SURGERY | ORIGINAL ARTICLE

BURST ABDOMEN: RELATED FACTORS AND POST-

OPERATIVE CHALLENGE FOR SURGEONS
Rajneesh Kumar a , Ritu Kataria 1,b , Sahil Singh c , Ankita Attri d , Harsimran Singh e and Arshdeep Jassal f
aM.S; FAIS; FLCS; FMAS; FIAGES; FICS. Professor, Department of Surgery, Punjab Institute of Medical Sciences [PIMS], Jalandhar. Punjab. E-mail:
drrajneeshkumar@ymail.com, Contact No: 09814052513 , b M.S, Senior Resident, Department of Obstetrics & Gynecology. Punjab Institute of Medical
Sciences [PIMS], Jalandhar. Punjab. E-mail: katariaritu390@gmail.com, Contact No: 9811847254 , c Emergency Medical Officer, Max hospital, Mohali , d
Senior Resident, Max hospital, Mohali , e Senior Resident, Department of Surgery, PIMS, Jalandhar , f Junior Resident, Department of Surgery, PIMS,
Jalandhar

ABSTRACT Background: Burst abdomen is post-operative dehiscence of the layers of the abdominal wall, including the
peritoneum, with exposure of the intestines and is one of the most frustrating and difficult. Type of incision, vertical or
transverse, nature of surgery, elective or emergency, and postoperative complications affect the outcome of Laparotomy.
Objective: To find and evaluate effective management of abdominal wound dehiscence in elective and emergency
Laparotomy and how to prevent and overcome its complications. This post-operative complication encountered by the
surgeon is always a challenge. The main concern is because of the risk of evisceration and the need to intervene; there is
always a possibility of recurrence of dehiscence. Patients and Methods: Our study was conducted on 310 patients who
had undergone exploratory laparotomy at Punjab Institute of Medical Sciences, Jalandhar, Punjab, India. Of 310 patients,
170 underwent emergency laparotomy, and 140 were elective cases. They were managed either by midline vertical incision
or transverse incision, and results were analyzed for wound dehiscence. Result: Most significant variation associated
with wound dehiscence was hypoproteinemia, anaemia, chronic cough and emergency procedures. Pre-operative and
post-operative etiological factors such as chronic cough, anaemia, hypoproteinemia, diabetes, obesity, use of Steroids,
wound infection, abdominal distension, bowel leaks, and electrolyte imbalances are significantly responsible for the
outcome of patients. Moreover, the hospital stay was too long in a burst abdomen, which added to the patient’s economic
burden. 3 patients developed an incisional hernia, managed after 6-8 months by Mesh Hernioplasty. Conclusion: Midline
Vertical incision is always the reason of choice in a condition where quick access to intra-abdominal entry is required, but
the transverse incision is good access to intra- abdominal approach, and the incidence of burst abdomen is less. Proper
single or mass closure techniques should be adopted, and every effort should be made to minimize pre-operative and
post-operative risk factors.

KEYWORDS Wound dehiscence, Laparotomy, midline vertical incision

Introduction on Healthcare costs both for the patient and the hospital. The in-
cidence, as described in Literature, ranges from 0.4% to 3.5%1−4 ,
A burst abdomen is a serious postoperative complication as- whereas the incidence in developing countries is high as 10 to
sociated with high morbidity and mortality. It is a common 45%.5−7 Risk factors for burst abdomen are either patient-related
challenge for abdominal surgeons. It has got a significant impact or related to the type of surgery. Management workup for this
complication is relatively unexplained in the field of surgery.8
Copyright © 2022 by the Bulgarian Association of Young Surgeons
DOI: 10.5455/ijsm.136-1643210348
Despite the performance of a technically perfect surgery in a
First Received: January 26, 2022 compromised diseased patient, this complication is bound to
Accepted: March 13, 2022 occur. It is always a concern for the surgeon because of the
Associate Editor: Ivan Inkov (BG); risk of evisceration. Timely intervention is required to prevent
1
Corresponding author: Dr. Ritu Kataria. Email: katariaritu390@gmail.com.
secondary wound infection and incisional hernia.
Contact No: 9811847254)

