ZONAL P.G CME , HYDERABAD

PROF. SREEJOY PATNAIKFAIS, FIAGES, FAMS.HON.PROF. IMAAMS

LIFE MEMBER OSSI, IFSO,ELSA, IHPBA, IFSOBARIATRIC AND METABOLIC SURGEON

SHANTI OMNI MULTI SUPER SPECIALITY HOSPITAL

CUTTACK, ODISHA

WOUND DEHISCENCE

Most Dreaded Complication faced by Surgeons. Risk of Evisceration is high. Intervention ? Possibility of repeat-

Dehiscence Wound Infection Incisional Hernia

Wound Dehiscence

It is a rupture of the wound along the surgical incision.

Complication of Surgery The split - Surface Layers

-Deep Layers (whole wound)

Abdominal wound dehiscence Wound failure Wound disruption Evisceration and Eventration.

SYNONYMS

Incisional hernia lie under a well

healed skin incision.

Partial or Complete postoperative separation of an abdominal wound closure with protrusion or evisceration of the abdominal contents. Dehiscence of wound occurs before cutaneous healing.

WOUND DEHISCENCE & INCISIONAL HERNIA

Wound dehiscence and incisional hernia are part of the same wound failure process: it is timing and healing of the overlying skin that distinguishes the two.

Partial postoperative separation

Complete postoperative separation

Incidence

1 to 3% of all abdominal operations. Develops 7 to 10 days Post-op. Anytime after Surgery, D1 to D20 It’s a morbid complication. Mortality rate -16% Male to Female ratio: 2:1 Age - < 45 yrs – 1.3% > 45 yrs – 5.4%

Factors for wound breakdown

A . Local-- Haematoma- Seroma

B. Regional-- Bowel Edema- Abdominal distention- Intra abdominal infections- Haemorrhage- Trauma

- Pre-op Int.obstruction

C. Systemic--Advanced age- Malnutrition- Pulmonary & Cardiac diseases- Renal Failure-Obesity- DM-RT & CT

- Jaundice - Alcoholism - Hypoproteinaemia

-

Factors for wound breakdown

D. Surgical - - Emergency Procedure

-Imperfect techniques of wound closure.

-Excessive tension - Imperfect incision - Prolonged OT time - Trauma to wound post.op - Poor knotting and suturing.

Factors for wound breakdown

E. Intra abdominal-

-Vomiting, sneezing, coughing

- Repeated urinary retention

- Prolonged Paralytic Ileus

Bleeding SwellingRednessPainUnexplained feverUnexplained tachycardia

Symptoms

Unusual wound pain Broken sutures The wound opening

spontaneously Pus and /or frothy drainage Paralytic ileus

The patient may present as one or more of the following: recent surgical wound not appearing to be healing properly

Dehiscence usually declares itself 7-14 days post.op and may occur without warning.

May manifest following straining or removal of sutures.

Patient often notes a “ ripping sensation” or a feeling that “ something has given way”.

Impending dehiscence is often preceded by the appearance of salmon pink serous discharge from the wound. ( 85% of cases.}

Clinical ManifestationsSigns

Failure of suture to remain anchored in the fascia. Suture breakage Knot failure Excessive stitch interval which allows protrusion of

viscera. Sutures and knots are intact, but the suture has pulled

through the fascia. (Result of fascial necrosis from sutures being placed too

close to the edge or under too much tension)

Causes of wound separation

Midline incision is the most common. The rate of dehiscence is higher in midline than in

transverse incisions.

Midline incision -”non-anatomic” cuts across the aponeurotic fibres,

Transverse incision which cuts paralell to the fibres.

Contraction of the abdominal wall causes laterally directed tension on the closure.

Operative FactorsIncision type?

Data suggest that mass closure is equivalent to or better than layered closure in preventing dehiscence.

Mass closure is currently favoured because of its safety,

efficacy, and speed

Operative Factors

Mass versus Layered Closure?

Several RCT’s - no statistically significant difference in the incidence of wound disruption between the two techniques.

Continuous suture is a reasonable closure technique because of its safety, efficacy, and speed.

Interrupted suture – Emergency procedure.

Operative FactorsInterrupted versus Continuous Sutures?

Numerous studies have shown no difference in the overall incidence of wound complications between both sutures.

Non-absorbable monofilament is ideal with high risk factors for delayed healing.

Operative FactorsAbsorbable vs. non-absorbable sutures?

The stitch interval and the tissue bite size? Should be 1 cm. average with a range between 1-2 cm.

Suture Length-to-Wound Length Ratio? Should be 4:1 or greater for continuous mass closure.

A ratio < 4:1 is associated with an increased risk of WD and the development of IH.

Operative Factors

Suturing the peritoneum is not vital to prevent wound dehiscence.

RCT‘s show no difference in the wound disruption rate with one-layered closure (peritoneum not sutured) than two-layered closure.

Normally peritoneal defects heal by simultaneous regeneration.

Operative FactorsPeritoneal Closure or not?

Examination Assess Incision: Examine the entire wound.

Look for leakage of fluid when palpated.

Look for signs of infection.

Wound or surrounding area look for signs of -purulent discharge, crepitus, cellulitis with fluctuance,

inspect the inside of wound.

Vital Signs: Look for fever

INSPECTION

Investigations:

LAB TESTS:Wound and tissues c/s Blood tests to determine if there is

an infectionIMAGING STUDIES:

X-ray: to evaluate the extent of wound separation.

