Burst Abdomen (Wound Dehiscence): A Surgical Challenge عامر التواتي

Burst Abdomen (Wound Dehiscence): A Surgical Challenge

Theophilus Bushan,^*  Amer .T. Irhuma,^** Mutwakil Ahmed,^*** Shanti Prakash,^****

Abstract:

Burst abdomen or wound dehiscence constitutes approximately 1% of all laparotomy wounds and is associated with a mortality rate of about 20%. Infection is present in more than half of the wounds that rupture.¹

Key Words: Burst abdomen, wound dehiscence, laparotomy.

Introduction:

Burst abdomen is a big surgical challenge as it involves multi-body systems and the patient is usually in the elderly age group.

With these patients management involves multidisciplinary approach and a close co-operation between various treating specialists.

We report a successful management of a BURST ABDOMEN in an 86–year-old Libyan man with multiple medical problems including C.O.P.D.

Case Report:

An 86-year-old Libyan male was presented to us on 14/10/01 with BURST ABDOMEN of cholecystcetomy wound whose sutures had been removed two days, on 12/10/01, prior to admission.

He had undergone cholecystectomy,  CBD exploration and choledocho jejunostomy on 4.10.01 in the capital city.

With a significant medical history, he had been suffering from IHD, severe C.O.P.D. and B.P.H. He had previous myocardial infarction and ® sided stroke partially recovered.

He was on  broncodilater and steroid inhaler with other medications. Fortunately he was neither diabetic nor hypertensive.

On examination, our patient was an elderly man, ill-looking, dehydrated, febrile, and dyspenic at rest with obvious laboured breathing.

His vital signs were Bp 140/70 mm of Hg. P-100/min. PR 24/min notcyanosed.

Chest examination revealed severe wheeze, bilateral rhonchi, crepitations both lung fields more on the ® side. There was increased JVP and pedal edema.

Abdomen showed distension, ® Kochar’s incision completely gaped with protrusion of the bowel along with sero-sanguineous fluid.

Immediate measure of packing the wound with wet sponge, covered with large pressure dressing. He was kept on N.P.O. IV fluids, catheter and N.G. tube were inserted. O₂ was supplied by mask. Blood sample was obtained for analysis (see table for investigations).

Broad spectrum antibiotic injection, Rocephine 1g iv, was given to the patient urgent medical consultation was sought as being a high risk patient.

Medical assessment categorised our patient to be in high risk group with ASA grade III. Accordingly, angisid tab. 5mg sub-lingually was given.

High risk informed consent was obtained for the operation. The patient underwent exploration of the wound at 7:30 pm the same day, under GA with E.T.T. The findings were: the tissues were edematous, thick, unhealthy and easily tearing at suture bites.

The wound was thoroughly lavaged with warm saline. Mass closure of the wound was done using prolene No. I. Skin closure was obtained with interrupted silk 2.0.

Post-op-period was stormy with fluctuating, fever, hyperglycemia, hypokalemia, exacerbated C.O.P.D. with ® sided pneumonia requiring care monitoring of  Iv fluids, urine output, and correction of electrolytes.

He received triple antibiotic regimen (Rocephin, gentamyin and flagyl) injection.

Penicillin  was added to combat pneumonia for two weeks.

Ventolin puffs, steroids and aminophyline suppository were needed for C.O.P.D.

* Lecturer in surgery, 2^nd March Hospital, (University Teaching Hospital) Sebha, Libya.

** Associate Profs & HOD Surgery, Faculty, sebha University, Medical School Sebha, Libya.

*** Associate prof. Medicine, 2^nd March Hospital, (University Teaching Hospital) Sebha, Libya.

**** Lecturer in Anaesthesia, 2^nd March Hospital, (University Teaching Hospital) Sebha, Libya.

DVT prophylaxis was done with injection heparin 5000 units three times daily for 8 days.

