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prepared
By
Ihab Samy
As s i s t an t l ec t u r er of S u r g i ca l O n co l o g y
N C I – C ai r o U ni v er s i t y
Management
Of The
Burst Abdomen
Definition
Incidence
Clinical Manifestations
Risk Factors For Abdominal Wound Dehiscence
Pre-Operative Factors
Operative Factors
Post-Operative Factors
Treatment
Non-operative Treatment
Operative Treatment
Retention Sutures
The Uncloseable Abdomen
OVERVIEW
Also known as abdominal wound dehiscence, wound failure,
wound disruption, evisceration, and eventration.
Describes partial or complete postoperative separation of an
abdominal wound closure with protrusion or evisceration of the
abdominal contents.
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.
Dehiscence of the wound occurs before cutaneous healing,
while incisional hernias lie under a well-healed skin incision.
DEFINITION
Wound dehiscence continues to be a major complication
of abdominal surgery despite significant progress in
operative and perioperative care over the last few decades.
Accompanied by high morbidity and mortality.
Reported incidence varies between 0.2% to 6%.
Associated with mortality rates between 10% and 40%.
INCIDENCE
Dehiscence usually declares itself 7-14 days post-op. and may
occur without warning.
May manifest following straining or removal of the sutures.
Patient often notes a “ripping sensation” or a feeling that
“something has given way”.
Impending dehiscence of the abdominal wall is often preceded
by the appearance of a salmon-pink serous discharge from the
wound. This is seen in up to 85% of cases.
CLINICALMANIFESTATIONS
Male Sex: Male : Female = 2:1
Age: < 45 years old dehiscence  occurs in 1.3%
> 45 years old dehiscence occurs in 5.4%
Emergency Operation: May be related to haemodynamic
instability.
Obesity: However several studies  No association.
Uncontrolled Diabetes: well controlled diabetes is not a risk
factor.
Renal failure
Jaundice
Anaemia : In some studies.
Pre-Operative Factors
Malnutritution:
 Protein deficencies: Hypo-albuminaemia can be used as
a marker of malnutritution.
 Vitamin C: is critical for strength gain in healing
wounds. Sub-clinical vitamin c deficency is associated
with an eightfold increase in the incidence of wound
dehiscence. Vitamin C supplementation seems reasonable
in malnourished surgical patients.
 Zinc deficency.
Corticosteriods: topically or systemically, have a
deleterious effect on wound healing.
Pre-Operative Factors
Incision type?
Closure: Mass versus Layered Closure?
Interrupted versus Continuous Sutures?
Peritoneal Closure or not?
Suture Materials: Absorbable versus non-absorbable?
Stitch interval and Size of Tissue Bite?
Suture Length-to-Wound Length Ratio?
Operative Factors
Incision type?
Inspite the midline incision is the most versatile The rate
of dehiscence is higher in midline incisions than in
transverse incisions.
Midline incision is ”non-anatomic”. It cuts across the
aponeurotic fibres, as opposed to the transverse incision
which cuts paralell to the fibres.
Contraction of the abdominal wall causes laterally
directed tension on the closure suture material cut
through by separation of the tranversily orientated fibres.
Closure?
Mass versus Layered Closure?
Closure of the abdominal wall in layers has been the traditional
approach.
Data have been published that suggest that mass closure (all
layers of the abdominal wall taken together) is equivalent to or
better than layered closure in preventing dehiscence.
Mass closure is currently favored because of its safety,
efficacy, and speed.
Interrupted versus Continuous Sutures?
Several randomised trials revealed no statistically significant
difference in the incidence of wound disruption between the
two techniques.
Several technical variations of the interupted stitch, including
the interrupted ‘figure of eight’, ‘far-and-near’ technique, or
interrupted “Smead-Jones’ technique did not improve
outcomes.
Continuous suture is a reasonable closure technique because of
its safety, efficacy, and speed.
Peritoneal Closure or not?
Suturing the peritoneum is not vital to prevent wound
dehiscence.
Randomised trials have shown no difference in the wound
disruption rate when one-layer closure (peritoneum not
sutured) and two-layer closure are compared in paramedian
and midline incisions.
The peritoneal defects heal by simultaneous regeneration of
the layer over the entire defect, not an incremental
advancement from the wound edge, as is seen with skin.
Suture Materials?
