SURGICAL WOUND DEHISCENCE:

RECENT RECOMMENDATION AND GUIDELINES

Lucia Anik Purwanngsih., SKep,Ns., M.Kep.,WOC(ET)N

(Consultant Nurse Specialist Wound Ostomy and Continence at Sardjito Hospital)

Webinar 27 Mei 2023

 Sekilas tentang saya

◦ Name : Lucia Anik Purwaningsih

◦ NIRA : 34040102240
◦ Phone Number/ WA : +62 81 329786169
◦ email : elanie_la@yahoo.com

◦ Education History :
◦ S2 Master of Nursing, (Twin Program Khon Kaen University Thailand - UMY Yogyakarta) 2014
◦ ET Nurse (WOCN), InETNEP (Indonesian Enterostomal Therapy Nurse Education Program),
Twin Program Indonesia-Australia, Universitas Indonesia Jakarta, 2007
◦ S1 Ners, PSIK Gadjah Mada University, Yogyakarta 2005
◦ D3 Keperawatan Akper Depkes, Yogyakarta, 1999
◦ Employment History
◦ Head Nurse Burn Unit- ICU Cardiac Surgery Sardjito General Hospital
◦ Wound Consultant Sardjito General Hospital
◦ Lecturer Magister Keperawatan – PSIK FKKMK Gadjah Mada University
◦ Kompartemen Manajemen Mutu dan Manajemen Risiko LAM-KPRS
◦ Surveior Akreditasi Rumah Sakit LIPA LAM-KPRS
◦ Organisation
◦ Bidang Pelayanan DPP InWOCNA
◦ Dewan Pakar HIPMEBI DPW DI Yogyakarta
◦ Professional Board InOA (Indonesian Ostomy Association) YKI – DIY
◦ Member of WCET (World Council of Enterostomal Therapy)
Outline

Overview In touch with “The Recent

Cause of Surgical recommendation
Surgical Woound Case Study
wound and guidelines
Healing dehiscence” SWD
01

Background
◦ RSUP Sardjito, rujukan pasien dengan wound komplikasi
semakin meningkat.
◦ Pengelolaan wound dengan komplikasi juga
berkembang berdasarkan evidence untuk hasil
penyembuhan yang lebih optimal, peningkatan quality
of life dan patient safety dengan memperhatikan
kendali mutu dan kendala biaya
Jenis Kasus Rujukan Wound dan Stoma
Komplikasi Tahun 2021-Februari 2023
131 PASIEN
EKSTRAVASASI
5%(5)
PRESSURE INJURY
13%(15)

WOUND CANCER STOMA KOMPLIKASI

11%(15) STOMA KOMPLIKASI
35% (46)
WOUND DEHESENSI
WOUND CANCER
WOUND DEHESENSI
DAN INFEKSI 36% (50) PRESSURE INJURY
EKSTRAVASASI
Impact
Burden-US
◦ ~300,000 SSIs/yr (17% of all HAI; second to UTI)
◦ 2%-5% of patients undergoing inpatient surgery
Mortality
◦ 3 % mortality
◦ 2-11 times higher risk of death
◦ 75% of deaths among patients with SSI are directly attributable to
SSI
Morbidity
◦ long-term disabilities
Length of Hospital Stay
◦ ~7-10 additional postoperative hospital days
Anderson DJ, etal. Strategies to prevent surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;29:S51-S61 for individual references
Overview

Surgical Wounds Healing

There are three possible wound healing scenarios or

responses.
◦ Primary intention : the surgical approximation of
edges.
◦ Secondary intention : heals without surgical
intervention but by granulation and epithelization
◦ Tertiary intention: a wound has remained opened for
a period of time and then heals through delayed
surgical closure (e.g., flap, graft, primary closure) or by
using an advanced modality
Normal Post-Surgical Wound Healing
02

