surgical wound dehiscence

296 MEDSURG Nursing—October 2006—Vol. 15/No. 5

MEDSURG NURSINGCE Objectives and Evaluation Form appear on page 301.SERIES

Surgical Wound Dehiscence

Barbara Hahler, MSN, RN, APRN,BC,CWOCN, is a Clinical Nurse Specialist,Wound, Ostomy, and ContinenceNursing, St. Vincent Mercy MedicalCenter, Toledo, OH.

Note: The author reported no actual orpotential conflict of interest in relationto this continuing nursing educationarticle.

Barbara Hahler

converted by cytokines into woundfibroblasts, which have increasedcollagen synthesis behavior. Insutured incisions, collagen synthe-sis peaks at day 5. Although granu-lation tissue is not present, by day5 it is possible to palpate a healingridge just under the intact sutureline (Waldrop & Doughty, 2000).Epithelialization occurs when gran-ulation is complete. This involvesthe migration of epithelial cellsacross the skin edges, a processthat begins almost immediatelyafter surgery and may be completein 2-3 days (West & Gimbel, 2000).

At approximately 7 days aftersurgery, the maturation phasebegins. This phase lasts for 1 yearor more. Continued collagendeposition and remodeling con-tribute to the increased tensilestrength of wounds. Approx-imately 20% of normal tensilestrength is present at 3 weeksafter surgery. A maximum of 70%-80% tensile strength is achievedafter 1 year (Jones, Bale, &Harding, 2004).

Factors Contributing toSurgical Wound Dehiscence

Very simply, dehiscence is amechanical failure of wound heal-ing. Conditions associated withincreased risk of wound dehis-cence are anemia, hypoproteine-mia, malnutrition, obesity, malig-nancy, jaundice, use of steroids,and diabetes (Sorensen et al.,2005). Male gender and advancedage also are associated withwound disruption. Specific surgi-cal procedures lead to a higherincidence of wound dehiscence,

Dehiscence is postopera-tive wound separation thatinvolves all layers of theabdominal wall. It is associat-ed with death, prolonged hos-pital stays, and incisional her-niation (Khan, Naqvi, Irshad,& Chaudhary, 2004). Becausemedical-surgical nurses fre-quently care for postoperativepatients, awareness of the riskfactors for dehiscence andmeasures to prevent dehis-cence is important.

Surgical incisions are acutewounds that activate the heal-

ing process. Although it has fouridentified stages, wound healing inreality is a complex, continuousprocess. The four stages are hemo-stasis, inflammation, proliferation,and maturation (Chin, Diegelmann,& Schultz, 2005). After a wound iscreated, hemorrhage is the initialresponse. During hemostasis,platelets aggregate and degranu-late, activating blood clotting.Once the clot forms, it begins tobreak down. As the clot is degrad-ing, the capillaries dilate andbecome more permeable. Fluidsflow to the wound site, activatingthe complement cascade. Thecomplement system induces lysis,the destruction of select cells. Thissystem helps neutrophils bind tobacteria, facilitating phagocytosisand bacterial destruction. Macro-phages also are present at thewound site and help destroy bac-teria. They are a source ofcytokines and growth factors thatare essential for normal woundhealing (Chin et al., 2005).

The proliferation phase ofwound healing usually begins 3days after injury and lasts for sev-eral weeks. During this phase, gran-ulation tissue forms in the woundspace. Fibroblasts, which move tothe wound and proliferate, areresponsible for the synthesis of col-lagen and other connective tissuedevelopment; they are critical forwound repair. The fibroblasts arestimulated by growth factors and

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SERIESSurgical Wound Dehiscence

which contributes to wounddehiscence (Waldrop & Doughty,2000).

Interventions to Reduce theIncidence of Dehiscence

Patients should be instructedto reduce or eliminate the use oftobacco products for at least 30days prior to surgery (Centers forDisease Control and Prevention[CDC], 1999). Medications withan anticoagulant effect, such asaspirin or nonsteroidal anti-inflammatory drugs, also shouldbe eliminated prior to surgery. Aphysician should be contacted todetermine when each medicationshould be stopped (Doughty,2005). These measures will helppromote hemostasis, and im-prove oxygenation and perfusionto the tissues. Patients alsoshould be encouraged to opti-mize their nutrition prior toscheduled surgery, especiallytheir protein intake, to facilitatewound healing (Doughty, 2005).Protein is responsible for repairand synthesis of enzymesinvolved in wound healing, cellreplication, and collagen synthe-sis. The recommended daily pro-tein intake for adults is 0.8g/kgper day (Posthauer & Thomas,2004). Patients should be encour-aged to increase their intake ofprotein-rich foods, such as meat,

