ORIGINAL ARTICLE Management of abdominal wound dehiscence: still a challenge 84
Transcription
ORIGINAL ARTICLE Management of abdominal wound dehiscence: still a challenge 84
84 ORIGINAL ARTICLE Management of abdominal wound dehiscence: still a challenge Abdul Qaiyoume Amini, Naveed Ali Khan, Javed Ahmad, Amjad Siraj Memon Abstract: Objective: To find out the effective way of management of abdominal wound dehiscence after emergency and elective laparotomies. Materials and methods: The study was carried out in Surgical Unit 5, Civil Hospital Karachi during January 2011 to April 2012. One hundred and thirty consecutive patients undergoing laparotomy through a midline incision either in emergency or elective setup were included in the study. They were followed by wound examination from second post operative day onwards to see normal or otherwise healing and findings were recorded. The cases of wound dehiscence were divided into two groups i.e. group A, managed with thorough abdominal wash and deep tension sutures and group B, managed with thorough abdominal wash and Bogota bag application. Results: 15 out of 130 (11.5%) patients developed complete wound dehiscence (burst abdomen). Frequency of burst abdomen was significantly higher after emergency laparotomies (14/94 i.e. 14.89%) while 1 patient undergoing elective laparotomy developed burst abdomen (1/36 i.e. 2.7%). Group A (n=8) was managed with deep tension sutures and group B (n=7) was managed with Bogotá bag. The outcome of deep tension sutures was associated with less morbidity, less number of further surgeries and low mortality. Conclusion: Thorough abdominal wash with copious amount of normal saline and closure with deep tension sutures is still an effective way of management of patients with complete wound dehiscence while Bogotá bag application is useful in cases abdominal closure is difficult due to generalized gut edema or need of further re-operations. Keywords: Abdominal wound dehiscence, midline laparotomy, deep tension suture, Bogota bag, burst abdomen Civil Hospital Karachi AQ Amini NA Khan J Ahmad AS Memon Correspondence: Abdul Qaiyoume Amini Resident year 4, Surgical Unit 5, Civil Hospital Karachi, Postal Address: House No. A-141, Behind Jama Masjid Afzal, Gulistan-eJauhar block 14, Karachi. email: aqamini@yahoo. com, Cell: 0345-2340172 Pak J Surg 2013; 29(2):84-87 Introduction: Abdominal wound dehiscence (burst abdomen) is a severe post operative complication experienced by surgeons who do a significant volume of surgery. The incidence as described in the international literature range from 0.4 to 3.5%1-7 and is associated with a mortality rate as high as 45%8-10 while our local data showed still higher frequency of wound dehiscence with overall rate of 4.8 and 6.6%11,12. Abdominal wound dehiscence can result in evisceration, requiring immediate treatment. Despite increased knowledge about wound healing, advances in perioperative care and suture materials, wound dehiscence continues to be a significant problem which prolongs hospital stay and is associated with patients’ morbidity, subsequent re-operations, high incidence of incisional hernia and increased mortality. This may be attributable to increasing rates of emergency laparotomies in high risk patients with multiple comorbids outweighing the benefits of technical achievements.2,7,13 The management of wound dehiscence ranges from simple dressing to further surgery for abdominal wash and subsequent closure of burst 85 AQ Amini, NA Khan, J Ahmad, AS Memon abdomen followed by a period of intensive care.14 We compared two management strategies for burst abdomen: Deep tension suture (DTS) which has been used for long time by many surgeons and Bogotá bag which are often used for temporary abdominal closure after damage control or staged laparotomy for trauma or release of abdominal compartment syndrome21, 22. Materials and methods: This comparative cross-sectional study was conducted at Surgical Unit 5, Civil Hospital Karachi from January 2011 to March 2012. A total of one hundred and thirty consecutive cases, irrespective of the age and sex, undergoing laparotomies through a midline incision, were included in the study. Patients under 12 years of age or operated through other incisions were excluded from the study. A detailed history and clinical examination was conducted. The data was noted on a proforma which also included all the major risk factors for wound dehiscence like age, gender, nature of disease, emergency surgery, nutritional status of patient, anemia, jaundice and presence of comorbids (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, steroid use, immunodeficiency states etc). Baseline investigations and total protein, albumin/globulin ratio were noted