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MRCOG PART 2 SBAs and EMQs

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ESSAY 176 - WOUND DEHISCENCE

Posted by Vaani M.
Complete abdominal wound dehiscence is a rare occurence but associated with significant mortality.

A detailed history of the pre-operative and post-operative status is important. Since she had been operated for a large fibroid, a history of obesity( note of her height, weight and BMI) should be done as excess obesity can be associated with poor wound healing and infection. Also a malnourished, anaemic woman has a higher incidence of wound infection.

A history of chronic cough, treatment for any other medical illness as diabetes or immunosuppressed status should be noted. A history of previous abdominal surgeries should be noted.

Pre-operative investigations as ultrasound or intravenous urography should be checked as a large fibroid may be associated with altered anatomy and a likelihood of intraoperative injuries to urinary tract or bowel.

Intra-operative details should be checked for any difficulties at the time of surgery, any injuries at surgery, type of incision, suture materials used and surgeon\'s experience.

History of post-operative fever, cough, wound infection, or urinary tract infection should be noted.

Investigations include a full blood count, urine microscopy and culture, wound swab for culture if wound infection noted. Ultrasound abdomen should be done to look for any pelvic haematoma. Chest x-ray to rule out chest infection or atelectasis.

Treatment includes initial resuscitation if required. Appropriate broad spectrum antibiotics for cough and wound infection is required. Pelvic haematoma may need to be drained if large. Wound closure is required. The bowel has to be replaced back into the abdomen and abdomen closed. If the defect is large a mesh may be required. Enmass closure of wound after wound cleaning is to be done under antibiotic cover.

Prevention of wound dehiscence can be done by appropriate pre-operative assessment, intra-operative technique and post -operative care of the woman. Pre-operative chest infection should be treated and proper assessment by surgeon and anaesthetist should be done. Prophylactic antibiotics at surgery would prevent wound infection. Appropriate intra-operative technique with pfannansteil rather than a vertical incision would help prevent wound dehiscence. Experienced surgeon and delayed absorbable suture materials used would also help prevent wound dehiscence. Good haemostasis and surgical technique is important. Enmass closure of abdomen if a vertical incision is used should be done. A drain placed within the abdomen will also prevent a pelvic haematoma forming. Good nutrition and pre-operative treatment of anaemia will help prevent infection.