Absorbable vs. non-absorbable sutures?
Numerous prospective and retrospective studies have shown no
difference in the overall incidence of wound complications between the
various absorbable and non-absorbable sutures. However some showed
prolonged wound pain and suture sinuses with non-absorbable sutures.
So the choice seems to be one of personal preference.
It may be wise, however, to use a non-absorbable monofilament in the
patient who has an excessive number of risk factors for delayed healing.
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 abdominal
dehiscence and the later development of incisional hernia.
Elevation of Intra-Abdominal Pressure (instigator
of dehiscence) due to either:
Coughing
Vomiting
Ileus
Urinary retention
Wound Infection.
Radiation Therapy (Both in the past and
perioperatively).
Antineoplastic Agents (postpone 2-3 weeks P.O.).
Post-Operative Factors
Non-Operative Treatment:
If patient very unstable, and there has been no evisceration.
Performed at bedside.
Involves either gauze packing of the wound or covering it
with a sterile occlusive dressing.
Abdominal binder may be used to support disrupted
abdominal wound.
Wound may subsequently contract to closure, or if the
patient’s condition improves, delayed operative closure may
be performed.
Hernia is a common sequela.
TREATMENT
Operative Treatment:
For most patients immediate re-suture (usually with a mass
closure) with the placement of deep retention sutures.
Pre-operative broad spectrum antibiotics should be given.
Deep bites of tissue, using plenty of suture material, and avoid
excessive tension on the wound.
Close the skin fairly loosely and consider using a superficial
wound drain. In the presence of gross wound sepsis, leave the
skin open and pack.
TREATMENT
retention sutures:
Use heavy non-absorbable suture e.g. No. 1 monofilament Nylon.
Wide interupted bites of at least 3 cm from the wound edge.
Stitch interval of 3 cm or less.
Either external (incorporating all layers peritoneum through to skin) or internal (all layers except skin)
may be used.
Internal retention sutures avoid producing an unsightly ladder-pattern scar, however they are unable to be
removed subsequently (increased infection risk).
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 are usually left in for at least 3 weeks.
TREATMENT
The Uncloseable Abdomen:
In a small number of patients it is inappropriate, technically unsafe or
even impossible to close the abdominal wall primarily.
Conditions which may predispose to an uncloseable abdomen 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.
TREATMENT
Mesh closure of the abdominal incision is usually indicated.
The defect is bridged with one or two layers of a prosthetic
mesh.
The mesh is sutured in place with sutures that penetrate the
full thickness of the abdominal wall.
Dressing changes and subsequent granulation tissue
formation ultimately result in a surface that can be covered
with a split-skin graft.
TREATMENT
PTFE
(e.g. Goretex)
Polypropylene mesh
(e.g. Prolene, Marlex)
Absorbable mesh
(polyglycolic acid e.g.
Dexon)
• Soft and pliable
• Less adhesions to
bowel
• Tolerates infection
poorly
• Erosion into bowel and
fistula formation
• Dense adhesions
formation
• Quite tolerant to
infection
• Temporary closure
• Subsequent incisional
hernia inevitable
• Good for infected
abdomen
TREATMENT
 Carlson MA. Acute Wound Failure. Surgical Clinics of North America 1997; 77: 607-636.
 Brolin RE. Prospective, Randomised Evaluation of Midline Fascial Closure in Gastric
Bariatric Operations. The American Journal of Surgery 1996; 172; 123-126.
 Ellis H, Colridge-Smith PD, Joyce AD. Abdominal incisions – vertical or transverse?
Postgrad Med J 1984; 60: 407 - 410).
 Weiland DE, Bay RC, Del Sordi S. Choosing the Best Abdominal Closure by Meta-
analysis. American journal of surgery 1998; 176: 666 - 670.
 Fagniez PL, Hay JM, Lacaine F, et al. Archives of Surgery 1985; 120: 1351.
 Van’t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of
techniques for closure of midline abdominal incisions. 2002 British Journal of Surgery; 89:
1350-1356.
 Israelsson LA, Jonsson T, Knutsson A. Suture Technique and Wound Healing in Midline
Laparotomy Incisions. European Journal of Surgery 1996; 162: 605-609.
