Burst abdomen

About burst abdomen , poor healing after surgery , wound dehescence

1. Burst Abdomen

2. Wound Dehiscence Wound dehiscence is disruption of any or all of the layers in a wound May occur in up to 3 per cent of abdominal wounds and is very distressing to the patient

3. Burst Abdomen Describes partial or complete postoperative separation of an abdominal wound closure with protrusion or evisceration of the abdominal contents Most commonly occurs from the 5 th to the 8 th postoperative day when the strength of wound is at its weakest Usually sutures opposing the deep layers, i.e , peritoneum and rectus sheath tear through causing burst abdomen

4. Predisposing Factors Pre-operative Operative Post-operative

5. Pre-operative Any factor which predisposes to faulty or delayed healing Debility & malnutrition Hypoproteinaemia Vit C deficiency Uraemia (CRF) Malignant disease Prolonged steroid therapy Obesity Jaundice Chronic cough, vomiting or bladder neck obstruction

6. Operative Any factor which means faulty technique Failure to use non-absorbable sutures Failure to control persistent leakage of pancreatic enzymes in cases of pancreatic trauma, pancreatitis or duodenal blowout Failure to avoid factors which predispose to wound infection Failure to decompress grossly distended bowel in the presence of obstruction Damage to motor nerves after a subcostal or para-rectal incision Inadequate or poor closure of the wound

7. 7. Incision type Midline (vertical) incision – greater tendency to burst than transverse incision

8. 8. Closure Mass vs Layered Closure? Incidence of burst – layered closure > mass closure Interrupted vs Continuous Sutures? Interrupted suturing – low incidence of bursts Peritoneal Closure or not? Suturing the peritoneal - not vital to prevent Burst Abdomen

9. Layered Vs Mass Closure

10. Post-operative Persistence of the pre-operative factors Wound hematoma Wound infection

11. Classification (Surgical Pathology) Superficial and revealed - occurs when the skin stitches are removed with separation of skin and sub-cutaneous layers only Deep and Concealed - there is separation of all layers of the abdominal wall with the exception of the skin. If not recognized while the patient is in the hospital, the patient will develop incisional hernia Complete and revealed (Burst Abdomen) - protrusion of a loop of bowel or a portion of an omentum

12. Clinical Features Symptoms No warning of an impending dehiscence Nausea, fever, local pain or discomfort Popping sensation in the wound after a bout of straining or coughing Signs Serosanguinous (pink) or blood stained discharge from the wound Bowel or omentum protruding through the wound spontaneously after removal of sutures Shock

13. Treatment options Non-operative Operative

14. Non-operative treatment If patient is unstable and there has been no evisceration Involves either gauze packing of the wound or covering it with a sterile occlusive dressing

15. Abdominal binder may be used to support disrupted abdominal wound

16. Vacuum Assisted Closure (VAC) Used in 10% of total patients Significantly reduces post operative infection Reduces the uses of antibiotics prescriptions Can be safely used in patients using anti-coagulants

17. Wound may subsequently contract to closure or if the patient’s condition improves, delayed operative closure may be performed

18. Operative Treatment Resuscitation if shock (+) Reassurance Appropriate analgesics Nothing by mouth Nasogastric tube insertion and suction A ntibiotic Cover the wound with sterile towel and transfer to OT Emergency operation for replacement of bowel and re-suturing of wound

19. Operative Procedure Each coils of intestine are washed with normal saline gently and thoroughly Return to abdominal cavity Clean the abdominal wall Re-approximated with through and through monofilament nylon Buttressed by tension suture Abdominal wall is supported by many-tail bandage, Adhesive plaster Post-operative - General build-up - Treat/Avoid Predisposing factors

20. Prevention Preoperative Correct the precipitating factors Manage causes of increased intra-abdominal pressure Omit medications like steroids if possible Prophylactic antibiotics GI decompression (Ryle’s tube suction) in case of intestinal obstruction

21. Per-operative Reduce septic load –peritoneal toilet Choice of suture –non-absorbable suture for wound closure Tension free closure Follow Jenkin’s rule in closing midline laparotomy wound Mass closure technique (include peritoneum + rectus sheath in closure) Continuous suture Suture should be FOUR times the length of the incision and bites should be taken 1cm from the wound edge at 1cm intervals Good surgical technique and principles

22. Post-operative Prevention of wound sepsis Manage causes of increased intra-abdominal pressure and GI distension Urgent recognition and treatment of wound dehiscence Follow-up

23. Thank You