Appropriate measures to prevent wound infection and a good technique by an experienced surgeon is more important in preventing wound dehiscence rather than treating it.
Posted by adnan S.
--Complete wound dehiscence means separation of layers of the abdominal incision including the peritoneum , If the intestine protrudes through the wound is called evisceration or burst abdomen.It is one of the major & serious post operative complication associated with morbidity & mortality. Mortality is usually due to evisceration associated with sepsis.
A detailed history is taken for the factors predisposing to wound dehiscence like diabetes, chronic lung diseases anemia .
H/of Drugs like corticosteroid used ,previous history of abdominal surgery should be obtained. I will go through her surgical notes for suture material used & technique of sutures like locked sutures which cause ischemia of the incision margins. .Type of anesthesia used GA, associated with post operative retching with , coughing etc.
On examination general condition like sick looking ,malnutrition, dehydration, obesity to be noted. Pulse ,BP, Temp should be checked. Examination of wound for extent of dehiscence , intestine protruding through the wound . Blood is sent for FBC, Serum U&E,cross match red cell concentrate,transfusion may be needed if sever anemia.
Complete dehiscence or evisceration should be closed as soon as they are recognized. In case of delay in several hours because of recent meal bowl can be replaced using sterile gloves & gently packed in place with lap pads soaked in povidone -iodine . An abdominal binder should be placed over the lap pads .
Broad spectrum antibiotics should be initiated .when the patient in the operating room, the wound should be meticulously explored to determine the extent of dehiscence . General anesthesia should be used.Necrotic tissue, clots & suture material to be removed. Aerobic & anaerobic culture should be obtained.The bowl & omentum should be inspected & thoroughly cleansed with warm normal saline. Facial margins can be closed with large-bore polypropylene or nylon .The subcutaneous tissue & skin are packed open for latter delayed closures.
If the patient condition is poor or wound adjust or ragged a through & through suture of no.2 nylon or polypropylene
is used. The sutures are placed at least 2.5cm- 3cm from the skin edges are passed through all layers.To allow for edema they are placed 2cm apart. Skin edges unopposed between the through & through sutures can be approximated with interrupted 3-0 polypropylene.The through & through sutures should be left in place for three weeks.A nasogastric tube should be used in the immediate post operative period to avoid abdominal distention.Broad spectrum antibiotic which was initiated is modified according to culture sensitivity later.
The risk of abdominal wound dehiscence can be minimized by preoperatively optimizing medical conditions like diabetes,chronic lung diseases, anemia & improving the nutrition.General advice regarding weight reduction if obese, reduce smoking.Avoid shaving the operative field the day before surgery as associated with increased risk of wound infection.Aneasthetic review should be done by aneasthetist GA associated higher risk of chest infection,prevention of hypothermia shown to significantly reduce the risk of post-op sepsis.Use of prophylactic antibiotic minimize post-op sepsis.surgical measures like disinfection prior to surgery ,minimising the blood loss and tissue injury ,meticulous heamostasis, avoid heamatoma formation. ,wound dehiscence and evisceration are associated with tissue failure not suturefailure large loose sutures with secure knots are preferable to tight locked sutures which cause ischeamia of incision margin .Mass closure of vertical incision reduce wound dehiscence.
Posted by Zaibunnisa khan K.
Wound dehiscence is partial or total disruption of any or all layers of operative wound .It occurs in1-3% of abdominal surgical procedure. The initial assessment will consists of detailed history , examination and relevant investigations.Her record should be reviewed and she should be asked for whether she is febrile, severe pain ,any discharge from wound,bowel or urinary complain or cough.
Her preoperative record should be reviewed to exclude risk factors for wound dehiscence such as diabetes mellitus ,uremia,hypoalbumenimia,jaundice,anaemia,chronic cough,immunosuppression.and smoking .Her drug history should be reviewed as patient on high doses of coticosteriods are prone to wound dehiscence.Prolong preoperative hospital stay also increases the risk to wound infection and need for anticoagulation.
Her general examination should include general appearance ,she has toxic look,obese,cachexic or malnourished,aneamia, cynosis and jaundice.Temperature ,pulse ,blood pressure and respiratory rate should be recorded to exclude infection as the most important cause for wound dehiscence.Her chest examination should be done to exclude respiratory tract infection and obstructive airway disease which increases intra abdominal pressure and lead to wound dehiscence.
Her dressing should be removed and abdomen should be examined for abdominal distention. Wound should be examined for signs of infection, ,any discharge from the wound ,its colour,smell and quantity should be noticed , look for whether the gut is out of the wound.Abdomin should be palpated for masses ,tenderness and viseromegaly.
Her blood should be send for haemoglobin ,total leukocyte count,urea and electrolyte.Sawab from the wound should be taken for culture and sensitivity .
Wound dehiscence is a surgical emergency demanding immediate treatment.General resuscitative measure should be done .Intravenouse fluid should be started ,nazogastric tube should be passed and parentral antibiotics should be started and blood should be cross matched in case she is anemic .wound should be covered with moist towels and explored under general anaesthesia .With the patient under general anaesthesia any exposed bowel or omentum should be rinsed with Ringers lactate solution containing antibiotics and then returned to the abdomen.Peritoneal levage should be performed . Any foreign body if present shold be removed .After thorough cleaning and copious irrigation of the wound ,the previous sutures should be removed and wound is reclosed using full thickness mass closure with nonabsorbable suture without tention.In case the wound dehiscence is without evisceration it is best managed as elective reclosure of the wound .
Patient with chronic medical diseases need to be controlled ,her general health should be improved ,postoperative breathing exercises should be advised ,thromboembolic prophylaxis should be don
.Wound dehiscence can be minimized by proper pre -operative work up of the patient .Efforts should be made to improve general health pre-operative.
General advise regarding cessation of smoking 6 weeks before surgery ,correction of gross obesity decreases intra-abdominal pressure and risk of wound dehiscence. Preoperative hospital should be as short as possible to minimize exposure to antibiotics resistant organisms.
Chronic medical disorder should be controlled pre-operatively.
At operation adequate asepsis ,good operative technique and skilled team
are important