 Nagy KK, Fildes JJ, Mahr C, et al. Experience with Three Prosthetic Materials in
Temporary Abdominal Wall Closure. American Surgeon 1996; 62: 331-335
References
Thank you

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Management of the burst abdomen.ppt

  • 1. prepared By Ihab Samy As s i s t an t l ec t u r er of S u r g i ca l O n co l o g y N C I – C ai r o U ni v er s i t y Management Of The Burst Abdomen
  • 2. Definition Incidence Clinical Manifestations Risk Factors For Abdominal Wound Dehiscence Pre-Operative Factors Operative Factors Post-Operative Factors Treatment Non-operative Treatment Operative Treatment Retention Sutures The Uncloseable Abdomen OVERVIEW
  • 3. Also known as abdominal wound dehiscence, wound failure, wound disruption, evisceration, and eventration. Describes partial or complete postoperative separation of an abdominal wound closure with protrusion or evisceration of the abdominal contents. 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. Dehiscence of the wound occurs before cutaneous healing, while incisional hernias lie under a well-healed skin incision. DEFINITION
  • 4. Wound dehiscence continues to be a major complication of abdominal surgery despite significant progress in operative and perioperative care over the last few decades. Accompanied by high morbidity and mortality. Reported incidence varies between 0.2% to 6%. Associated with mortality rates between 10% and 40%. INCIDENCE
  • 5. Dehiscence usually declares itself 7-14 days post-op. and may occur without warning. May manifest following straining or removal of the sutures. Patient often notes a “ripping sensation” or a feeling that “something has given way”. Impending dehiscence of the abdominal wall is often preceded by the appearance of a salmon-pink serous discharge from the wound. This is seen in up to 85% of cases. CLINICALMANIFESTATIONS
  • 6.
  • 7.
  • 8.
  • 9. Male Sex: Male : Female = 2:1 Age: < 45 years old dehiscence  occurs in 1.3% > 45 years old dehiscence occurs in 5.4% Emergency Operation: May be related to haemodynamic instability. Obesity: However several studies  No association. Uncontrolled Diabetes: well controlled diabetes is not a risk factor. Renal failure Jaundice Anaemia : In some studies. Pre-Operative Factors
  • 10. Malnutritution:  Protein deficencies: Hypo-albuminaemia can be used as a marker of malnutritution.  Vitamin C: is critical for strength gain in healing wounds. Sub-clinical vitamin c deficency is associated with an eightfold increase in the incidence of wound dehiscence. Vitamin C supplementation seems reasonable in malnourished surgical patients.  Zinc deficency. Corticosteriods: topically or systemically, have a deleterious effect on wound healing. Pre-Operative Factors
  • 11. Incision type? Closure: Mass versus Layered Closure? Interrupted versus Continuous Sutures? Peritoneal Closure or not? Suture Materials: Absorbable versus non-absorbable? Stitch interval and Size of Tissue Bite? Suture Length-to-Wound Length Ratio? Operative Factors
  • 12. Incision type? Inspite the midline incision is the most versatile The rate of dehiscence is higher in midline incisions than in transverse incisions. Midline incision is ”non-anatomic”. It cuts across the aponeurotic fibres, as opposed to the transverse incision which cuts paralell to the fibres. Contraction of the abdominal wall causes laterally directed tension on the closure suture material cut through by separation of the tranversily orientated fibres.
  • 13.
  • 14. Closure? Mass versus Layered Closure? Closure of the abdominal wall in layers has been the traditional approach. Data have been published that suggest that mass closure (all layers of the abdominal wall taken together) is equivalent to or better than layered closure in preventing dehiscence. Mass closure is currently favored because of its safety, efficacy, and speed.
  • 15. Interrupted versus Continuous Sutures? Several randomised trials revealed no statistically significant difference in the incidence of wound disruption between the two techniques. Several technical variations of the interupted stitch, including the interrupted ‘figure of eight’, ‘far-and-near’ technique, or interrupted “Smead-Jones’ technique did not improve outcomes. Continuous suture is a reasonable closure technique because of its safety, efficacy, and speed.
  • 16. Peritoneal Closure or not? Suturing the peritoneum is not vital to prevent wound dehiscence. Randomised trials have shown no difference in the wound disruption rate when one-layer closure (peritoneum not sutured) and two-layer closure are compared in paramedian and midline incisions. The peritoneal defects heal by simultaneous regeneration of the layer over the entire defect, not an incremental advancement from the wound edge, as is seen with skin.
