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%.

Introduction

• Abdominal wound dehiscence can result in

evisceration, requiring immediate treatment.

Prolonged hospital stay, high incidence of

incision hernia, and subsequent reoperations underline the severity of this complication.

Introduction

• Despite advances in perioperative care and

suture materials, 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.

Types of Wounds

Recent Literature

• In this study by Van Ramshorst et al (World J

of Surg 2010;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. The study

was conducted at the department of surgery,

Erasmus University Medical Center, Rotterdam,

Netherlands.

Recent Literature

• A total of 363 cases and 1,089 controls were

analyzed. Major independent risk factors were:

age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection.

Recent Literature

• In the validation population, risk scores were

significantly higher (P<0.001) for patients with

abdominal wound dehiscence (n = 19)

compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%.

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.

Risk Formula

• First, the total risk score is calculated byadding the weights of the various variablesshown in Table 1. In the second step, theprobability of developing abdominal wounddehiscence, P, is calculated according to thelogistic formula: P= eх/ (1+ex )x100%;where ‘ex’represents the exponential function and ‘x’represents ‘-8.37 + (1.085 x calculated total riskscore)’.

Risk Calculation

• For example, the risk score for a 67-year-old manwho undergoes an elective reconstruction of theabdominal aorta and is known to have a history ofchronic pulmonary disease is 0.9 (score for age 60–69 years) + 0.7 (score for male gender) ? 1.3 (scorefor vascular surgery) + 0.7 (score for chronic pulmonarydisease), for a total of 3.6. The probability, P, of thispatient’s developing abdominal wound dehiscence is:e(-8.37+(1.085x3.6)) /1+e (-8.37+(1.085x3.6)) x100%= 1.1%

Risk Calculation

• An emergency repair in a similar patient with

a ruptured aneurysm and subsequent anemia

results in a total score of 4.9 (i.e., subtotal of

3.6 points + 0.6 emergency + 0.7 anemia). Thus, the absolute risk rises to 4.5%.

Risk Score Intepretation

Risk factors

• Patients who undergo emergency surgery aregenerally in worse condition and nutritionalstate, and the chance of contamination of thesurgical field is higher than in elective surgery. Moreover, the performance of the surgeon might be affected at night, which could lead tosuboptimal closure of the abdomen at the endof the operation.

Risk factors

• Old age is another independent risk factor for

abdominal wound dehiscence. Age has also

been reported as a risk factor in other studies.

The explanation for this might lie in deterioration

of the tissue repair mechanism in the elderly.

Especially during the first few days of the wound

healing process, the immune system plays a key

role.

Risk Factors

• One of the interesting risk factors found in this

Rotterdam study, is gender. In previous studies, males have been reported to have a higher risk of developing abdominal wound dehiscence.

This was attributed to smoking as a possible

confounder and its effect on tissue repair.

Risk Factors

• Another explanation may be that men build

up higher abdominal wall tension than females.

An increase in intra-abdominal pressure results in higher strain on the wound edges, causing the sutures to cut through the muscles and fascia.

Risk Factors

• In the Rotterdam study, wound infection proved

to be the risk factor with the highest relative

weight. Its importance has been confirmed by

virtually every study on this topic. Continued

presence of bacteria causes influx and

activation of neutrophils and increases in levels

of degradative matrix metalloproteinases(MMPs).

Risk Factors

• In the absence of sufficient tissue inhibitors ofMMPs, wound degradation will occur. Therelease of endotoxins by bacteria leads to theproduction of collagenase, which degradescollagen fibers. Infection thereby causes aprolongation of the inflammatory phase andnegatively affects deposition of collagen and fibroblast activity.

Risk factors

• In wounds of patients with abdominal wound

dehiscence, it has been observed that

degradation of collagen exceeds the synthesis

of collagen, which adversely affects breaking

strength. Adequate tissue breaking strength is

necessary, however, to provide support for the

sutures that hold the wound edges together.

Risk Factors

Low breaking strength can therefore amount to

abdominal wound dehiscence, especially in the

presence of increased intra-abdominal pressure

and abnormal inflammatory response.

Risk factors

• Primary repair can be difficult or impossible

when tissue has low breaking strength, creating the need for the use of mesh or acceptance of the high risk of recurrent abdominal wound dehiscence.

Risk factors

• Risk factors that did not have independent

effects in the Rotterdam study included:

1.hypertension

2.uremia

3. corticosteroid use.

Risk Factors

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

Risk factors

• This was surprising because it was suspected

that the presence of scar tissue, microvascular

changes due to hypertension and diabetes,

poor tissue perfusion, and poor overall

condition of the patient, associated with sepsis and malignancy, would be risk factors.

Risk factors

• Jaundice, on the other hand, 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.e., 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, B2, B6, C and zinc,

selenium and copper have been associated with poor wound repair.

Risk Factors

• Anemia is a risk factor that is related to

increased perioperative stress, blood

transfusions, and decreased tissue oxygenation, all of which can affect the immune system and the wound healing process.

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.

American Risk Model

• There are several limitations to this study.

Because the veterans carry more comorbidities than the general population, our results may not be generalizable to the public at large.

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 .

Abdominal Wall Closure

Well-done, large, 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; this is where the surgical training

dictum of 1-cm ‘‘bites’’ followed by 1 cm of

progress originated.

Conclusion

• Important risk factors for abdominal wound dehiscence have been identified in the Rotterdam case-control study 2010 including:

• 1. age, • 2. gender • 3. chronic pulmonary disease, • 4.ascites, jaundice, anemia, emergency

surgery, type of surgery, coughing, and wound infection.

Conclusion

• 5.jaundice

• 6.anemia

• 7.emergency surgery

• 8.type of surgery

• 9.coughing

• 10.wound infection

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.

References

• Abdominal wound dehiscence in adults. Van Ramshorst et al. World J of Surg 2010;34:20-27.

• Prognostic models of wound dehiscence. Webster et al. J Surg Research 2003, 109: 130-137.

• The biology of acute wound failure. Dubay et al. Surg Clin North Am 2003,83:464-481