Definition
◦ Surgical wound dehiscence (SWD) is the separation of the margins of
a closed surgical incision that has been made in skin, with or without
exposure or protrusion of underlying tissue, organs or implants.
◦ Separation may occur at single or multiple regions, or involve the full
length of the incision, and may affect some or all tissue layers. A
dehisced incision may, or may not, display clinical signs and
symptoms of infection.
◦ SWD is a significant issue that affects large numbers of patients and is
almost certainly under-reported. The impact of SWD can be
considerable: increased mortality, delayed hospital discharge,
readmission, further surgery, delayed adjuvant treatment, suboptimal
aesthetic outcome and impaired psychosocial wellbeing.
 Synonyms for surgical wound dehiscence (SWD)
◦ Wound disruption
◦ Wound separation
◦ Wound opening
◦ Wound rupture
◦ Wound breakdown
◦ Wound failure
◦ Surgical site failure
◦ Post-operative wound dehiscence
◦ Burst abdomen
◦ Fascial dehiscence
◦ Deep SSI
The causes of SWD can be categorised as:
◦ Technical issues with the closure of the incision –
e.g. unravelling of suture knots

◦ Mechanical stress – e.g. coughing can cause

breakage of the sutures or rupture of the healing
incision after suture or clip removal/reabsorption

◦ Disrupted healing – e.g. due to comorbidities or

treatments that hamper healing, or as a result of a
surgical site infection (SSI)
 Contoh kasus
SWD with abscess
formation
and draining pus following Abdominal wound dehiscence
total post-laparotomy SWD after reduction
knee arthroplasty mammoplasty

WORLD UNION OF WOUND HEALING SOCIETIES CONSENSUS DOCUMENT

Contoh Kasus
Wound complication

Wound dehiscence Wound

Wound dehiscence dehiscence
and FEK and FEK

Wound dehiscence Wound dehiscence Wound dehiscence

and FEK and FEK
How to
care……???
03 Recent recommendation and guidelines

Ten top tips: management of surgical wound

dehiscence
1. Identify risk factors (classification of surgery (Culver et al, 1991); clean, clean-contaminated or dirty,
duration of procedure and intraoperative warming (Leaper, 2006; Wong et al, 2007)
2. Identify signs and symptoms of wound dehiscence (Opposed sutured margins open or separated at
any point along the incision site, Broken sutures (non-healed opposing margins, Redness at the
incision site, Patient experiencing pain at the incision site)
3. Accurately assess and categorise type of wound dehiscence including ongoing assessment of the
patient ( There are two types of dehiscence: Partial dehiscence and Full-thickness dehiscence)
4. Assess for clinical indicators of infection
5. Determine goal of care (e.g. surgical debridement/closure versus healing by secondary intention)
6. Correct wound bed preparation (TIME or DIME management)
7. Managing patient’s expectations
8. Multidisciplinary management approach: (Nutrition, Infection Control)
9. Patient and carer education
10. Post-discharge surveillance

Wounds Asia 2018 Vol 1.Wounds International 2018

Pathway pencegahan dan manajemen dehisence wound (orsted,2010)

WBP
 Pencucian dan Penggantian balutan luka
paska operasi dari berbagai Jurnal
No Jurnal Tahun Isi jurnal
1. Prevention of Post-Operative Wound 2012 • Ganti balutan luka diperbolehkan 48
Infection in jam setelah operasi
Accordance with Evidence Based • Cairan pencuci luka sangat
Practice dirokemandasikan menggunakan
(Archana Maurya, Seema Mendhe) saline steril

2. Post-operative wound management 2013
(Kaihan Yao, Lily Bae, Wei Ping Yew)
• Usahakan luka tidak dibuka dan tidak
tersentuh selama 48 jam setelah
operasi
• Cairan pencuci luka yang
direkomendasikan adalah saline steril
atau air mengalir jika luka terdapat
pus

3. Prevention and 2018 • Luka di ganti balutan selama 24 jam-

Management of Surgical 48 jam setelah operasi, karena luka
Wound Complications akan re-epitelisasi dalam 2 hingga 3
(Connie L. Harris, Janet Kuhnke, hari.
Algoritma Pemilihan Topikal Terapi Berdasar Warna Luka
Di RSUP DR.SARDJITO

