BURST ABDOMEN

S4
S3
S2
ICU

B SINGH
KING EDWARD VIII HOSPITAL
PRETORIA CONTROVERSIES MEETING
4th October 2013
 BURST ABDOMEN
Partial or complete separation of an abdominal
wound with protrusion (evisceration) of
abdominal contents
 Wound dehiscence & incisional hernia are part of the
same wound failure process
 Distinguished by timing and healing of overlying skin

“PARTIAL’ - separation of fascial edges without evisceration

- loose fascial sutures
- occasionally, fibrin covered intestinal loops

“COMPLETE” - full separation of fascia & skin

- intestinal loops (if not glued by fibrin) eviscerated
BURST ABDOMEN = ABDOMINAL DEHISCENCE
 BURST ABDOMEN
Major complication despite significant advances in
pre-operative and operative care in 21st century

Incidence largely unchanged since 1940’s*

 before 1940’s: 0.4% (0.24 – 3%): >71,000 incisions
 1950 -1984: 0.59% (0.24 – 5.8%): >320,000 incisions
 1985: 1.2% - 18,333 incisions
 1990 – 1992: 2% - 599 incisions #

Current documented incidence = 0.2 – 6% with mortality 10 – 40%

? more complex surgeries
? ageing populations

* Carlson MA. Acute wound failure. Surg Clin North America 1997; 77:667-636
# Gislason H el. Burst abdomen and incisional hernia after major gastrointestinal operations—

comparison of three closure techniques. Eur J Surg 1995 May;161(5):349-54.

 BURST ABDOMEN
Clinical manifestations
• Evident day 7 – 14
• May develop without warning, following straining or removal
of sutures
• May be preceded by a sero-sanguineous discharge

RISKS FACTORS
Pre-operative
Operative
Post-operative

“Commonly, dehiscence of the abdomen represents a spontaneous

decompression of infra-abdominal hypertension and thus could be
defined as a ‘beneficial’ complication”
Schein’s Common Sense Emergency Abdominal Surgery. Springer 2005; Ch 47:Pg 414
 BURST ABDOMEN
 Pre-operative risk factors
 Sex - M:F = 2:1
 Age - <45 = 1.3% vs > 45 = 5.4 %
 Emergency surgery – maybe related to haemodynamic instability
 Obesity - not a significant association!
 Diabetes – well controlled not at risk!
 Renal failure – probably due to uraemia induced malnutrition
 Jaundice - probably due to malnutrition associated to biliary
obstruction
 Anaemia – not a consistent factor!
 Malnutrition – protein, Vit C & zinc defiency
 Corticosterioids – topical or systemic

• Van Ramshorst el al World J Surg 2010

• Makela et al Am J Surg 1995; 170: 387-90
• Afzal S, Bashir MM. Annals 2008; 14: 110 -115
 BURST ABDOMEN
 Operative risk factors
 Incision type
- midline at greater risk than transverse
 Closure
- mass closure equivalent or better than layered
- interrupted vs continuous no difference!
- variants of interrupted do not improve outcome
(Figure of 8, “far-near-near-far”)
- peritoneal closure not necessary
 Suture material
- no difference between slowly absorbable and non-
absorbable suture
- monofilament non-absorbable advocated in at risk patient
 Suture technique
 BURST ABDOMEN

Post operative risk factors

 Elevated intra-abdominal pressure
• coughing
• vomitting
• ileus
• urinary retention
 Intra abdominal sepsis
 Wound infection
 Radiation therapy
 Anti-neoplastic therapy

• Van Ramshorst el al World J Surg 2010

• Makela et al Am J Surg 1995; 170: 387-90
• Afzal S, Bashir MM. Annal 2008; 14: 110
BURST ABDOMEN: PROGNOSTIC MODELS FOR DEHISCENCE
Webster Risk Index (point values)
- CVA with no residual deficit 4
- history of COPD 4
- current pneumonia 4
- emergency procedure 6
- operative time greater than 2.5 hr 2
- PGY 4 level resident as surgeon 3
- clean wound classification -3
- superficial, or deep wound infection 5 17
- failure to wean from the ventilator 6
- one or more complications other than dehiscence 7
- return to OR during admission -11
# Scores of 11-14 are predictive of 5% risk
# Scores of >14 predict 10% risk
Webster C et al. Prognostic models of abdominal wound dehiscence after laparotomy.
J Surg Res 2003 Feb;109(2):130-7

