Wound Dehiscence

Janix M. De Guzman, MD

Surgical Resident

Department of Surgery, OMMC

jan6mdg@yahoo.com

 

 

Definition:

            Wound dehiscence is separation within the fascial layer. This is a common complication of deep surgical site infection. 1-2

 

Epidemiology:

Based on the 1997 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database for 19 States, the Postoperative Wound Dehiscence (Hospital-Level) rate was 1.95 per 1,000 population at risk.3 Dehiscence occurs in 1.3% of patients under 45 years of age, and 5.4% of patients over 45 years of age.

 

Affects 0.5 to 3.0% with an average of 2.6% of all mid-line laparotomy wounds.

 

Etiology:

Fascial dehiscence is maybe caused by technical factors, patient characteristics and local factors.

Technical factors include failure of wound closure techniques such as broken sutures, slipped knots or inadequate suture bites. A multicenter, randomized, prospective trial comparing interrupted versus continuous polyglycolic acid suture closure of midline abdominal incisions showed a significantly higher dehiscence rate in the interrupted suture group.5

Patient characteristics and local factors that contribute to fascial dehischence with statistical significance include malnutrition, low albumin, respiratory problem, and wound infection.5  

 

Diagnosis:

            Abdominal wound dehiscence presents as with or without evisceration. Evisceration indicates extrusion of peritoneal contents through the fascial separation. Dehiscence without evisceration can be detected by the classical appearance of salmon-colored fluid draining from the wound and evisceration manifest when skin sutures are removed. As compared to a superficial surgical site infection which manifests with purulent discharge from the incision or a drain located above the fascial layer and after wound is deliberately opened no evisceration was noted. The average time between surgical procedure and wound dehiscence was 2.7 days.5

Abdominal fascial dehiscence was associated with intra-abdomial infection in trauma laparotomy cases. No clinical or laboratory factors help identify FD patients likely to have IAI. Therefore, FD should be viewed as a sign of possible underlying IAI. Appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued before managing the dehisced fascia.6

 

Management:

 

            Medical

                        Appropriate antibiotics7

                        Analgesia

                        Fluid Resuscitation

 

Coupled with either of the following depending on the patients condition:

 

Non-operative

                        Sterile occlusive wound dressing

                                    Use of absorbant and binder

                        Vacuum Assisted Closure8

           

            Operative

                        Wound debridement and resuturing

Interrupted or mass closure with non-absorbable sutures often used

The use of 'deep tension' sutures is controversial            

Outcome:

Based on the matching analysis of the 2000 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) data reported by Zhan and Miller, postoperative wound dehiscence was associated with an excess length of stay of 9.42 days, excess charges of $40,323, and an excess mortality rate of 9.63%.9

Wound dehiscence repair by interrupted sutures had no better outcome than repair by continuous sutures. Suture material did not influence incidence of incisional hernia. Incisional hernia develops in the majority of patients after wound dehiscence repair, regardless of suture material or technique. The cumulative incidence of incisional hernia was 69 per cent at 10 years.10

 

 

Reference:

 

1. Nichols RL. Surgical Wound Infections. Am J Med 1991 91:54S.

 

2. Sawyer RG, Pruett TL. Wound Infection. Surg Clin North Am 1998; 74:519.

3. AHRQ quality indicators. Guide to patient safety indicators [revision 1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2003 May 28. 143 p. (AHRQ Pub; no. 03-R203).

4. Knight CD, Griffen FD. Abdominal wound closure with a continuous monofilament polypropylene suture. Arch Surg 1983; 118:1305

5. Sánchez-Fernández P, Mier J, Castillo-González A, Blanco-Benavides R, Zárate-Castillo J. Factores de riesgo para dehiscencia de herida quirúrgica
Cir Ciruj 2000; 68(5): 198-203

6. Tillou A, Weng J, Alkousakis T, Velmahos G. Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis. Am Surg. 2003 Nov;69(11):927-9.

7. Domaradzki W, Wos S, Szafranek A, Mrozek R, Jasinski M. Management of purulent mediastinitis with sternal dehiscence - a case report. Kardiol Pol. 2003 Apr;58(4):299-301.

8. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective Evaluation of Vacuum-Assisted Fascial Closure After Open Abdomen: Planned Ventral Hernia Rate Is Substantially Reduced. Ann Surg. 2004 May;239(5):608-616.

9. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003 Oct 8;290(14):1868-74.

10. van't RM, De Vos Van Steenwijk PJ, Bonjer HJ, Steyerberg EW, Jeekel J. Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg. 2004 Apr;70(4):281-6