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
 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.