Dr. Ritu Kataria et al./ International Journal of Surgery and Medicine (2022) 8(6):27-31
 Though there are technical advancements in perioperative
care and suture materials, this complication is bound to occur in
some high-risk cases with multiple comorbid conditions and
where emergency laparotomy has to be done in such acute
situations.2,3,9 This abdominal wall wound disruption usually
occurs after the 6th to 7th postoperative day with serosan-
guinous (pink) discharge, which indicates a burst abdomen.10,11
There can be partial to complete disruption of abdominal wound
closure without protrusion of abdominal contents. Partial
wound dehiscence is the separation of fascial edges without
evisceration and occasionally covered intestinal loops. Com-
plete wound dehiscence is a full separation of fascia and skin
with evisceration of intestinal loops.12 For proper abdominal
wound closure technique, intra-abdominal faecal contents, intra-
abdominal pressure, and poor metabolic state of patients are
common risk factors.13
The study aims to evaluate the challenges that surgeons face
after elective and emergency laparotomy regarding the techni-
cality of suturing and considering the comorbid conditions. And
is a challenge for the surgeon to prevent such complications, fur-
ther development of incisional hernia and decrease the patient’s
and the hospital’s economic load.
Methods
Our study was conducted on 310 patients who underwent ex-
ploratory laparotomy at Punjab Institute of Medical Sciences,
Jalandhar, Punjab, India. The patients were randomly selected
from an emergency as well as elective surgeries where Ex-
ploratory Laparotomy was performed for one reason or the
other with various factors. The most common pathologies were
Peptic Ulcer perforation, Typhoid perforation, intestinal obstruc-
tion, malignancy, large bowel perforation, Tubercular abdomen,
and blunt trauma abdomen.
Out of 310 patients, 170 were emergency, and 140 were elec-
tive cases. Of the 170, who had undergone emergency surgery,
26 patients were open through a transverse incision. Even pa-
tients with Appendicular lump or Phlegmon was extended trans-
versely. In the remaining 144 cases, a midline vertical incision
was given. In 140 elective cases, 32 were given transverse inci-
sions, and 108 were given midline vertical incisions. A trans-
verse incision was given in children and most patients with
pelvic or lower abdominal masses and gynaecological proce-
dures. The age of patients in both groups varied from 2 years to
75 years. Proper history was taken, and a physical examination
was done. After thorough investigations and taking consent,
they were taken up for surgery.
Inclusion and exclusion criteria
Patients undergoing emergency laparotomies and elective la-
parotomies were included in the study. Patients with previous
laparotomies were excluded. In addition, all the patients with
burst abdomen during the study period were included, and
those who died were excluded from the study.
Results
Out of 310 patients in our study group, 170 patients had un-
dergone Emergency Laparotomy, and 140 cases had undergone
elective surgery. Out of 170 emergency cases, 16 (9.4%) patients
had burst abdomen, and out of 140 elective surgery groups, only
3 (2.14%) patients had wound dehiscence.
Dr. Ritu Kataria et al./ International Journal of Surgery and Medicine (2022) 8(6):27-31
Burst abdomen was significantly higher in the older age
group compared to the younger age group. Out of a total num-
ber of Burst abdomen cases, emergency surgery cases were 16