in all cases as well as abdominal radiographs and ultrasonography. CT scan abdomen was also done where required. After optimization of patient and anesthesia clearance every patient underwent laparotomy through a midline incision. Postoperatively, abdominal wounds were examined from third postoperative day onwards on daily basis to see the signs of wound infection, dehiscence including redness (erythema), seroma formation, discharge of serosanguinous fluid or pus from one or more sites and subsequently partial or complete wound dehiscence. Partial wound dehiscence was managed conservatively by laying open the wound, daily wound wash and dressing along with intravenous antibiotics according to culture and sensitivity. Cases of complete wound dehiscence (burst abdomen) were divided randomly into two groups i.e. group A, managed with thorough abdominal wash and deep tension sutures and group B, managed with thorough abdominal wash and application of Bogotá bag. In group A patients, deep tension sutures applied using 1.0 prolene with suture 2 cm from wound edges and 3 cm apart with a plastic tube of 4 cm length to avoid cutting of skin. Interrupted mattress sutures also applied in between the deep tension sutures. In Group B, Bogotá bag applied, made from transparent side of a urine bag and sutured on all sides of open wound at least 3 cm apart from wound edges. Patients of both groups received broad spectrum antibiotics and daily sterilized dressing by a doctor. Results: A total of 130 patients underwent laparotomy through a midline incision during the study period. Mean age of patients was 34.22 years (standard deviation: 14.9) including 86 males (66.2%) and 44 females (33.8%). Male to female ratio was 2:1. Emergency laparotomies for various pathologies were done in 94 patients (72.3%) while elective laparotomies were performed on 36 patients (27.7%). Out of 130 patients undergoing a midline laparotomy, 15 developed complete wound dehiscence (burst abdomen) giving an overall frequency of 11.5% although emergency laparotomies showed a much higher frequency (14/94 i.e. 14.89%) while 1 patient developed burst abdomen after an elective laparotomy (1/36 i.e. 2.7%). Majority of cases were dirty having gut perforations and a fecal peritonitis (11/15 i.e. 73.3%). [Table 1] Group A patients (n=8) were managed with thorough abdominal wash and deep tension sutures while group B patients (n=7) were managed with abdominal wash and application of Bogotá bag. The mean length of stay was longer in group B (39.14 ± 12.95) with patients requiring 2 or more abdominal washes and later development Pak J Surg 2013; 29(2): 84-87 86 Management of abdominal wound dehiscence: still a challenge Table 1: Frequency of burst abdomen in different pathologies 40 Group B (Bogotá) Diagnosis Frequency No of Burst Abdomen 35 Group A (DTS) TB Abdomen 21 4 30 Gunshot Abdomen 19 0 25 Obst due to post-op bands/adhesions 17 0 20 Typhoid Ileal Perforation 16 3 15 Perf DU 10 2 10 Colorectal tumor 6 2 5 Perforated Apendix 5 0 0 Sigmoid Volvulus 5 1 Biliary perotonitis 5 1 Gangrenous Bowel 4 0 Iatrogenic injuries during Obs procedures 4 1 Stab Wound 4 1 Blunt Abdominal Trauma 4 0 Pancreatitis 3 0 Others 7 0 Total 130 15 Incisional hernia Mortality (%) Figure 1: Outcome of both groups Table 2: Comparison of Management Groups Groups Mean Length of stay in days Abdominal washes Incisional hernia Mortality (%) Group A (DTS) 18.5 4 0 25 Group B (Bogotá) 39.14 25 5 28.6 of incisional hernias. The mean length of stay in group A was 18.5 (± 5.3). 4 patients died giving an overall mortality of 26.6%. It included 1patient from group A (2/8 i.e. 25%%) and 2 from group B (2/7 i.e. 28.6%). [See Table 2 and Figure 1] Discussion: A burst abdomen is considered present when intestine, omentum or other visceras are seen through the abdominal wound following surgery. It occurs mostly on 6th to 8th day post operatively. Factors relating to the incidence of burst abdomen are suture material, closure technique, postoperative coughing and vomiting, distention, obesity, malignancy, hypoproteinemia, anaemia, immunocompromised states and contaminated surgeries15. The frequency of burst abdomen in our study was 11.5% which is higher than other local data which showed a frequency ranging from 5.3 to 8.3%11, 16-18. The higher frequency of burst abdomen is in contrast with many Western studies which showed Pak J Surg 2013; 29(2): 84-87 Mean Length Abdominal of stay in days washes an incidence of 0.4 to 3.5% but is in accordance with the study done by Mathur19 which showed that the problem of wound dehiscence is much more prevalent in South East Asia than the Western world. This may be attributable to poor nutritional state of patients, delayed presentation to