Wound dehiscence is a complication of surgery where the surgical incision ruptures or reopens. It can lead to evisceration of internal organs. Risk factors include obesity, diabetes, wound infection, and surgical factors like tension on the incision. Symptoms include pain, swelling, and drainage at the wound site. Treatment depends on the severity but may involve antibiotics, packing the wound, or re-suturing the incision. Negative pressure wound therapy can also be used to help close wounds at high risk of dehiscence. Preventing wound dehiscence requires proper surgical technique like layered closure with adequate suture length and tissue bites.

1. ZONAL P.G CME , HYDERABAD
PROF. SREEJOY PATNAIK
FAIS, FIAGES, FAMS.
HON.PROF. IMAAMS
LIFE MEMBER OSSI, IFSO,ELSA, IHPBA, IFSO
BARIATRIC AND METABOLIC SURGEON
SHANTI OMNI MULTI SUPER SPECIALITY
HOSPITAL
CUTTACK, ODISHA

2. WOUND DEHISCENCE
 Most Dreaded Complication faced by Surgeons.
 Risk of Evisceration is high.
 Intervention ?
 Possibility of repeat-
 Dehiscence
 Wound Infection
 Incisional Hernia

3. Wound Dehiscence
 It is a rupture of the wound along the surgical
incision.
 Complication of Surgery
 The split - Surface Layers
-Deep Layers (whole wound)

4.  Abdominal wound dehiscence
 Wound failure
 Wound disruption
 Evisceration and Eventration.
SYNONYMS

5. 
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.

6. Partial postoperative separation 
Complete  postoperative separation

7. 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%

8. Factors for wound breakdown
A . Local-
- Haematoma
- Seroma
B. Regional-
- Bowel Edema
- Abdominal distention
- Intra abdominal infections
- Haemorrhage
- Trauma
- Pre-op Int.obstruction

9. C. Systemic-
-Advanced age
- Malnutrition
- Pulmonary & Cardiac diseases
- Renal Failure
-Obesity
- DM
-RT & CT
- Jaundice
- Alcoholism
- Hypoproteinaemia
-
Factors for wound breakdown

10. 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

11. Bleeding
Swelling
Redness
Pain
Unexplained fever
Unexplained 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

12.  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 Manifestations
Signs

13.  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

14.  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 Factors
Incision type?

15.  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?

16.  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 Factors
Interrupted versus Continuous Sutures?

17.  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 Factors
Absorbable vs. non-absorbable sutures?

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 WD and the
development of IH.
Operative Factors

19.  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 Factors
Peritoneal Closure or not?

20. 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

21. Investigations:
LAB TESTS:
Wound and tissues c/s
Blood tests to determine if there is an
infection
IMAGING 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.

22.  Focus should be based on-
 Nutritional support
 Circulatory support
 Therapy to be designed to –
 Eliminate necrotic tissue
 Control Bio burden
 Maintain optimal environment for granulation tissue formation
& epithelial migration.
 Broad spectrum Antibiotic therapy
 Frequent 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.
Treatment
Non-operative treatment

23. 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

24. Pre-operative broad spectrum antibiotics
Re-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
TREATMENT
Operative Treatment:

25. 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 Closure
Infected & necrotic - Debridement
 Closure :
Retention Sutures
Prosthetic 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

26.  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.
TREATMENT
Retention sutures:

27.  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
TREATMENT
The Uncloseable Abdomen:

28. 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

29. 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.

30. 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.

31. Guidelines for Wound Closure
A .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 = 4:1
 Lower 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

32. 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.

33. 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.