Tulle gras, Transparant film,

RED :Jaringan Epitel Keep
moist Hidrokoloid Thin

Hidrokoloid, foam dressing,

RED: Jaringan Keep
ca alginater
Granulasi moist

Antiseptik PHMB, Antimikrobial dressing,

Yellow :Exudate, rongga absorb absorb dressing, silver dressing

Hydroactive gel,
Black: Avascular hidrasi
Autolitic debridement

Antimicrobial dressing, PHMB

Infected control Silver dressing, Hidrofobik dressing
 Bagan Alur Perawatan Luka Paska Operasi
(Konsep Moist Wound Healing)
Pasien operasi

Pengkajian balutan
luka • Kassa
• NaCl 0,9% atau cairan PHMB
Persiapan alat • ST steril
• Salep antimicrobial
• Plester / adhesive tape
Balutan dibuka

Ganti ST Steril Penutupan luka

Kassa + NaCl 0,9% atau
Cuci luka dan kassa dan cairan PHMB
keringkan
Kassa + tulle + salep
Evaluasi karakteristik Luka akut kering antimicrobial
luka
Kassa + dressing
Luka akut basah/eksudat antimicrobial yang
Evaluasi luas luka dapat mengabsorb
exudate
Dokumentasi luka/foto

Penutupan luka

Balutan sekunder dan

tersier
Perawatan Wound dehisence
1. VAC (Vacum assisted Closure)
2. Parcel dressing
• Metode perawatan luka
dehisence dengan
menggunakan skin-
protective barriers,
sealants, dan powders
(Rolstad & Bryant, 2000).
• Melindung kulit sekitar
dengan menciptakan
lapisan dari cairan yang
korosif, mencegah
maserasi.
Peralatan Parcel dressing
◦ Hidrokoloid sheet
◦ Skin barrier
◦ Double addhesive tape
◦ kantung plastik
◦ Ostomy paste
◦ Antimikrobial dressing
◦ Pads/kassa
◦ Perekat/plester
Prosedur perawatan parcel dressing:
◦ Setelah luka dibersihkan dengan Aquabidest, beri skin barrier
◦ Ukur bentuk luka utk membuat pola
◦ Pilih satu/lebih hidrokoloid
◦ Potong lebar 3 cm , tempelkan sesuai bentuk luka
◦ Tempelkan double tape sesuai bentuk hidrokoloid
◦ Buat pola pada kantong plastik tebal
◦ Potong sesuai pola
◦ Tempelkan kantong plastik diatas double tape
◦ Tutup luka dengan antimicrobial dressing dan kassa tebal
◦ Tutup kantong plastik diatas kassa, beri plester utk penguat
◦ Ganti kassa bila telah penuh cairan,pertahankan parsel dressing
Parcel dressing

Tempelkan Tempelkan double Tempelkan kantong Tutup luka dengan

hidrokoloid sheet tape sesuai bentuk plastik diatas double antimicrobial
hidrokoloid tape dressing dan kassa
sesuai bentuk luka tebal
Atau
3. Pouch System (Kantong) /stoma bag
 4. Case study
Wound Dehisence dan FEK with Parcel Dressing
Aplikasi Bag for FEK
Wound dehisence dan FEK
Wound dehiscnce
FEK
Daftar pustaka
◦ Muneiah et all, 2015, Abdominal wound dehiscence- A look into the risk factors , IOSR
Journal of Dental and Medical Sciences, Volume 14, Issue 10
◦ Bryant et all,. , 2007, Akut & Chronic Wound Current Management Concept, Mosby Elsevier.
◦ Orsted, et all,2010, Best Practice Recommendations for the Prevention and Management of
Open Surgical Wounds, Wound Care Canada
◦ Amini AQ, 2013, Management of abdominal wound dehiscence: still a Challenge, Civil
Hospital Karachi
◦ Gabrie¨lle, 2010, Abdominal Wound Dehiscence in Adults: Development and Validation of a
Risk Model, World J Surg
◦ Denham, 2014, Ostomy ,Wound Management: Treating Enterocutaneous Fistulas With a
Hydroconductive Dressing
◦ Wounds Asia 2018 Vol 1.Wounds International 2018
Let’s to discuss