Adequate approximation of the anatomic layers is essential for adequate wound closure
.Most wound dehisce because the suture cut through the fascia.
This can be avoided by neat incision,proper handling of the tissues,placing and tying sutures correctly and selecting the proper suture material.
Adequate hemostasis is important to avoid wound hematoma and dehiscence.
Dead spaces should be obliterated properly
Ostomies and drains should be brought out through separate stab incisions .
Postoperative early mobilization, proper respiratory care and careful attention to fluid and electrolyte needs are important factors.
e correct my essay answer.
Posted by Zaibunnisa khan K.
hi mr paul
i am a new member.i answered two essays.please correct my essays
thank you
Posted by Zaibunnisa khan K.
hi mr paul
i am a new member.i answered two essays.please correct my essays
thank you
Posted by M H.
It is important to further information about the preoperative, intraoperative and postoperative status of the patient. Preoperative history of conditions that would predispose her to a would breakdown, ie diabetes (and its control), nutrition status, obesity, collagen disease, immunosuppression and chronic cough and attempts of optimisation prior to surgery should be sought. It would also help to know the intraoperative events, incision made, the length of the surgery, the complexity, whether any complications occurred, the suture material used. Postoperatively, it is important to obtain information as to whether she had post operative antibiotics, sepsis,pyrexia and the condition of the wound upon inspection, the presence of pus and other signs of local infection / inflammation.

Investigations should include a FBC, blood and wound swab cultures, a groud and cross match if neccesary.

The wound dehiscence would need to be adequately explored under analgesia to determine the extent of the dehiscence(ie whether the rectus sheath is intact). If the rectus sheath is compromised, then immediate surgery is warranted. At the same time, an assessment should be made to see if there is pus or collection within the pelvis (ultrasonography is an important imaging tool here). If the lady is in sepsis, the wound is infected and the rectus sheath is compromised, broad spectrum antibiotic should be started after obtaining blood and wound swab cultures.

Ideally, the wound should be debrided and closed under anaesthetia. If the defect is too large or dirty, it may be better to close it in a second procedure or use of a mesh to facilitate closure. Closure of the wound ideally would use non absorbable interrupted sutures. A drain could be left either in the subrectal plane (to reduce collection of fluid) or in the pelvis if there was evidence of a pelvic collection. The woman and her partner should also be adequately informed and counselled about the complication and proposed management plans. Their complaints and concerns should be adequately dealt with as this complication will prolong her hospitalisation and her recovery from the surgery.