USG : to evaluate for pus and pockets of

fluid.CT Scan : to evaluate for pus and

pockets of fluid.

Focus should be based on- Nutritional support Circulatory support Therapy to be designed to –Eliminate necrotic tissueControl Bio burdenMaintain optimal environment for granulation tissue formation &

epithelial migration.Broad spectrum Antibiotic therapyFrequent changes in wound dressing to prevent infection Wound exposure to air to accelerate healing and prevent infection, and

allow growth of new tissue from below.

TreatmentNon-operative treatment

Treatment

Depends on Extent of Fascial Separation. Presence of Evisceration. Intra-abdomen Pathology (Int. leak, Peritonitis)

Small Dehiscence Conservative Management Saline moistened gauze packs Abdominal Binders

Large Dehiscence with Evisceration Saline moistened towel packing IV fluids resuscitation Preparation for closure OT Adequate Relaxation of the Patient

Pre-operative broad spectrum antibioticsRe-suture with a mass closure with the placement of deep

retention sutures. Deep bites of tissue, using plenty of suture material, and avoid

excessive tension on the wound. Close the skin fairly loosely Superficial wound drain. Gross wound sepsis - leave the skin open and pack

TREATMENTOperative Treatment:

Steps of Management in OT

Thorough exploration of abdominal cavity. Rule out presence of septic focus or anastomotic leak. Manage Infection. Assess the condition of fascia.

Strong & intact - Primary ClosureInfected & necrotic - Debridement

Closure : Retention SuturesProsthetic material-Absorbable mesh or Permanent (Polyglactin or PTFE-

Poly Tetra Fluro Ethylene) Synthetic Materials: Silicone Sheets sutured to fascial edges VAC (Vaccum Assisted Closure) Therapy

Use No. 1 monofilament Nylon. NA Wide interrupted bites of at least 3 cm from the wound

edge. Stitch interval of 3 cm or less. External retention sutures (incorporating all layers

peritoneum through to skin) or internal (all layers except skin) may be used.

Internal retention sutures . Thread each suture through a short length (5-6cm) of

plastic or rubber tubing to prevent suture erosion into the skin.

Do not tie too tightly. External retention sutures- 3 weeks.

TREATMENTRetention sutures:

In a small number of patients it is impossible to close the abdominal wall primarily

Conditions which may predispose include: 1. Major abdominal trauma. 2. Gross abdominal sepsis. 3. Retroperitoneal haematoma e.g. post ruptured

AAA. 4. Loss of abdominal wall tissue e.g. Necrotizing

fasciitis. Attempted closure abdominal compartment

syndrome

TREATMENTThe Uncloseable Abdomen:

Open abdomen technique Abdomen left open or closed with temporary closure

device. Avoids IAH ,preserves fascia & facilitates reaccess of

abdominal cavity.

Mesh closure of the abdominal incision is usually indicated. The defect is bridged with one or two layers of a prosthetic mesh.

Synthetic mesh - PTFE Biological graft (Acellular dermal matrix) Porcine int.

submucosa.

Dressing changes granulation tissue formation surface covered with a split-skin graft.

Uncloseable Abdomen T/t

VAC Therapy

Negative Pressure wound therapy. Allows open drainage to absorbs exudate. Stimulates granulation tissue and increases blood flow in adjacent tissues. Approximate wound edges & provide a mass filling effect with low deg of

surgical trauma. MinimizesIAH Prevents loss of domain. Macrodeformation – Contraction of the wound Micro deformation of foam - wound interface Stabilises wound environment. Induces cellular proliferation & angiogenesis. Results in successful closure of fascia is 85% cases.

Procedure of VAC

Foam based sponges are used

(Pore size – 400-600 Am) placed inside the wound.

Suction unit placed on the Sponge.

Area sealed with adhesive .

Suction tube then connected to Vaccum pump & Sub-atmosphere pressure is applied- 50mmHg to 125 mmHg.

Foam dressing Changed every 3-5days.

Guidelines for Wound ClosureA .SL TO WL RATIO:

SL : WL has a strong co-relation with development of Incisional Hernia.

The total length of the suture should be approximately four times the length of the incision.

Rate of IH is lower if SL:WL = 4:1Lower or higher ratio > 4 is associated with 3 fold increase in IH.Small tissue bites with reasonable limits of stitch intervals ↓ incidence of

IH.Sutures placed at short intervals & at good distance from wound edges

WD

B. STITCH LENGTH TENSION

Ratio of SL & no. of stitches – important

Optimal stitch length - < 5cm

Rate of infection is if stitch length is too long.

Excessive tension on suture rate of wound Infection.

Button hole hernias- common, suture cuts through the aponeurotic tissue.

TAKE HOME MESSAGE(RECOMMENDATIONS)

Lap wounds should be closed by continuous technique in one-layer. Self locking knots should be used for the anchor knots. Suture material- Monofilament ( NA) suture or- Polydioxanone/ PDS-(A) but

contributes wound strength for 6wks Aponeurotic tissue closure should be atleast 10 mm from wound edges.( vertical

midline) Length of each stitch should be < 5cm Do not incorporate Peritoneum, muscle & sub. Cut fat in the suture. Excessive tension on suture line to be avoided. All wounds should be closed with a SL:WL ratio of 4:1 or optimal ratio in

between 4 and 5. Adequate care to be taken – long lap. Wounds Prolonged operative time –easy closure methods by tired surgeon should be

avoided.