medical record prior to handing off the
patient to surgical personnel

Red Flags
› Wound dehiscence carries a high risk for infection and even death if untreated
› Wound evisceration is an emergency and under no circumstances should the nurse or another medical professional attempt
to force the protruding organs into the abdominal cavity

What Do I Need to Tell the Patient/Patient’s Family?

› Educate the patient/family about the normal process of wound healing and strategies for minimizing risk for PWDE
• Teach the patient to splint the surgical area independently or to ask for assistance with splinting when coughing, vomiting,
or bearing down to defecate
› Explain that it may take some time before the incision closes if dehiscence or evisceration occurs
› Describe how frequent dressing changes may be necessary, particularly if continuous or excessive wound drainage is present
› Recommend limiting or ceasing smoking because tobacco use is correlated with reduced wound healing
› Encourage adequate nutritional intake to promote wound healing
› Before discharge, instruct the postsurgical patient and his/her family members in emergency care if dehiscence or
evisceration occurs; provide written instructions, if available, to reinforce verbal education
• Cover the wound area with the cleanest sheet, towel, or bandage available after wetting it thoroughly (e.g., with sterile NS
if available or bottled water if not)
• Help the patient maintain an upright position with knees bent
• Transport the patient to the closest emergency department or contact emergency medical services
› Advise patient not to lift anything heavier than 5 lb (~ 2.3 kg) for at least two weeks following surgery
› Instruct the patient and family to adhere to all prescribed wound care treatments, medications, and activities as recommended
at discharge, and to keep all follow-up appointments as scheduled
Note
› Recent review of the literature has found no updated research evidence on this topic since previous publication on Marc 18,
2016

References
1. Burki, T., Misra, D., Ward, H., Patricolo, M., & Cord-Udy, C. (2009). Conservative management of major abdominal wound dehiscence in premature babies - A seven-year
experience. European Journal of Pediatric Surgery, 19(4), 232-235. doi:10.1055/s-0029-1215602 (R)
2. Eckman, M. (Ed.). (2014). Wound dehiscence and evisceration management. In Lippincott’s nursing procedures (6th ed., pp. 793-795). Philadelphia, PA: Wolters Kluwer
Health/Lippincott Williams & Wilkins. (PP)
3. Hendrickson, M. A. (2009). Optimizing wound care by integrating negative pressure wound therapy (NPWT) adjunctive topical treatments and surgical debridement.41st Annual
Wound, Ostomy and Continence Nurses Annual Conference, St. Louis, Missouri, June 6-10, 2009. Journal of Wound, Ostomy, and Continence Nursing, 36(3S Suppl.), S15.
(C)
4. Johnson, C. M. (2009). Development of abdominal wound dehiscence after a colectomy: A nursing challenge. Medsurg Nursing, 18(2), 96-102. (C)
5. Lachmandath, S. T., Menon, A. K., Hatam, N., Amerini, A., MOza, A. K., Autschbach, R., & Goetzenich, A. (2012). Prevention of sternal dehiscence with the sternum external
fixation (Stern-E-Fix) corset – A randomized trial in 750 patients. Journal of Cardiothoracic Surgery, 7, 85. doi:10.1186/1749-8090-7-85 (RCT)
6. Marcarelli, M., Trovato, L., Novarese, E., Riccio, M., & Graziano, A. (2016). Rigenera protocol in the treatment of surgical wound dehiscence. International Wound Journal,
14(1), 277-281. doi:10.1111/iwj/1260 (R)
7. Reaves, K. (2009). Dilemmas of dehiscence. Ostomy/Wound Management, 55(11), 14. (GI)
8. Sandy-Hodgetts, K., Ousey, K., & Howse, E. (2017). Top ten tips: Management of surgical wound dehiscence. Wounds International, 8(1), 11-14. (GI)
9. Spiliotis, J., Tsiveriotis, K., Datsis, A. D., Vaxevanidou, A., Zacharis Giafis, K., & Rogdakis, A. (2009). Wound dehiscence: Is still a problem in the 21th [sic] century: A
retrospective study. World Journal of Emergency Surgery, 4, 12. doi:10.1186/1749-7922-4-12 (R)
10. UPDATE on serious complications associated with negative pressure wound therapy systems: FDA safety communication. (2011, February 24). U.S. Food & Drug
Administration. Retrieved from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm (PGR)
11. Yao, K., Bae, L., & Yew, W. (2013). Post-operative wound management. Australian Family Physician, 42(12), 867-870. (R)
12. Wound dehiscence and evisceration. (2017, February 3). Lippincott Procedures. Retrieved April 12, 2017, from http://procedures.lww.com/lnp/view.do?pId=792857 (PP)