To reduce the incidence of dehiscence in the primary surgery, measures that can be taken include the type of incision used, Pfannestial is more protective than vertical incisions, type of suture material used for closure of the wound (delayed absorbable sutures superior). It is important that the surgery should be done by a person with adequate experience and training. Intraoperative prophylactic antibiotics may prevent wound dehiscence. Adequate haemostasis prior to wound closure also prevents this complication. Any pre-operative medical conditions that will increase the risk of developing this complication should be optimised prior to embarking on surgery. Post operatively, it is important to ensure adequate nutrition, hygiene and also optimisation of predisposing medical conditions to aid healing and prevent wound dehiscence.
Posted by Aroosha B.
Wound dehiscence is associated with considerable morbidity. The initial assessment and treatment will be done by reviewing the case history, examination and then treatment.
The important things to know in the history, whether the patient is a smoker has any chronic cough or on any medication like steroids as these may be underlying cause or precipitating factors . Her BMI should be known as obesity can also lead to poor wound healing. Her past medical illness and previous abdominal surgery and its outcome should be known from her previous notes. Her operation notes should be read to know the type of suture material and whether appropriate surgical technique was used. On examination her general condition should be accessed specially for pallor and signs of systemic infection. Local examination of the wound should be carried out to see if there is any infection or discharge from the wound.
Investigation which are helpful is culture and sensitivity from wound, full blood count to know hemoglobin as anemia can lead to poor wound healing, knowledge of WBCs will help to determine any infection her serum urea and electrolytes should also be determined.
Before any treatment is carried out it is very important to explain and give detailed information of the treatment. In case the wound is clean an immediate closure can be carried out. But if infection is present it should be treated with antibiotics according to culture and sensitivity results. Any necrotic tissue should be removed. Closure should be done with prolene no.1 or 2, but if wound edges cannot be brought closer easily than prolene mesh can be used. Additional tension sutures should be applied to avoid any risk. The patient should be given soft diet and laxatives to avoid constipation which can lead to increased intra abdominal pressure
The risk of abdominal wound?s dehiscence can be minimized preoperatively by treating and properly advising the patient, like weight reduction give up smoking treating any infection especially chest infection.
Transverse incision should be preferred as incidence of wound dehiscence is low and doing mass closure in case of longitudinal incision decreases the risk of dehiscence . Good surgical technique, appropriately trained surgeon, appropriate suture material, good homeostasis all lead to good surgical outcome. Prophylactic antibiotic should be given and any anemia corrected before surgery.
Posted by Srivas  P.
Complete Fascial dehiscence is also known as burst abdomen or evisceration, and is defined as postoperative separation of the abdominal musculo-aponeurotic layers. It usually presents in early postoperative period (3?7 days) and occurs approximately in 1% of abdominal wounds. Although alarming in appearance, wound is relatively painless.

This is an emergency with risks of maternal mortality. The woman and her partner might be alarmed at seeing the loops of intestine at the incision site. The woman should be made supine on her bed and the wound should be covered with sterile swab soaked in saline or povidone-iodine. An abdominal binder may help to keep the eviscerated intestines inside the abdomen.

The couple needs to be explained about the nature of the emergency, the need for immediate resuturing and informed consent should be taken. Preparations are made to return her to operation theatre immediately. A senior colleague should be informed as also the Anesthetist, operation theatre nurse. The help of a senior surgical colleague or sub-specialists in trauma surgery may be taken especially if a difficult procedure is anticipated in a grossly obese, debilitated or severely infected patients with potential for recurrence of dehiscence.

Medical stabilization is begun after quick assessment of her general condition, Pulse, B.P presence of fever, pallor, chest examination for presence of chest infection, nature of abdominal discharge, suture line, presence of erythema, induration etc should be noted. Intravenous line should be started and she should be given broad spectrum antibiotics because the evisceration of bowel and subsequent repair is bound to cause infection and possible peritonitis that is sure to accompany such an event

Often a naso-gastric tube can be placed to decompress the intestine to facilitate closure. General anesthesia with muscle relaxants is required. Blood may be arranged and transfused if she is anemic. Sufficient exploration should be performed to rule out any visceral trauma related to the evisceration, and then careful inspection of the subcutaneous tissues and fascial layers should be done. Wide debridement of any necrotic or infected tissues is necessary and fascial edges, if unhealthy, must be debrided back to healthy bleeding tissue for a durable repair.

Abdomen is closed by mass closure of all musculofascial layers using large caliber delayed absorbable or permanent monofilament sutures. Sutures should be widely placed with 2-2.5 cm bites of the edges. Closing the abdomen under tension should be avoided to prevent later ischaemia of the wound edges. Interposing with Poly propylene Mesh may be done if wound is wide, in the absence of gross peritonitis or extensive fascial infection. Omentum is interposed between mesh and bowel to prevent subsequent fistula formation. In Obese patients, closure of the subcutaneous layer decreases the potential dead space and subsequent seroma formation and is helpful in preventing wound separation or else a drain may be left in the space.

It is important to give post operative chest physiotherapy to avoid cough. She may be given prophylactic thrombo-prophylaxis depending on her risk profile.

