Treatment:
Non-Operative:
Patient very unstable and there has been no evisceration. Preferably to treat non-operatively:
- Guaze packing of the wound or covering it with a sterile occlusive dressing
- Abdominal binder may be used to support disrupted abdominal wound
- Wound may subsequently contact to closure, or if the patient's condition improves, delayed operative closure may be performed.
- Hernia is a common sequela
- For most patients immediate re-operation is indicated
- Most common technique is immediate resuture with retention sutures
- Pre-operative broad spectrum antibiotics should be given
- Free the omentum and bowel for a short distance on a deep surface of the wound on both sides
- Insert deep retention sutures, and then proceed with mass closure of the abdominal wall.
- Be certain to take deep bites of tissues, using plenty of suture material, and avoid excessive tension on the wound.
- Close the skin fairly loosely and consider using a superficial wound drain.
- In the presence of gross wound sepsis, leave the skin open and pack
- Use heavy non-absorbable suture e.g. No.1 monofilament nylon
- wide interrupted bites of at least 3cm from the wound edge and a stitch interval of 3cm or less
- either external (incorporating all layers peritoneum through to skin) or internal (all layers except skin) may be used.
- Internal retention sutures avoid producing an unsightly ladderpattern scar, however they are unable to be removed subsequently (increased infection risk) a buttress device is used to prevent suture erosion into the skin e.g. thread each suture through a short length (5-6 cm) of plastic or rubber tubing do not tie too tightly external retention sutures area usually left in for at least 3 weeks
- major abdominal trauma
- grosss abdominal sepsis
- retroperitoneum hematoma e.g. post ruptured AAA
- Loss of abdominal wall tissue e.g. necrotizing fasciitis
- attempted closure may lead abdominal compartment syndrome
Temporarily close abdomen by packing the wound and taking a further look in 24-48 hours.
OR
Mesh closure of the abdomen
- The defect is bridged with one or two layers of a prosthetic mesh
- The mesh is sutured in place with sutures that penetrate the full thickness of wound
Granulation tissue formation ultimately result in a surface that can be covered with a split-skin graft
Prosthetic Mesh:
Absorbable mesh (polyglycolic acid eg. Dexon)
- temporary closure
- good for infected abdomen
- subsequent incision hernia inevitable
- erosion into bowel and fistula formation
- dense adhesion formation
- quite tolerant of infection
- Soft and pliable
- less adhesions to bowel
- tolerates infection poorly
- Once well enough and intestinal edema has resolved, usually return to operating theatre for attempt at abdominal wall closure
References:
- Hampton J. R., B.M. The Burst Abdomen. British Medical Journal 1963 Oct 1032-35
- Bucknall T E, Cox P J, Ellis Harold. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. British Medical Journal 1982 284:931-33
- Ramshorst G. Abdominal Wound Dehiscence in Adults: Development and Validation of a Risk Model. World J Surg 2010 34:20–27 [PMID: 19898894 ]
- Bucknall T. E. Factors influencing wound complications: A clinical and experimental study. Annals of the Royal College of Surgeons of England 1983 65:71-77
- Lotfy, Wael. Burst Abdomen: Is it a Preventable Complication. Egyptian Journal of Surgery 2009 July 28(3):128-32
- Carlson MA. Acute Wound Failure. Surgical Clinics of North America 1997 77:607- 636
- Keill RH, Keitzer WF, Nichols WK, Henzel J and De Weese MS. Abdominal wound dehiscence. Arch Surg 1973 106:573-7
- Reitamo J., and Moller C. Acta Chirurgica Scandinavica 1972 138:170
- Alexander, H. C. and Prudden, J. F. The causes of abdominal wound disruption. Surg., Gynec g: Obst. 1966 122:1223-1229
- Goligher, J C, et al. British Journal of Surgery 1975 62:823
- Standeven, A. Lancet 1955 1:533
- Haxton, H A. British Journal of Surgery 1963 50:534
- Spiliotis John. Wound dehiscence: is still a problem in the 21th century: a retrospective study. World Journal of Emergency Surgery. 2009 4:12
- Kirk R.M. The Incidence of Burst Abdomen: Comparison of Layered Opening and Closing with Straight-through One-layered Closure. Lancet 1972 ii 352
- Jenkins, T P N. British Journal of Surgery 1976 63:873
- Dudley HAF. Layered and mass closure of the abdominal wall - a theoretical and experimental analysis. Br J Surg 1970 57:664-7
- Gupta Himanshu et al. Comparison of Interrupted Versus Continuous Closure in Abdominal Wound Repair: A Meta-analysis of 23 Trials. Asian Journal of Surgery 2008 July 31(3):104 - 114
- Varshney Subodh, Manekt Parimal, Johnsont CD. Six-fold suture:wound length ratio for abdominal closure. Ann R Coll Surg Engl 1999 81:333-336
- Weiland DE, Bay RC, Del Sordi S. Choosing the Best Abdominal Closure by Meta-analysis. American Journal of Surgery 1998 176:666-670
- Hodgson N. C. F., Malthaner R. A. The Search for an Ideal Method of Abdominal Fascial Closure: A Meta-Analysis. Annals of Surgery. 2000 231(3):436–442
- Varshney Subodh, Manekt Parimal, Johnsont CD. Six-fold suture:wound length ratio for abdominal closure. Ann R Coll Surg Engl 1999 81:333-336
- Cengiz Yucel, Blomquist Peter, Israelsson Leif A. Small Tissue Bites and Wound Strength: An Experimental Study. Arch Surg. 2001 136: 272-275
- Ellis Harold, Coleridge-Smith Philip D., Joyce Adrian D. Abdominal incisions-vertical or transverse?. Postgraduate Medical Journal 1984 june 60:407-410
- Burger J. W. A., Riet M. van ‘t, Jeekel J. Abdominal incisions: techniques and postoperative complications. Scandinavian Journal of Surgery. 2002 91:315–321
- Nagy KK, Fildes JJ, Mahr C, et al. Experience with three Prosthetic Materials in Temporary Abdominal Wall Closure. American Surgeon 1996 62:331-335
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