BURST ABDOMEN-etiology,management a.pptx

Etiology and management of burst abdomen

1. BURST ABDOMEN PRESENTER:DR CHAITANYA KRISHNA MODERATOR:DR PRUTHVI RAJ

2. DEFINITION -Burst abdomen is also known as abdominal wound dehiscene,wound failure,wound disruption,evisceration and eventration. -Describes partial or complete postoperative separation of an abdominal wound closure with protusion or evisceration of the abdominal contents

3. Wound dehiscence and incisional hernia are part of the same wound failure process. But wound dehiscence occurs before cutaneous healing while incisional hernias lie under a well healed skin incision Most commonly occurs from the 5th to 8th postoperative day when the strength of the wound is at its weakest.

4. Usually sutures opposing the deep layers i.e.,peritoneum and rectus sheath tear through causing burst abdomen. Other than technical errors , deep wound infection causes localised seperation of the wound which in addition to raised intra abdominal pressure leads to wound dehiscence

5. INCIDENCE Wound dehiscence continues to be a major complication of abdominal surgery despite significant progress in operative and peri operative care over the last few decades. Associated with high morbidity and mortality Incidence varies between 0.2% to 6%

6. CLINICAL FEATURES May manifest following removal of sutures or on straining. Patient often notes a “Ripping sensation” or a feeling that something has given away. Impending dehiscence of the abdominal wall is often preceeded by the appearance of a salmon pink serous discharge

7. Often omentum or coils of the intestine are forced out of the wound probing of the wound using gloved finger appreciates dehiscence of musculoaponeurotic layer

8. PRE OPERATIVE FACTORS Male:female-2:1 <45yrs dehiscence occurs in 1.3% >45 yrs occurs in 5% Emergency operation:may be related to haemodynamic instability Obesity Anemia Previous laparotomy Duration of surgery >150 mins

9. Protein deficiences:Hypo albuminemia can be used as a marker of malnutrition Vitamin C :is critical for strength gain in healing wounds.sub clinical vit c deficiency is associated with eight fold increase in wound dehiscence Zinc deficiency Corticosteroids ,topically or systemically has deleterious effect on wound healing.

10. OPERATIVE FACTORS 1.Incision type? 1.Transerse vs 2.Linear 2.Type of closure: a)mass versus layered? b)continous vs interrupted c)peritoneal closure done or not?

11. 3.Suture materials:absorbable vs non absorbable 4.Suture length to wound length ratio 5.Stich interval and size of tissue bite?

12. INCISION TYPE The rate of dehiscence is more in midline incisions than transverse incisions Mid line incision is non anatomic.It cuts across the aponeurotic fibres,as apposed to the transverse incision which cuts parallel to the fibres.

13. MIDLINE INCISION Reduced incision to delivery time Incision may be extended upward Procedure can be performed under local anaesthesia

14. TRANSVERSE INCISION Reduced risk of infection Reduced risk of incisional hernia Improved cosmetic result Reduced postoperative pain Reduced risk of hypertrophic scar

15. CLOSURE MASS VERSUS LAYERED TECHNIQUE: closure of the abdomen wall in layers has been the traditional approach. Studies suggest that mass closure (All layers of the abdominal wall taken together)is equivalent or better than layered closure in preventing dehiscence.

16. INTERRUPTED VS CONTINUOUS SUTURES Several randomized trials revealed no statistically significant difference in the incidence of wound dehiscence between the two techniques Several technique variations of the interrupted stich,including the interrupted”figure of eight”,Or ”far and near”techniques did not improve outcomes

17. PERITONEAL CLOSURE OR NOT Suturing the peritoneum is not vital to prevent the wound dehiscence. Randomised trials have shown no difference in the wound disruption when one layer closure and two layered closure are compared. Peritoneum defects heal by simultaneous regeneration of the layer over the entire defect.

18. SUTURE MATERIALS ABSORBABLE VS NON ABSORBABLE: Numerous prospective and retrospective studies have shown no difference in the overall incidence of wound complications between the absorbable and non absorbable sutures. However some showed prolonged wound pain with non absorbable sutures.

19. So the choice of suture materials seems to be of personal preference It may be wise,however,to use a non absorbable monofilament in the patient who has excessive number of risk factors for delayed wound healing

20. THE STICH INTERVAL AND THE TISSUE BITE SIZE? Should be 1 cm,average with a range between 1-2cms

21. SUTURE LENGTH TO WOUND LENGTH RATIO? Should be 4:1 or greater for continous mass closure. A ratio of less than 4:1 is associated with increased risk of abdominal dehiscence and incisional hernia.

22. POSTOPERATIVE FACTORS Elevation of intra abdominal pressure(the instigator of wound dehiscence)due to either: Coughing Vomiting Ileus Urinary retention

23. Wound infection Radiation Therapy(both in the past and peri operatively) Use of anti neoplastic agents(better to postpone the usage of them 2-3 weeks post operatively)

24. TREATMENT NON OPERATIVE TREATMENT: If the patient is stable and there is no evisceration ,guaze packing of the wound or covering it with a sterile occlusive dressing is done at bed side

25. Abdominal binder is used to support disrupted abdominal wound. Incisional hernia is a common sequalae Wound may subsequently contract to closure or if the patient condition improves delayed operative closure of the wound is done.

26. OPERATIVE TREATMENT For most of the patients,immediate re suture with a mass closure with placement of deep retention sutures is done. Pre operative broad spectrum antibiotics should be given

27. RETENTION SUTURES: Use non absorbable suture materials:monofilament nylon no 1 Wide interrupted bites of atleast 1cm from the wound edge Stich interval of 1 cm or less Either external(incorporating all layers from peritoneum to skin)or internal (all layers except skin may be used)

28. Thread each suture through a short length 5-6 cm of plastic or rubber tubing to prevent suture erosion into the skin Do not tie too tightly External retention sutures left for 3 weeks

29. Avoid excess tension on the wound Close the skin fairly loosely and consider using a superficial wound drain. If gross wound sepsis is present leave the skin open and pack.

30. 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: Major abdominal trauma Gross abdominal sepsis Retroperitoneal hematoma(eg:post ruptured AAA)

31. Loss of abdominal wall tissue(eg:necrotising fasicitis) Attempted closure in such conditions might lead to abdominal compartment syndrome

32. BOGOTA BAG Bogota bag is a sterile plastic bag used for closure of abdominal wounds It is sewn to the skin or fascia of the anterior abdominal wall. ADVANTAGE-abdominal contents can be visually inspected which is particularly useful in cases of ischemic bowel.

33. WITTMAN PATCH The Wittmann Patch is used for bridging and re-approximating abdominal wall openings where primary closure is not possible and/or repeat abdominal entries are necessary Wittmann Patch consists of hook-and-loop (Velcro-like) sheets that are pressed together to form a secure closure

34. MESH CLOSURE MESH CLOSURE of the abdominal incision is usually indicated when the fascia is strong and intact primary closure can be done The defect is bridged with one or two layers of prosthetic mesh

35. 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 grafting

36. VACCUM CLOSURE Wound vacuum system using open cell foam, semi occlusive drape over the foam and suction apparatus. it provides immediate coverage, minimises heat loss by negative pressure it clears interstitial fluid, reduces bowel edema and contamination, increases wound blood flow and promotes wound healing.

37. THANK YOU!