Local factors also are veryimportant to consider. For exam-ple, infection predisposes awound to disruption in the earlypostoperative period (Sorensenet al., 2005). Increased abdominalpressure also is associated withwound disruption. This may becaused by abdominal complica-tions, such as nausea and vomit-ing, ileus, or a bowel obstruction,or by pulmonary complications,such as atelectasis or bronchitis(Doughty, 2005). Infection andpoor wound healing frequentlyare seen in ischemic wounds (seeTable 1). Low blood oxygen con-tent can predispose devitalizedtissue to bacterial colonization(McGuckin, Goldman, Bolton, &Salcido, 2003). The persistentpresence of micro-organismsleads to an increased number ofphagocytes that release prote-olytic enzymes, free radicals, andinflammatory mediators. Theeffect of these substances is addi-tional tissue injury and wounddeterioration (Gardner & Frantz,2004). The inflammatory media-tors produce local thrombosis,resulting in hypoxia. The hypoxiacontributes to further bacteriagrowth, establishing a prolongedinflammatory cycle (Gardner &Frantz, 2004). Chronic tissuehypoxia also leads to collagenwith inadequate tensile strength

including procedures for colondiseases, peptic ulcer disease,and emergency laparotomy(Waqar et al., 2005).

Obesity is associated with anincreased infection rate and tech-nical difficulties in closing anincision (Meeks & Trenhaile,2005). Steroids given in moderatedoses over a long period of timeseem to decrease the tensilestrength of a healing wound.Diabetics encounter more heal-ing problems than non-diabetics,and have a greater risk of devel-oping wound infections. Patientswith diabetes experience lesscollagen synthesis and deposi-tion, decreased wound breakingstrength, and impaired leukocytefunction (Waldrop & Doughty,2000). These differences inwound repair may occur partiallydue to altered insulin levels anddecreased levels of growth fac-tors, such as insulin-like growthgrowth factor-1 and transforminggrowth factor-beta. Insulin thera-py and exogenous growth factorscan increase collagen depositionand increase tensile strength ofwounds (Waldrop & Doughty,2000). The jaundiced patient mayexperience prolonged healingand risk for wound dehiscence,which is related to a pro-inflam-matory state resulting from por-tal and systemic endotoxemia.Endotoxemia is a result of analtered bowel barrier functiondue to the absence of bile in thebowel (Koivukangas, Oikarinen,Risteli, & Haukipuro, 2005).

Malnutrition or radiationtherapy associated with malig-nancies may lead to wound sepa-ration. Radiation may causeobliterating endarteritis, result-ing in decreased blood supply tothe tissues. Patients with malig-nancies also are more likely tohave a contaminated wound orabscess cavity (Meeks &Trenhaile, 2005). Male patientsoutnumber women by at least 2to 1 for wound dehiscence (Hanifet al., 2000).

Source: CDC, 1999

Table 1. Factors Contributing to Wound Dehiscence

▲ Anemia▲ Malnutrition▲ Obesity▲ Malignancy▲ Jaundice▲ Use of steroids ▲ Diabetes▲ Male gender▲ Advanced age▲ Wound infection▲ Increased abdominal pressure (coughing, vomiting, distention, ascites)

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the incision (Gardner & Frantz,2004). The incision should be pal-pated for evidence of a healingridge (commonly present by day5). This will feel like an area ofinduration beneath the skinextending to about 1 cm on eachside of the incision (West &Gimbel, 2000). If the healing ridgeremains absent by day 5 to 9, thenurse will suspect delayed heal-ing and risk for dehiscence.Systemic factors, such as malnu-trition and elevated glucose level,that hinder wound healing alsoshould be evaluated (Gardner &Frantz, 2004).

Signs of Wound DehiscenceWound dehiscence frequently

occurs without warning. Thediagnosis may be obvious if evis-ceration is present. Frequentlypatients report a pulling or rip-ping sensation, or note that“something has given way.” In23%-83% of cases, serosan-guinous drainage is present fromthe wound prior to the dehis-cence (Waqar et al., 2005). Mostdehiscences occur 4-14 days aftersurgery, with a mean of 8 days(Meeks & Trenhaile, 2005; van’t,De Vos Van Steenwijk, Bonjer,Steyerberg, & Jeekel, 2004).Diagnosis can be made based onclinical presentation and woundinspection in the majority ofcases. Imaging studies, such asultrasound, computerized tomog-raphy scan, or MRI, can be used ifthe diagnosis is unclear (Meeks &Trenhaile, 2005).

