Abdominal Wound Dehiscence
Wound dehiscence and eventration after an abdominal operation is one of the most serious postoperative complications, associated with up to 30% mortality. In this phenomenon, about 1 week after laparotomy the wound suddenly opens up: The common name burst
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Wound dehiscence and eventration after an abdominal operation is one of the most serious postoperative complications, associated with up to 30% mortality.1-3 In this phenomenon, about 1 week after laparotomy the wound suddenly opens up: The common name burst abdomen captures its calamitous nature. The reported incidence has not diminished appreciably in the past five decades and varies between 0.5 and 5%, excluding some individual series in which disruption has never occurred. 1.4-7 In a large randomized multicenter trial, Wissing et al. 6 reported 2.3% wound dehiscences in 1491 patients. Only since the mass closure technique became popular has the incidence fallen to 1% or less of all major laparotomy incisions. 1.8 The disruption may be complete or incomplete, early or late, septic or aseptic. The disruption is incomplete when the skin or the peritoneum remains intact, preventing evisceration, but complete when all layers separate and viscera protrude into the wound or even onto the skin or the bed sheets (Fig. 83.1). An early dehiscence, within 4 days, usually signifies faulty technique, whereas in a late dehiscence other factors may also playa role. The difference between wound rupture and incisional hernia is not clearly defined; we suggest a division in terminology at 1 month. Small incomplete ruptures may be asymptomatic and later present as an incisional hernia. Also small complete ruptures may be mi~udged and appear to heal after conservative treatment (Figs. 83.2 to 83.4). There is evidence that all or most incisional hernias have their beginnings in the first weeks after operation. 9.10•11
Etiology There is no single cause for abdominal wound dehiscence. Many factors may lead to the ultimate breakdown of the wound, usually a combination of internal and external, local and systemic factors. Mechanical and technical factors seem to play a crucial role in most cases of wound disruption.l· 2.4 •7.11 In any case, knots slip, sutures break, or tissues tear, and the wound disrupts, following a sudden and temporary or a gradual and more permanent rise in intraabdominal pressure (Figs. 83.5 and 83.6).
Systemic Factors Wound dehiscence is more likely to occur in men, due, it is thought, to the greater ability of the male to raise his intraab-
dominal pressure. 12 In most series males outnumber females by 3 to 1. 1.3•8.13-16 Increased age is another independent factor outside the surgeon's control. Wound dehiscence is more likely to occur in the elderly, although the problem is striking in newborn patients as well. Systemic factors such as obesity, malnutrition, hypoproteinemia, diabetes, jaundice, uremia, anemia, and hypoxia all may contribute to wound healing problems. The use of steroids, anticoagulants, or cytotoxic agents seems to playa role only in experimental models.8.12.17 Emergency operations carry a much higher risk. In a recent survey of 3768 patients, those who were operated on electively developed wound dehiscence in 0.5% of cases. Acute operations progressed to wound breakdown in 3.3%, an odds rat
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