Pre Operative risk factors for wound disruption include poor nutritional status, obesity, anaemia, diabetes, uraemia, irradiation, drugs, malignancy, use of steroids and chronic airway disease. This woman is likely to have been anemic prior to surgery and might have had heavy bleeding at surgery. Blood replacements should be meticulous. Diabetes should be well controlled.

Among the peri-operative factors the important are the site of incision, technique of closure, suture material used; drain site. In this woman pre operative GnRH administration for 3 months may decrease the size of a fibroid to afford a smaller vertical incision or even a pfannensteil incision. She may also have lesser blood loss at surgery due to smaller size of the fibroid. Abdominal Skin and fascia should be opened by using cutting current and using coagulation current only to coagulate vessels. Proper surgical technique is very crucial avoiding tension at sutures and creation of dead space, antibiotic coverage, proper antisepsis and haemostasis and use of drains when indicated.

Significant postoperative risk factors for wound dehiscence include intraperitoneal sepsis; with wound infection being probably the commonest event leading to Abdominal wall dehiscence. Other factors are uncontrolled diabetes, malignancy, anemia, hypoxia, uremia, hypoalbuminaemia and haematoma formation. Prolonged ileus, abdominal distension, persistent cough, persistent vomiting, hiccough, constipation and ascites and sneezing are the conditions leading to raised intra abdominal pressure which has significant contribution towards wound disruption especially if there is associated poor wound healing.

The notes should be complete and the woman and her partner should be given all explanations and information they seek. Audit should be done to identify a possible preventable cause of this event, review surgical techniques, educate the junior colleagues about any wrong technique or possible poor antisepsis etc under no blame culture. It is possible it was not a preventable event and she was a high risk patient. This should be explained to the woman.
Posted by Aruna M.
Wound dehiscence is a serious complication of laparotomy and is associated with a high morbidity and even mortality (up to 30%). It occurs mostly due to failure of wound closure technique or coexisting conditions in the patient.
The immediate assessment of the patient is important as it is a relative emergency which could be associated with shock and a potential for infection.
General status and vital signs are assessed including blood pressure, pulse rate and temperature as the patient could be in neurogenic shock. If the patient is conscious, she has to be immediately reassured and the pain level ascertained. Resuscitative measures by intravenous fluids should immediately be carried out with a large bore intravenous access. Bloods should be collected for a full blood count, CRP, urea and electrolytes, LFT, a clotting profile and a group and save. Opioid analgesia is prescribed as the condition can be very painful. Immediate attention is then given to wound, a wound swab is taken for culture and sensitivity and a sterile dressing is applied. A multidisciplinary approach by involving the surgical team would be ideal in order to provide adequate closure.
Early return to the theatre should be arranged and a resuturing should be undertaken under general anaesthesia. Non- absorbable suture material should be used to provide a good repair with a mass closure technique. Thromboprophylaxis should be considered. Broad spectrum intraoperative antibiotics to cover the anaerobic and gram negative organisms as well should be administered and continued for 5 days.
The postoperative care should involve close monitoring and early ambulation is encouraged. The timing of suture removal however is variable; 5-7 days seem to be appropriate for complete wound healing.
Abdominal wound dehiscence occurs as a result of poor patient selection, poor surgical technique or postoperative infection. Patient selection issues include appropriate preoperative assessment to rule out medical conditions such as chronic cough, constipation (which could increase abdominal pressure) diabetes and anaemia (increased risk of infection and impaired wound healing), reviewing medication such as steroids (which impair would healing) and planning appropriate surgery. In this case the fibroids could have been shrunk in size to facilitate a pfannensteil incision which has a lesser rate of dehiscence compared to midline vertical incisions.
Surgical issues revolve round use of intraoperative antibiotics and proper selection of type of incision and suture material. If any laxity of tissues exists, a non-absorbable suture material could be used for repair of the rectus sheath. Adequate haemostasis is important to reduce risk of wound haematoma and skin necrosis.
Postoperative care ideally should involve inspection of the wound for early signs of dehiscence such as serosanguinous discharge. Any suspicion should be taken seriously.
Since this is a risk management issue, an incident form has to be filled and adequate measures should be taken to avoid similar mishaps in the future.