Immediate NursingInterventions

If wound dehiscence isdetected, the nurse will returnthe patient to bed and lower thehead of the bed to no higher than20 degrees (Moz, 2004). Evi-sceration also may have occurredand measures to reduce abdomi-nal pressure should be imple-mented. The patient should bendthe knees and avoid coughing to

sures. Retention sutures willreduce the incidence of wounddehiscence, but not eliminate it(Meeks & Trenhaile, 2005). TheCDC recommends that incisionsbe covered by sterile dressingsfor at least 24-48 hours postoper-atively (CDC, 1999). Some sur-geons will continue dressingsuntil epithelialization is com-plete. The skin’s bacterial barrieris established once the incision isepithelialized. The edges of theincision will be approximated andno drainage is present. At thistime, dressings are optional.

Wounds heal by primary, sec-ondary, or tertiary intention.Surgical wounds that are approxi-mated heal by primary intention,mainly by deposition of connec-tive tissue. Wounds that dehiscefrequently are left to heal by sec-

ondary intention. These woundsheal more slowly due to theamount of connective tissue thatis necessary to fill the wound.Some surgical wounds initiallyare left open; then later the super-ficial edges are closed, and thecenter heals by granulation tis-sue. These wounds heal by ter-tiary intention (Waldrop &Doughty, 2000).

Incisional supports should beconsidered for patients at risk forwound dehiscence, includingthose patients who are obese ormalnourished, or have a chroniccough or chronic steroid use(Doughty, 2005). Supports in-clude binders for abdominal inci-sions and surgical bras forpatients with sternal wounds orlarge breasts (Doughty, 2005).

The nurse should inspectincisions each shift for evidenceof separation, and assess for anysigns of infection such as red-ness, warmth, and edema around

fish, legumes, milk, and cheese.Supplemental drinks also mayprovide additional protein. TheInstitute for Healthcare Im-provement (IHI) also recom-mends several measures toreduce surgical site infections.These include maintaining highlevels of inspired oxygen, avoid-ing shave prep of the operativesite, controlling serum glucoselevels, preventing hypothermia,and using prophylactic antibi-otics (IHI, 2006).

During the surgical proce-dure, measures to reduce the riskof infection are implemented.Immediately after surgery, thenurse should maintain patients’warmth and manage painbecause both measures help toreduce vasoconstriction (Doughty,2005; West & Gimbel, 2000).Hypovolemia is a potent vasocon-trictor (West & Gimbel, 2000).Adequate blood volume will helpmaintain tissue oxygen levels.Tissues that are adequately per-fused usually are able to heal(Waldrop & Doughty, 2000).Patients who are well perfusedrarely get wound infections, acontributing factor for wounddehiscence (West & Gimbel,2000). Blood volume also shouldbe maintained by adequate fluidreplacement. Supplemental oxy-gen should be used to maintainnormal oxygen levels as needed.Good blood glucose control alsois important for healing (Doughty,2005). Wound repair in patientswith diabetes mellitus is charac-terized by decreased collagensynthesis and deposition anddecreased breaking strength.Many of the effects of diabetesmellitus are related to glycemiccontrol. The management ofpatients with diabetes andwounds should include strictglycemic control, and measuresto reduce trauma and maximizetissue perfusion (Doughty, 2005;Waldrop & Doughty, 2000).

Retention sutures may beplaced to reinforce other clo-

Wound dehiscence frequently occurswithout warning.


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of collagen in the wound bed(Hess & Kirsner, 2003). Thesedressings are available in sheets,pads, gels, and particles. Collagendressings may be used as the pri-mary dressing for dehiscedwounds with minimal-to-heavyexudates. A secondary dressingwill be required (Hess, 2002).

Negative pressure woundtherapy may be used for full-thickness dehisced wounds withmoderate-to-heavy drainage. Neg-ative pressure is applied to a spe-cial dressing that is placed in thewound bed. Interstitial fluid isremoved from the wound, circula-tion increased, and more rapidformation of granulation tissueoccurs (Hess, 2002) (see Table 2).

SummaryDespite advances in preoper-

ative care, the rate of surgicalwound dehiscence has notdecreased in recent years; 1%-3%of patients experience wounddehiscence. A nursing goal for thepostoperative patient is alwaysprevention of wound dehiscence.Recognition of risk factors isessential. For example, oldermales with ascites are at veryhigh risk. Prevention of woundinfection and mechanical stresson the incision are important.

Management of dehiscedwounds may include immediate

drainage. Alginates, which arederived from brown seaweed,consist of woven fibers formedinto sheets or ropes. When usedto fill a wound, alginates absorbdrainage and form a soft gel.Some formulations can absorb upto 20 times their weight in fluid.They can be covered with sec-ondary gauze dressing or a trans-parent film dressing (Hess, 2002).