  • 17. Suture Materials? Absorbable vs. non-absorbable sutures? Numerous prospective and retrospective studies have shown no difference in the overall incidence of wound complications between the various absorbable and non-absorbable sutures. However some showed prolonged wound pain and suture sinuses with non-absorbable sutures. So the choice seems to be one of personal preference. It may be wise, however, to use a non-absorbable monofilament in the patient who has an excessive number of risk factors for delayed healing.
  • 18. 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 abdominal dehiscence and the later development of incisional hernia.
  • 19. Elevation of Intra-Abdominal Pressure (instigator of dehiscence) due to either: Coughing Vomiting Ileus Urinary retention Wound Infection. Radiation Therapy (Both in the past and perioperatively). Antineoplastic Agents (postpone 2-3 weeks P.O.). Post-Operative Factors
  • 20. Non-Operative Treatment: If patient very unstable, and there has been no evisceration. Performed at bedside. Involves either gauze packing of the wound or covering it with a sterile occlusive dressing. Abdominal binder may be used to support disrupted abdominal wound. Wound may subsequently contract to closure, or if the patient’s condition improves, delayed operative closure may be performed. Hernia is a common sequela. TREATMENT
  • 21. Operative Treatment: For most patients immediate re-suture (usually with a mass closure) with the placement of deep retention sutures. Pre-operative broad spectrum antibiotics should be given. Deep bites of tissue, using plenty of suture material, and avoid excessive tension on the wound. Close the skin fairly loosely and consider using a superficial wound drain. In the presence of gross wound sepsis, leave the skin open and pack. TREATMENT
  • 22. retention sutures: Use heavy non-absorbable suture e.g. No. 1 monofilament Nylon. Wide interupted bites of at least 3 cm from the wound edge. Stitch interval of 3 cm or less. Either external (incorporating all layers peritoneum through to skin) or internal (all layers except skin) may be used. Internal retention sutures avoid producing an unsightly ladder-pattern scar, however they are unable to be removed subsequently (increased infection risk). 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 are usually left in for at least 3 weeks. TREATMENT
  • 23.
  • 24. The Uncloseable Abdomen: In a small number of patients it is inappropriate, technically unsafe or even impossible to close the abdominal wall primarily. Conditions which may predispose to an uncloseable abdomen 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. TREATMENT
  • 25. Mesh closure of the abdominal incision is usually indicated. The defect is bridged with one or two layers of a prosthetic mesh. The mesh is sutured in place with sutures that penetrate the full thickness of the abdominal wall. Dressing changes and subsequent granulation tissue formation ultimately result in a surface that can be covered with a split-skin graft. TREATMENT
  • 26. PTFE (e.g. Goretex) Polypropylene mesh (e.g. Prolene, Marlex) Absorbable mesh (polyglycolic acid e.g. Dexon) • Soft and pliable • Less adhesions to bowel • Tolerates infection poorly • Erosion into bowel and fistula formation • Dense adhesions formation • Quite tolerant to infection • Temporary closure • Subsequent incisional hernia inevitable • Good for infected abdomen TREATMENT
  • 27.  Carlson MA. Acute Wound Failure. Surgical Clinics of North America 1997; 77: 607-636.  Brolin RE. Prospective, Randomised Evaluation of Midline Fascial Closure in Gastric Bariatric Operations. The American Journal of Surgery 1996; 172; 123-126.  Ellis H, Colridge-Smith PD, Joyce AD. Abdominal incisions – vertical or transverse? Postgrad Med J 1984; 60: 407 - 410).  Weiland DE, Bay RC, Del Sordi S. Choosing the Best Abdominal Closure by Meta- analysis. American journal of surgery 1998; 176: 666 - 670.  Fagniez PL, Hay JM, Lacaine F, et al. Archives of Surgery 1985; 120: 1351.  Van’t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. 2002 British Journal of Surgery; 89: 1350-1356.  Israelsson LA, Jonsson T, Knutsson A. Suture Technique and Wound Healing in Midline Laparotomy Incisions. European Journal of Surgery 1996; 162: 605-609.  Nagy KK, Fildes JJ, Mahr C, et al. Experience with Three Prosthetic Materials in Temporary Abdominal Wall Closure. American Surgeon 1996; 62: 331-335 References