the tertiary care hospitals, poor quality of suture material, disease like tuberculous abdomen which is endemic to countries of South East Asia and higher load of emergency surgeries. Our study also showed a significantly higher frequency of burst abdomen in emergency laparotomies i.e. 14.89% as compared to elective laparotomies i.e. 2.7%. This is also reflected in many other studies 7, 11-18,20. This may be because of the fact that patients who undergo emergency surgery are generally in suboptimal condition and nutritional state and the chances of contamination of the surgical field is higher than in elective surgery. Moreover the performance of the surgeon might be affected at night which could lead to suboptimal closure of the abdomen at the end of operation. Our study showed that deep tension suturing (DTS) is a simple an effective way of managing burst abdomen which is associated with less morbidity and mortality. The mean length of stay was significantly higher in Bogota bag group (39.14) than DTS group and later development of incisional hernia was also a problem which was seen in Bogotá bag group which increased he frequency of re-explorations and further surgeries on patients. The mortality in group B was 28.6% % which was similar to group A (25%) and is also similar to another study by Krishtein 87 AQ Amini, NA Khan, J Ahmad, AS Memon et al21. which showed a mortality of 24% associated with Bogota bag. Conclusion: Deep tension suture is an effective way of managing patients with burst abdomen and associated with less morbidity in terms of length of stay, further need of re-operations and later development of incisional hernia as compared to Bogotá bag. The mortality of both is almost comparable and owes more to the condition of the patient rather than the modality of management. References: 1. Swaroop M, Williams M, Greene WR et al. Multiple laparotomies are a predictor of fascial dehiscence in the setting of severe trauma. Am Surg 2005;71:402–405 2. Gislason H, Grønbech JE, Søreide O. Burst abdomen and incisional hernia after major gastrointestinal operations—comparison of three closure techniques. Eur J Surg 1995;161:349–354 3. Penninckx FM, Poelmans SV, Kerremans RP et al. Abdominal wound dehiscence in gastroenterological surgery. Ann Surg 1979;189:345–352 4. Pavlidis TE, Galatianos IN, Papaziogas BT et al. Complete dehiscence of the abdominal wound and incriminating factors. Eur J Surg 2001;167:351–354 5. Ma¨kela¨ JT, Kiviniemi H, Juvonen T et al. Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995;170:387–390 6. Keill RH, Keitzer WF, Nichols WK et al. Abdominal wound dehiscence. Arch Surg 1973;106:573–577 7. Co¨l C, Soran A, Co¨l M. Can postoperative abdominal wound dehiscence be predicted? Tokai J Exp Clin Med 1998 ;23:123–127 8. . Fleischer GM, Rennert A, Ru¨hmer M. Die infizierte Bauchdecke und der Platzbauch. Chirurg 2000;71:754–762 9. Poole GV Jr. Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence. Surgery 1985; 97:631– 640 10. Carlson MA. Acute wound failure. Surg Clin North Am 1997;77:607–636 11. Adnan A, Shams NA, Irfan S, Manzar S. Abdominal wound dehiscence: An ongoing dilemma. Pak J Surg 2009;25(3):204-8 12. Badar M, Saira S, Muhammad AS. Post operative Complications in emergency versus elective laparotomies at a peripheral hospital. J Ayub Med Coll Abottabad 2010;22(3):42-7 13. Riou JP, Cohen JR, Johnson H Jr (1992) Factors influencing wound dehiscence. Am J Surg 163:324–330 14. David CB, Andrew NK. Abdominal wound ehiscence and incisional hernia. Surg 2006;24(7):234-8 15. Begum B, Zaman R, Ahmed M, Ali S. Burst abdomen: A preventable morbidity. Mymensingh Med J 2008;17(1):63-6 16. Lodhi F, Ayyaz M, Majeed HJ etal. Etiological factors responsible for abdominal wound dehiscence and their management. Ann King Edward Med Coll 1999;5(3-4):312-4 17. Khan MNS, Naqvi AH, Irshad K et al. Frequency and risk factors of abdominal wound dehiscence. J Coll Physicians Surg Pak 204;14(6):355-7 18. Shaikh MS, Shaikh SA, Shaikh BA. Abdominal wound dehiscence: Frequency and risk factors. J Surg Pak 2005;10(4):30-3 19. Mathur SK. Burst abdomen: A preventable complication, monolayer closure of the abdominal incision with monofilament nylon. J Postgrad Med 1983;29 20. Waqar SH, Zafar IM, Asma R et al. Frequency and risk factors for wound dehiscence/ burst abdomen in midline laparotomies. J Ayub Med Coll Abbottabad 2005;17(4): 21. Kirshtein B, Roy-Shapira A, Lantsberg L, Mizrahi S. Use of the “Bogota bag” for temporary abdominal closure in patients with secondary peritonitis. Am Surg. 2007 Mar;73(3):249-52. 22. Myers JA, Latenser BA Nonoperative progressive “Bogota bag” closure after abdominal decompression. Am Surg. 2002 Nov;68(11):1029-30 Pak J Surg 2013; 29(2): 84-87