CRITICIZED FOR LACK OF VALIDATION

 VARIABLE RISK
SCORE Van Ramshorst GH, Nieuwenhuizen J et al. Abdominal wound
AGE CATEGORY dehiscence in adults: development and validation of a risk model.
40-49 0.4 World J Surg 2010 Jan;34(1):20-7
50-59 0.9
60-69 0.9
>70 1.1  Identify independent risk factors for AWD & to
Male Gender 0.7 develop a risk model to recognize high-risk
Chronic Pulmonary Disease 0.7  20 year study period - 363 AWD analyzed
Ascites 1.5  Major independent risk factors defined
Jaundice 0.5
Anaemia 0.7
Emergency Surgery 0.6
TYPES OF SURGERY
Biliary 0.7
Oesophagus 1.5 RISK SCORE PROBABILITY (%)
Gastroduodenal 1.4 0–2 0.1
Small Bowel 0.9 2-4 0.7
Large Bowel 1.4 4–6 5.5
Vascular 1.3 6–8 26.2
Coughing 1.4 >8 66.5
Wound Infection 1.9
Risk scores for AWD VALIDATED RISK MODEL SHOWED HIGH PREDICTIVE VALUE
Score 0 - 10.6 FOR AWD
 BURST ABDOMEN

• Value of risk scoring systems – POSSUM, APACHE etc

• Evaluation of surgical competence
 risk judgement
 intra-operative decision making
 situation awareness
 judgemental ability
 HIV/AIDS?
 WOUND HEALING IN HIV POSITIVE & AIDS
 Data regarding surgical morbidity and mortality largely
predates availability of HAART
 Few prospective studies
*In the HAART era, generally good outcomes have been reported
 Most important risk factor for post-op complications is ASA class
(measure general health status)
 HIV (+) not independent risk factor
*Jones S et al. Is HIV infection a risk factor for complications of surgery?
Mt Sinai J Med 2002 Oct;69(5):329-33

“AIDS patients with more advanced disease, low CD4 (<100) or poor
performance status are at increased risk for poor wound healing”
Horberg MA et al. Surgical outcomes in human immunodeficiency virus-infected patients
in the era of highly active antiretroviral therapy. Arch Surg 2006;141(12):1238-45
 WOUND HEALING IN HIV POSITIVE

RISK FACTORS

 ASA risk classification

 CD4 <100cell/mm³
 CD4 percentage of lymphocyte population <18
 Pre to post-operative change in percent CD4 of 3 is
independent risk factor *
 Viral load > than 10 000 copies/ml

*Tran HS et al. Predictors of operative outcome in patients with human immunodeficiency

virus infection and acquired immunodeficiency syndrome. Am J Surg 2000;180(3):228-33
 BURST ABDOMEN
Intra abdominal abscess (IAI) & burst abdomen*

 “Fascial dehiscence” (FD) after trauma laparotomy is

associated with technical failure, wound sepsis, IAI
 The majority of trauma patients with FD have IAI
 The association of IAI with FD is inadequately evaluated
 Confirming IAI is essential to guide clinical diagnosis and
management
 FD should be viewed as a sign of possible underlying IAI
 Imaging or direct visualization of the entire abdominal cavity
mandatory before managing the dehisced fascia

* Tillou A et al. Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis.
Am Surg 2003 Nov;69(11):927-9
 BURST ABDOMEN
With IAI, the fatal factor leading to high mortality is
not the dehiscence itself but an inappropriate
emergency procedure to correct it

INTRA-ABDOMINAL HYPERTENSION

ADVERSE EFFECT ON CVS, RESPIRATORY, RENAL AND INTESTINAL FUNCTION

MULTIORGAN DYSFUNCTION SYNDROME

RATIONALE FOR TEMPORARY ABDOMINAL CLOSURE

 BURST ABDOMEN

“Forewarned, forearmed; to be
prepared is half the victory”
Miguel de Cervantes

Don Quixote - cited as arguably the "best literary work ever written"
 BURST ABDOMEN:MANAGEMENT

Preventive strategies - Finding the Best Abdominal Closure

“ …an optimal technique involves mass closure, incorporating all

of the layers of the abdominal wall (except skin) as 1 structure, in a
simple running technique, using #1 or #2 absorbable monofilament
suture material with a suture length to wound length ratio of 4 to 1”

Finding the Best Abdominal Closure: An Evidence-based Review of the

Literature
Adil Ceydeli, James Rucinski, and Leslie Wise
CURRENT SURGERY 2005; 62: 220-225
 BURST ABDOMEN:MANAGEMENT

Several preventive strategies

 Smead-Jones technique (1941)
 "May/Mary closure"
 Retention sutures
Smead-Jones
 “Interrupted X-suture”
 TI, TIE and TIES incisions
 Far-and-near double horizontal mattress
………….. and more!