He needed O₂ by mask almost continuously for 8 days then gradually weaned off. Blood gas analysis was not available.

NGT was removed on the 5^th day and oral fluid commenced gradually and increased to soft diet.

The skin sutures were removed on the 10^th POD and tension sutures on the 16^th POD and the patient was discharged on 1.11.01 in good general condition.

The pateint is doing well under medical supervision.

Investigations table:

	14/10	15/10	17/10	28/10
Hb	-----	12.4g%	11.5g%	12.0g%
TLC	12,000	13400	15,600	10.000
HCT	---	37%	35%	39%
Poly	---	85.5%	83.3	88.0%
Lym	---	9.3%	8.6%	9.2%
PLT	---	208x103	190x103	210x103

                                        

Bl group O neg.

	14/10	15/10	17/10	21/10	24/10	28/10
BU	17mg%	21	54	15	15	15 mg%
Creat	---	0.7	---	0.8	0.8	0.8 mg%
Na	144	143	142	137	137	132 mmol
K	3.12	3.30	3.26	4.31	4.31	4.65 mmol
Ca	1.03	1.04	1.01	1.03	1.03	1.08 mmol
BS	128	210	147	----	---	240mg%

Urine proteins + sug-neg pus cells 10.12

                                        RBC 8-10

                                        Yeast cells ++

CXR – emphysematous chest, ® upper zone pneumonia

ECG- ischemic changes

USG abdomen – absent GB. No. collection.

Lt cortical renal cyst and BPH.

Discussion:

Burst abdomen or wound disruption is common in the elderly age group patients who often have multiple medical problems.

Our patient was an elderly male aged 86, suffering from IHD, with previous stroke and myocardial infection and had severe C.O.P.D.

He  is on multiple medications including intermittent steroids oral as well inhalers.

Our patient also had B.P.H on medical therapy.

Burst abdomen / wound dehiscence has an incidence ranging from 0.5% to 3%¹ and 3.5% in 370 cases using PDS for closure.²

In recent years there has been considerable drop in the incidence of wound dehiscence as a result of popular method of mass closure technique (maingot).

In the mass closure technique the suture is passed through all the layers of the abdomen with each bite, it is recommended for midline and paramedian incisions.³

Wound disruption occurred in 3.8% of 341 cases when closed by layered technique in 1975-1977.⁴

Mass closure technique adopted in 788 pts and the incidence of burst abodomen fell down to 0.8% (Harold Ellis).

Use of suture materials:

Cat gut is still extensively used all over the world for wound closure. Controlled studies have shown disastrously high failure rate when cat gut alone is used.^5,6,7

Most surgeons nowadays use mono filament nylon for anterior sheath and linea alba closure.

A part from the choice of suture material the geometry of the suture technique is also important for wound stability.

Big bites of aponeurosis with sutures placed at least 1 cm from the wound margin are essential. The sutures should be close together so that the length of the suture is at least four times greater than the length of the wound of continuos suture is employed (Jenkins rule).⁸

Most surgeons are employing non-absorbable suture material in closing abdominal wounds in frankly infected and in heavily contaminated cases.

Monofilament nylon is extremely non-reactive and healing will take place even when there is gross suppuration with breaking down of superficial layers exposing the nylon in anterior sheath.⁹

Reduction of the gut and repair with polypropelene mesh sutured to the margins of the aponeurons is easily achieved, less traumatic and probably better for the patients in intensive care units.¹⁰

Techniques of wound closure:

The peritoneum adds little, if any, strength to abdominal closure and some wonder if it is necessity to close it or not.¹¹ However, most surgeons do close the peritoneum for aesthetic reasons.

When the peritoneum is not closed, there is no obvious difference in abdominal wound closure, but the incidence of wound disruption is higher than in the wounds where peritoneum is closed.¹²

One group closed 280 midline wounds with all coats continuos nylon without a single wound dehiscence.¹³

Wound Healing:

Factors that appear to interfere with wound healing and are associated with wound failure include malnutrition, sepsis, anaemia, uremia, liver failure, diabetes mellitus, steroid therapy, and obesity.

