Evisceration and Dehiscence
Dehiscence of the abdominal wound, causing a defect in the fascia, is a complication with high morbidity and mortality rates of up to 35 %. The incidence of dehiscence, or burst abdomen, has been reported to lie between 0.2 and 3.5 %. Reported risk factor
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42
Gabriëlle H. van Ramshorst
42.1 Introduction Dehiscence of the abdominal wall, or burst abdomen, can be regarded as an acute postoperative hernia. In contrast to a superficial dehiscence of skin and/or subcutaneous tissue, a defect occurs at the level of the fascia. Its presentation can vary from a small defect in the linea alba, causing leakage of serosanguineous fluid through nearly intact skin, to a sudden burst with evisceration of abdominal contents. Dehiscence appears to occur more frequently in patients who are in poor clinical condition. A high proportion of patients who develop dehiscence, eventually develop incisional hernia. In incisional hernia, a defect of the fascia is covered by healed, intact skin. In case of elevated abdominal pressure, a bulge may be noticed as intestines, omentum, or preperitoneal tissue protrude through this defect.
42.2 I ncidence and Risk Factors Relating to Dehiscence/Evisceration In most recent studies, the incidence of dehiscence varies between 0.2 and 3.5 %. Many studies have attempted to identify risk factors for dehiscence. As many patients who develop dehiscence are in poor clinical condition, it is difficult to establish solid evidence for independent effects of individual risk factors. As an example, it is difficult to distinct the individual effects of chronic obstructive pulmonary disease, smoking, and hospital-acquired pneumonia. It has to be emphasized that data on abdominal wound dehiscence need to be interpreted with caution, as most studies were retrospective and lacked multivariate statistical analyses. Risk factors can be attributed to the patient, type of operation, surgical technique, and postoperative period.
42.2.1 Patient Basic patient characteristics that have been associated with increased risk of dehiscence include male gender, advanced age, malignancy, and uremia [1–9]. These factors are beyond the influence of surgeons. Some risk factors are clearly indicative of patients’ clinical condition, and may be subject of preoperative optimalization in certain patients. These variables include, e.g., presence of ascites, chronic (obstructive) pulmonary disease, jaundice, anemia, and sepsis or systemic infections [1–4, 10–15]. A few risk factors may be influenced by patients themselves, such as nutritional status. Low levels of serum albumin and protein have been associated with dehiscence [1, 2, 4, 5, 14–16]. In a post hoc analysis of a randomized controlled trial, smoking and alcohol abuse (consumption of >4 units of alcohol per day) were identified as risk factors for abdominal wound dehiscence. However, the possible effects of surgical site infection were disregarded in multivariate analysis [17]. Smoking was also identified as a risk factor in a small casecontrol study, whereas two other studies could not confirm these results [18, 19, Van Ramshorst unpublished]. Alcoholism was not identified as a risk factor for abdominal wound dehiscence in two previous studies [10, 14]. The associations between superficial wound infection and the risk factor
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