(9.41%), and elective surgery cases were 3 (2.14%). 13 cases were
seen in patients above 45 years of age. It constitutes 68.4 2%
of the total abdominal dehiscence cases. The youngest patient
in our study was 2 years old, and the oldest patient was 75
years old. The incidence of burst abdomen was much higher
in patients operated on as emergency cases compared to elec-
tive surgery. The most common predisposing factors in patients
who had burst abdomen were malnutrition, obesity, anaemia,
wound infection, chronic smokers, chronic alcoholics, abdominal
distension, immunocompromised, Diabetes mellitus, post-op
vomiting, post-operative paralytic ileus and distension.
Common types of surgeries done in an emergency were gan-
grene bowel, perforated appendix, typhoid perforation, perfo-
rated peptic ulcer, blunt abdominal trauma, obstruction due to
bands and adhesions, volvulus intussusception, and diverticulo-
sis.
The maximum percentage of cases of burst abdomen in an
emergency is attributed to the fact that most cases operated in an
emergency were of intestinal perforation 101 (59.41%) patients
due to one reason or the other. Out of these, the most common
surgeries performed in an emergency were for perforated pep-
tic ulcer and typhoid perforation, 44(25.88%) and 38(22.35%),
respectively.
This is one of the most important reasons attributed to most
cases of burst abdomen in peritonitis emergency cases because
of soiling of the peritoneal cavity and wound despite the best
aseptic precautions during surgery.
Two cases were operated on by Transverse incision with
wound dehiscence, and both were acute appendicitis with phleg-
mon.
Types of incisions: Out of all the wound dehiscence cases, 3
(15.78%) patients with transverse incisions had burst abdomen
were as in this study, in16 (84.21%) patients burst abdomen
occurred after vertical midline incision.
Pre-operative risk factors: Out of all the burst abdomen
cases, the most common predisposing factors were anaemia,
hypoproteinemia, cough, diabetes, obesity and use of steroids.
Post-operative causes: Common postoperative predisposing
factors for burst abdomen in our study were cough and dys-
pnea, wound infection, abdominal distension, bowel leak and
electrolyte disturbances. These were the main causes of burst
abdomen in the majority of cases. In addition, in most patients,
more than one factors were responsible for wound dehiscence.
The mean hospital stay in burst abdomen cases was 26.5(+/-
6.4) days, whereas in normal patients, the mean hospital stay
was 7 days (+/-4.2). This was statistically significant.
Wound Discharge is a Serosanguinous discharge seen from
the wound on the 6th to 7th postoperative day. In our study,
out of 19 cases of burst abdomen, 12 patients had a complete
burst, whereas 7 patients had only a partial burst. Management
of patients was done with conservative treatment in 3(15.78%)
cases whereas, in cases of complete burst in 16(84.21%) patients,
mass closure was done, a standard technique that incorporates
all the layers of the abdominal wall after a thorough abdominal
wash. 3 patients developed an incisional hernia, managed after
6 to 8 months by Meshplasty.
Table 1 Showing incidence of burst abdomen in different age groups.
Burst Abdomen Burst Abdomen
Age group Emergency (170 cases) Elective (140 cases) Emergency 16 (9.41%) Elective 3 (2.14%)
patients patients
Below 20 years 32 (18.8%) 42 (30%) 2 0
20 - 45 years 40(23.52%) 52 (37.14%) 3 1
45 years and above 94 (55.29%) 46(32.85%) 11 2

