WOUND DEHISCENCE

A MUST FOR ALL POST GRADUATES IN GENERAL SURGERY

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 W ound failure W ound disruption E visceration and E ventration . 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. A nytime 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 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. F ailure of suture to remain anchored in the fascia . S uture breakage K not failure E xcessive stitch interval which allows protrusion of viscera. S utures 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 , T ransverse 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. W ound 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 F requent changes in wound dressing to prevent infection W ound 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 R e - 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 S uperficial wound drain. G ross 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. A ssess 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.  E xternal 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 g ranulation tissue and increases b lood 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 o n the Sponge. Area s ealed 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. T he 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 r atio 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.