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COMPLICATIONS OF ABDOMINAL INCISIONS:A REVIEW OF PREVENTION, DIAGNOSIS, AND TREATMENTBlaine Campbell, PGY3Grand RoundsKUMC – Wichita, Department of OBGYNMay 10, 2017
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Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections
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Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections
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TerminologyWound classification:• Clean – uninfected; no encounter with potential infection source; no viscous entry
• Clean-contaminated – viscous is entered, but under controlled conditions
• Contaminated – fresh accidental wounds; major breaks in sterile technique; gross spillage;
non-purulent infection
• Dirty – grossly purulent, retained foreign body (trauma), devitalized tissue, fecal
contamination
Healing by:• Primary/first intent – surgical approximation of tissues
• Secondary intent – allowing the wound to close naturally
• Delayed wound closure – surgical closure of the wound after appearance of granulation
tissue
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Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections
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Complications• Collection of blood or serum• Asymptomatic; pain, drainage, swelling (fever, erythema, induration)• Predisposition to infection; impede wound healing
DIAGNOSIS• Inspection/palpation• Within a few days or delayed• CT or ultrasound
HEMATOMA/SEROMA
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PREVENTION• Subcutaneous, retrofascial• Surgical technique
- Avoid excessive tissue handling and trauma- Fewest strokes/dissection possible- Decrease necrotic tissue and tissue ischemia- Scalpel vs electrocautery
*No benefit of one over other for both skin and subcutaneous incisions *Non-modulated (cutting) current similar tissue damage to scalpel [1]
HEMATOMA/SEROMA Complications
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PREVENTION• Dead space as potential risk • Closure of subcutaneous tissue
*General surgery: no evidence to suggest increased incidence of wound complications if subcutaneous tissues not sutured [2]
*Cesarean section/hysterectomy: benefit in closure of Camper’s fascia [3,4]
HEMATOMA/SEROMA Complications
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TREATMENT• Simple seroma/hematoma: expectant management• Large collections should be drained
Seromas: sterile needle aspiration (+/- ultrasound)Hematomas: partial or complete reopening (+/- OR)
- No evidence of infection = primary closure- (+) infection = debridement, irrigation, delayed closure or secondary intent
*Delayed closure significantly reduces healing time compared to secondary intent [5,6]
HEMATOMA/SEROMA Complications
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TREATMENT• If lymphatic, serum, or blood collection anticipated (Ex: Maylard & oblique incisions,
accessing space of Retzius) -OR- chronic seroma formation- Consider drain placement- Puncture wound separate from primary incision- Open vs closed systems- Active vs passive systems
*Meta-analysis and RT have shownclosed systems do NOT significantlyprevent wound complications [7]
HEMATOMA/SEROMA Complications
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Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections
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• Disruption of fascial closure• Incidence 0.4-3.5% depending on type of surgery• Early (emergency) or delayed (incisional hernia)
- Mean 8 days postop
*Wounds have <5% of the tensile strength of unwounded tissue in the first postoperative week, thus wound security solely dependent on suture in healthy tissue
FASCIAL DEHISCENCE Complications
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• *The knot is the weakest part of a suture- No benefit to using surgeon’s knot over square knot [8]
- Braided suture has better knot security compared with monofilament- Tying a single strand to a double strand of suture reduces knot security [9]
• Up to 95% of cases of abdominal wound dehiscence have intact knots and sutures, but suture has pulled through fascia [10, 11]
- Facial necrosis
ComplicationsFASCIAL DEHISCENCE
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PREVENTIONTechnique, technique, technique!
Spacing: 1cm x 1cm- <5mm from tissue edge = risking nonviable or weak suture anchoring- >10mm from edge = increases compressive forces on bunched tissue [12]
- European Hernia Society
Length of suture: 4x length of incision; 4:1 recommended to reduce hernia [13]
ComplicationsFASCIAL DEHISCENCE
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PREVENTIONTechnique, technique, technique!
Mass closure: Smead-Jones or continuous single- or double-loop closure- Significantly decreases dehiscence [14, 15]
Suture: slowly absorbable sutures [16]
Continuous closure: distributes tension evenly along incision; allows better perfusion; saves time; less knots. Downside is reoperation/removal
- Interrupted closure had significantly higher hernia rate regardless of type of suture [16]
ComplicationsFASCIAL DEHISCENCE
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DIAGNOSIS• Clinical• “Pink lemonade” sign; copious serosanguinous• Popping sensation, incisional bulge increased with valsalva• Ultrasound or CT
TREATMENT• Wound exploration in OR• Until OR, can place moist dressing over incision and abdominal binder• +/- Retention sutures
ComplicationsFASCIAL DEHISCENCE
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Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections
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TerminologyGranulation tissue• Beefy, fleshy, red• Neovascularization• Tissue of healing Vs.