Silver is a broad-basedantimicrobial agent that controlsbacteria, mold, and yeast. Somesilver agents control methicillin-resistant staphylococcus aureus(MRSA) and vancomycin-resis-tant enterococci (VRE) when atappropriate concentrations. Silverinhibits cellular respiration, dena-tures nucleic acids, and alters cellmembrane permeability (Warriner& Burrell, 2005). Silver dressingscome in several formulations,including sheets, combined withalginates and foams, as well aswound fillers. Some silver-impreg-nated dressings are meant to beworn for up to several days.These dressings are usually cov-ered with a dry gauze secondarydressing. Because several typesof silver dressings are available, itis imperative to read the productinsert carefully prior to use ofthese dressings.

Collagen dressings encouragethe deposition and organization

reduce abdominal pressure.Sterile gauze or towels soaked insterile saline should be placedover the wound or any exposedbowel. The nurse should not tryto push any viscera back intoabdomen. The color of the tissueand any exposed bowel should beassessed, and the supervisor andsurgeon notified of the change inthe patient’s condition. The nurseshould assess the patient’s vitalsigns and oxygen saturationevery 15 minutes. The patientshould be reassured regardinghis or her condition. Pain shouldbe assessed and managed appro-priately. An intravenous lineshould be present in case thepatient needs immediate surgery.The patient should have nothingby mouth. It is important for thenurse to stay with the patient tomonitor vital signs and monitorfor shock until the patient is seenby a physician (McConnell, 1998;Moz, 2004). After a surgeon hasexamined the wound, an abdomi-nal binder may be ordered to sup-port the abdomen if surgery isnot indicated (Meeks & Trenhaile,2005)

Wound ManagementThe dehisced wound is man-

aged the same as any other openwound if immediate surgical clo-sure is not done. Topical therapyshould include measures to main-tain a moist environment, reduceinfection, manage pain, and elimi-nate all necrotic material(Doughty, 2005). Hydrogel or geldressings are water-based orglycerin-based products availableas amorphous gels, gauze impreg-nated with gel, or sheet gels.Hydrogels help maintain a moistwound environment for drywounds, and they promote granu-lation and epithelialization. Afterapplication, they are coveredwith a dry dressing, or a drydressing and transparent film(Hess, 2002). Alginate dressingscan be effective for wounds witha moderate-to-large amount of

Table 2.Wound Care Products

Dressing Drainage Absorbed Function

Hydrogel Minimal Hydrate wound

Alginate Moderate to large Absorb drainage; promotemoist wound healing

Silver dressings Minimal to large Reduce bacterial load ofwound; some absorption ofdrainage

Collagen dressings Minimal to large Provide collagen to woundbed

Negative pressure wound therapy

Minimal to large Stimulate granulation tissue;absorb drainage

Source: Hess, 2002




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McGuckin, M., Goldman, R., Bolton, L., &Salcido, R. (2003). The clinical rele-vance of microbiology in acute andchronic wounds. Advances in Skin andWound Care, 16(1), 12-25.

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Waqar, S., Malik, Z., Razzaq, A., Abdullah,M., Shaima, A., & Zahid, M. (2005).Frequency and risk factors for wounddehiscence/burst abdomen in midlinelaparotomies. Journal Ayub MedicalCollege Abottabad, 17(4), 70-73.

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surgery if bowel is protrudingfrom the wound. If surgery is notneeded, management is essential-ly the same as that of any otherwound through maintenance of amoist wound environment, reduc-tion of bioburden and pain, andpromotion of granulation tissue.Mortality rates associated withdehiscence have been reportedbetween 14% and 50% (Hanif etal., 2000; Waqar et al., 2005). Oneof the complications (morbidity)of dehisced wounds is an inci-sional hernia, which develops inan estimated 43% of patients(van’t et al., 2004). Researchersfollowed 126 patients who hadwound dehiscence repair for amean of 37 months and foundthat 31% of the hernias were diag-nosed more than 2 years postop-eratively. Nurses need to ensureadequate nutrition and reducedtension on the abdomen, andimplement measures to preventincisional infections. ■

ReferencesCenters for Disease Control and Prevention

(CDC). (1999). Guideline for preventionof surgical site infection, 1999.Retrieved June 27, 2006, fromhttp://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf

Chin, G., Diegelmann, R., & Schultz, G.(2005). Cellular and molecular regula-tion of wound healing. In A. Falabella &R. Kirsner (Eds.), Wound healing (pp.17-37). Boca Raton, FL: Taylor &Francis Group.

Nurses need to ensure adequate nutrition andreduced tension on the abdomen, and implement

measures to prevent incisional infections.


surgical wound dehiscence

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