Ascites in post-operative period causes strain on the wound and pre-dispose to wound failure.

Wound DEHISCENCE is an avoidable complication if the wound is closed securely with good surgical technique.

The strength of the wound lies in its musculo-aponeurotic layers.

In the early post-operative period it depends  upon the sutures that hold this layer.

Wound disruption occurs because sutures break, stretch or cut through the tissues either because of slipping of knots or insufficient sutures inserted.

Causes of wound disruption:

1. imperfect technical closure.

2. increased intra abdominal pressure from bowel distension ascites, coughing, vomiting or straining.

3. infection systemic or local.

4. metabolic diseases, diabetes mellitus, uremia, cushing disease.Malgnancy, liver failure etc.

5. patent on steroid therapy.

6. collegen diseases.¹⁴

Vitamin C is essential in collagen synthesis.

In man half  life of vit. C is 16-20 days. It takes 90-120 days to deplete 2-3 gms of body pool and result in deficiency.

In patients with peptic ulcer who usually avoid fruits and vegetables, and in patients with dysphasia (ca-oseophageus) which exsist in tea, bread and jam, there is a fall in blood vit. C levels, after operation and returns to wound within one week after resumption to normal diet.¹⁵

Our patient was suffering from C.O.P.D. Patients with history of COPD, smoking and abnormal results of pulmonary tests are at high risk for developing pulmonary complications following surgery.^16,17

Patients undergoing upper abdominal and thoracic surgery are at greatest risk.^18,19

The pulmonary evaluation of this patient included recording of medical history that focuses on ascertaining the presence of dysponea and its severity, smoking history, productive cough, wheezing and the effects of previous anaesthesia.

The  patient’s ability to cough and clear secretions was also of considerable importance.

Being over 60 years and obese had increased the pre-operative risk.

Our patient was 86 years old with previous stroke.

The physical examination focused on the patients breathing pattern (rate, depth and accessory muscle use) and chest auscultation.

A chest radiograph was obtained to assess lung hyper ventilation, cardiac enlargement, atalectasis pneumonia and pleural effusion that are indicative of perioperative risk.

In such patients with clinical history of moderate C.O.P.D., spirometry would certainly be necessary before surgery, which we could not do as it was an emergency situation. Blood gas measurement would be an excellent method to determine patient’s ability to exchange O₂ and CO₂ at rest.

An upper abdominal incision is associated with reduced diaphragmatic excursion and the effectiveness of cough is decreased by pain.

These two factors lead to atalectasis, bronchitis and pneumonia in 25% of normal patient and 42-60% in patients with COPD. Proper pre-operative preparation of patients with COPD can reduce the post-operative complications from 60% to 22%.²⁰

An increased likelihood of post-operative complications which can be anticipated of the FVC is < 75% predicted, the FEV₁ is  < 50% of the FVC and the maximum voluntary ventilation is <50% of predicted value.²¹

Therapy offered to reduce pulmonary risk includes:.

1. cessation of smoking

2. treatment of pulmonary infection

3. bronchodilator therapy

4. nutritional support

5. respiratory physiotherapy

6. decreased anaesthesia / surgery time (risk increased with operation of more than 3 hours).

7. effective post-operative analgesia

8. maximum breathing (incentive spirometry  nasal/ mask continuous positive airway pressure)

9. early postoperative mobilisation

10. Heparin prophylaxis.^22-25

Summary and conclusion:

Prevention of wound disruption depends upon the expertise of anaesthetist, good surgical technique, patients diet and careful post operative monitoring.

If wound disruption occurs it needs a co-ordinated team management of various specialties including intensive care nursing personnel.

We have successfully managed such a patient, and he is doing well now under medical follow-up.

References:

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