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SURGICAL SITE INFECTION
• 4% of clean and 35% of dirty wounds• Superficial, deep, organ/space• Risk factors: DM, obesity, immunosuppression, smoking, cancer, previous surgery,
malnutrition, prior irradiation
PREVENTION• Sterile technique• Irrigation• Prophylactic antibiotics
Complications
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Antibiotic Prophylaxis for Gynecologic ProceduresACOG Practice Bulletin 104, reaffirmed 2016
Prophylaxis Regimens by Procedure
ComplicationsSURGICAL SITE INFECTION
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DIAGNOSIS• Erythema, induration, fluctuance/purulence discharge, fever, wound separation
- Necrotizing fasciitis• Culture and sensitivity
TREATMENT• Conservative vs reexploration
1. Exploration: - Anesthesia needs on a case-by-case basis- Fascial involvement requires the OR
ComplicationsSURGICAL SITE INFECTION
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TREATMENT2. Debriding:- Mechanical vs enzymatic- Remove all devitalized tissues- Debride until level of granulation tissue or uninvolved tissue is reached
Sharp excisional debridement of chronic wounds decreases bacterial load and stimulates wound contraction/epithelialization [17]
ComplicationsSURGICAL SITE INFECTION
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TREATMENT3. Irrigation:
- Pressurized vs passive- Isotonic solution preferred (saline)- Tap water in ambulatory setting- Addition of iodine or antiseptic solutions may impede wound healing [18, 19]
4. Antibiotics:- Targeted treatment according to potential contamination source and cultures
ComplicationsSURGICAL SITE INFECTION
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• Delayed closure:- Secondary intent used to be standard of care - Delayed closure safe & effective; only 5% incidence of re-exploration for reinfection- Ideally between day 3-5, no later than day 10*Significantly decreases healing time over secondary intent
ComplicationsSURGICAL SITE INFECTION
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DRESSINGS• Significant effect on speed of healing, wound strength, skin function, and cosmetics• Adjusted in case-by-case basis
- Some impede some aspects of healing (ex: silver dressings)- Charts available, providing visual description of wound and recommended dressing- In general:
Hydrogels for debridement stageLow-adeherent & moisture retentive for granulationLow-adherent for epithelialization (i.e. “let it breathe”) [20]
• Dressing changes daily or every other day • Initial bandage removal in first 48 hours after procedure
SURGICAL SITE INFECTION
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WOUND PACKING• Wounds with large soft-tissue defects (tunneling, undermining) need packing• Document accurate depth of wound and its dimensions
• Wet to Dry packing- Used in healing by secondary intent or delayed closure- Contaminated wounds, or incision after debridement/reoperation- Wet gauze packed into incision; removal of necrotic tissue as dry out and changed
(up to 2-3x daily)- Discontinuation when granulation tissue is noted
*Chronic wounds should never be closed primarily
SURGICAL SITE INFECTION
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WOUND VAC
Decreases surrounding edemaIncreases circulationIncreases granulation
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QUESTIONS/COMMENTS?
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REFERENCES
1. Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011; 253:8
2. Paral J, Ferko A, Varga J, et al. Comparison of sutured versus non-sutured subcutaneous fat tissue in abdominal surgery. A prospective randomized study. Eur Surg Res 2007; 39:350.
3. Del Valle GO, Combs P, Qualls C, Curet LB. Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption? Obstet Gynecol 1992; 80:1013.
4. Naumann RW, Hauth JC, Owen J, et al. Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Obstet Gynecol 1995; 85:412.
5. Dodson MK, Magann EF, Meeks GR. A randomized comparison of secondary closure and secondary intention in patients with superficial wound dehiscence. Obstet Gynecol 1992; 80:321.
6. Walters MD, Dombroski RA, Davidson SA, et al. Reclosure of disrupted abdominal incisions. Obstet Gynecol 1990; 76:597.
7. Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery--a metaanalysis. Am J Obstet Gynecol 2007; 197:229.
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REFERENCES
8. van Rijssel EJ, Trimbos JB, Booster MH. Mechanical performance of square knots and sliding knots in surgery: comparative study. Am J Obstet Gynecol 1990; 162:93.
9. Muffly TM, Boyce J, Kieweg SL, Bonham AJ. Tensile strength of a surgeon's or a square knot. J Surg Educ 2010; 67:222.
10. Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 2005; 62:220.
11. Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations. Cochrane Database Syst Rev 2013; :CD010424.
12. Cengiz Y, Gislason H, Svanes K, Israelsson LA. Mass closure technique: an experimental study on separation of wound edge. Eur J Surg 2001; 167:60.
13. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015; 19:1.
14. Seid MH, McDaniel-Owens LM, Poole GV Jr, Meeks GR. A randomized trial of abdominal incision suture technique and wound strength in rats. Arch Surg 1995; 130:394.
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15. Meeks GR, Nelson KC, Byars RW. Wound strength in abdominal incisions: a comparison of two continuous mass closure techniques in rats. Am J Obstet Gynecol 1995; 173:1676.
16. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg 2010; 251:843.
17. Brem H, Stojadinovic O, Diegelmann RF, et al. Molecular markers in patients with chronic wounds to guide surgical debridement. Mol Med 2007; 13:30.
18. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.
19. Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med 1998; 5:1076.
20. Paddle-Ledinek JE, Nasa Z, Cleland HJ. Effect of different wound dressings on cell viability and proliferation. Plast Reconstr Surg 2006; 117:110S.
21. https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html
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THANK YOU