Table 2 Showing Primary cause of surgery.

Diagnosis Number of Patients
Peritonitis 8
Intestinal obstruction 3
Tuberculosis 2
Blunt abdominal trauma 1
Malignancy of stomach 1
Penetrating abdominal injury 1
Carcinoma rectosigmoid 1
Ovarian mass 1
Acute appendicitis 1

Table 3 Showing Types of incision.

Incisions Number of patients with burst abdomen Percentage
Midline vertical incision 16 84.21%
Lower transverse incision 3 15.78%

Table 4 Showing Pre-operative risk factors.

Causes Number of cases
Chronic cough 8
Anaemia 10
Hypoproteinemia 14
Diabetes 4
Obesity 2
Use of steroids 3

Table 5 Showing Post-operative risk factors.

Causes Number of cases
Cough and dyspnea 15
Wound infection 16
abdominal distension 11
Bowel leak 4
Electrolyte imbalance 3

Table 6 Showing Mean hospital stay

Hospital stay Number of patients Days p-value
Burst abdomen 19 26.5(+/-6.4) <0.001
Abdominal Wound Dehiscence 291 7(+/-4.2)

Dr. Ritu Kataria et al./ International Journal of Surgery and Medicine (2022) 8(6):27-31
Discussion
Burst abdomen (wound dehiscence) is a serious postoperative
complication when abdominal contents are seen through an
abdominal wound. It usually occurs on the 6th to 8th postopera-
tive day. It needs immediate intervention with the possibility of
repeat dehiscence, surgical site infection and incisional hernia
formation.14 Incidence can be reduced by taking prophylactic
measures and controlling risk factors.15 Incidence of burst ab-
domen in the present study was 6.12%, similar to the studies
showing frequency range from 5.3% to 8.3%.16
A high incidence of burst abdomen was noted in patients
with gastrointestinal perforation and more so in patients who
had undergone emergency laparotomy and that too through
a vertical midline incision. Pre-operative predisposing factors
such as chronic smoking, anaemia, hypoproteinemia and post-
operative factors like cough, wound infection, anaemia, abdomi-
nal distension, bowel leak, vomiting, electrolyte imbalance and
immunocompromised patients are the factors which are sig-
nificantly responsible for the occurrence of burst abdomen17
and management of most of the patients requires ICU care
postoperatively.18
In our study, the incidence of burst abdomen was significantly
higher in the older age group compared to the younger age
group. Out of 19 cases of burst abdomen, 13 cases were above 45
years of age, contributing to about 68.42% of the total abdominal
dehiscence cases. Age has also been reported as a risk factor in
our studies.19 Our study showed the incidence of burst abdomen
in emergency surgeries was 9.41% compared to 2.41% in elective
surgery. The high frequency may be attributed to sub-optimal
conditions during emergencies leading to more complications.20
Though some studies interpret similar results during emergency
as well as elective surgeries,21,22 few other authors have reported
burst abdomen occurrences as high as 10 to 30% of emergency
cases.23,24
In the present study, a burst abdomen is more common in
males. Out of 19 who had wound dehiscence,13 (68.4 2%) pa-
tients were males, and 6 (31.57%) patients were female, which is
comparable to other studies.20,25
Multiple studies have concluded that vertical midline inci-
sion increases the risk of wound dehiscence.2 In the present
study, out of all burst abdomen cases, 16 (84.21%) patients un-
derwent surgery with a vertical midline incision and 3 (15.78%)
patients had undergone transverse incision. This has been at-
tributed to interference with blood supply. Elastic fibres of skin
run transversely, so they are cut in the vertical incision, and
the strength of the wound is decreased. In the transverse ap-
proach, pulmonary functions are not compromised as in upper
midline incisions, mainly attributed to a lower rate of wound
dehiscence with the transverse incision.26−28 Peritonitis due to
hollow viscus perforation and drainage of an abdominal abscess
may result in unavoidable contamination of the wound, interfer-
ing with wound healing and increasing the bacterial load of the
wound. Our study showed wound dehiscence more in patients
operated for peritonitis, and acute appendicitis in 9 (43.36%)
patients, almost similar to studies showing a high incidence of
burst abdomen due to perforations.16,2930
In our study, anaemia, hypoproteinemia, and chronic
cough/dyspnea were important factors which led to burst ab-
domen. Similar results are shown by various studies.19,20
Mass closure of burst abdomen with polypropylene sutures
with continuous sutures seems to be the best method of closure
as it is fast, easy, and cost-effective with the least complications31
Dr. Ritu Kataria et al./ International Journal of Surgery and Medicine (2022) 8(6):27-31
we also used the same suture material we could achieve facial
closure in all the patients who had undergone surgery for burst
abdomen. Out of 16 (84.21%) patients, only 3(15.78) patients
(15.78%) who had partial wound dehiscence were treated conser-
vatively by use of dressings only, followed by incisional hernia,
which was later repaired by mesh hernioplasty.
A most common complication of a burst abdomen includes
recurrence, mortality and incisional hernia. Enterocutaneous
fistula is another complication of a burst abdomen due to gut
erosion.32 In a few patients, the disruption is violent and sud-
den, with the protrusion of intestines through the wound to the
surface of the abdomen.11
Conclusion
Midline Vertical incision is always the reason of choice in condi-
tions where quick access to intra- abdominal artery is required.
Still, a transverse incision is good access to an intra-abdominal
approach, and the incidence of burst abdomen is less. Proper su-
perficial technique and every effort should be made to minimize
both pre-operative and post-operative risk factors.
Conflict of Interest
Nil.
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