Interrupted X suture

Practice driven by institutional bias & tradition, prompted by

anecdotes
 BURST ABDOMEN

Retention sutures Far-and-near double 3L Bag – ‘planned hernia’

horizontal mattress
 BURST ABDOMEN:MANAGEMENT

Preventive & responding strategies

Interrupted Smead-Jones sutures with non-absorbable suture material for

closure of linea alba combined with mass closure in high risk laparotomies

 36 patients: 20 (55.55%) intra-abdominal sepsis

8 (22.22%) trauma
7 (19.44%) cancer
1 (2.77%) vascular aetiology
 1 (2.77%) had “partial” wound dehiscence
 1 (2.77%) developed incisional hernia
 Wound infection was noted in 12 (33.33%) cases
 4 (11.11%) experienced pain over the subcutaneous palpable knots
 3 (8.33%) developed sinus due to the knots
 Average follow-up period was 12.47+7.17 months

Murtaza B et al. Modified midline abdominal wound closure technique in complicated/high risk
laparotomies. J Coll Physicians Surg Pak 2010;20(1):37-41
 BURST ABDOMEN:MANAGEMENT

Preventive & responding strategies

Prophylactic retention sutures in midline laparotomy in high-risk

patients for wound dehiscence: a randomized controlled trial.
Khorgami Z et al.
J Surg Res 2013 Apr;180(2):238-43

302 high-risk patients with at least 2 risk factors for dehiscence

 Prophylactic retention sutures reduce the occurrence of WD
 No ‘remarkable postoperative complications”
 BURST ABDOMEN: MANAGEMENT
 Conservative management options
 saline-soaked gauze dressings
 negative pressure wound therapy
 Operative management options – a farrago
 temporary closure options (open abdomen treatment)
 primary closure with various suture techniques
 closure with application of relaxing incisions
 synthetic (non-absorbable and absorbable) & biological
meshes
 tissue flaps
“Randomized controlled clinical trials needed to provide a greater level
of evidence for the optimal treatment strategy” *

*van Ramshorst GH el. Therapeutic alternatives for burst abdomen.

Surg Technol Int 2010;19: 111-19
 BURST ABDOMEN:MANAGEMENT
Outcome to re-suture of burst abdomen
 78 patients re-sutures – followed for 1 year
 Comparison of 5 different surgical techniques for closure of
burst abdomen and later development of incisional hernia
 Over 40% incisional hernias
 No significant differences in the incidence of incisional hernias
when continuous and interrupted techniques compared
 Retention sutures do not reduce the incidence of incisional
hernias
Gislason H, Viste A. Closure of burst abdomen after major gastrointestinal operations –
comparison of different surgical techniques and later development of incisional hernia.
Eur J Surg 1999;165(10):958-61

No comment on role of temporary closure options

Distinction between “complete” and “partial” dehiscence not made
 BURST ABDOMEN:MANAGEMENT
Outcome to re-suture of burst abdomen

 27 studies identified, reporting at least one surgical outcome in at

least 10 patients with burst abdomen
 Relevant surgical outcome include
 recurrence
 incisional hernia
 mortality
 No prospective studies
 Range of conservative and operative therapies
 Treatment associated with “unsatisfactory” surgical outcome

“Randomized controlled clinical trials needed to provide a greater

level of evidence for the optimal treatment strategy”
van Ramshorst GH el. Therapeutic alternatives for burst abdomen
Surg Technol Int 2010; 10: 111-9

Management prompted by institutional bias, tradition & anecdotes

 BURST ABDOMEN: SUGGESTED ALGORITHM

PATIENT AT RISK BURST ABDOMEN

NON-SEPTIC SEPTIC ‘COMPLETE’ ‘PARTIAL’

evisceration fascial separation
IAS* technical factors
superficial sepsis

RETENTION SUTURES

CONSERVATIVE
OPEN ABDOMEN
? RE-SUTURE
*intra-abdominal sepsis
 BURST ABDOMEN

With the widespread understanding of IAP and its

management, the issue of burst abdomen may well be
relegated to the surgical archives!

A REQUIEM FOR THE BURST ABDOMEN?

 BURST ABDOMEN

 A systematic outcome analysis associated with different

surgical techniques is absent
 Management is based on institutional, sometimes individual
experiences, rather than on scientific evidence
 In “open abdomen’ era incidence may be decreased

“A PLANNED HERNIA IS MUCH BETTER TOLERATED THAN FASCIAL DEHISCENCE!”

Schein’s Common Sense Emergency Abdominal Surgery. Springer 2005:Pg 559

BUTS BRINGS ALONG OTHER CHALLENGES

SURGICAL NOUS, INSIGHT, EXPERIENCE PARAMOUNT