Burst Abdomen
Presented by Dr. Saifuddin
Ahmed
Definition
Post-operative separation of the abdominal musculo-aponeurotic layers.
Mean time for dehiscence after 8 to 10 days.
Incidence Historical 10%Recent study – 3.2% [Veterens Affairs
Quality programme]
Incidence
Predisposing factors
6SSurgerySurgeonSuturesSepsisStrainingSick patient
Predisposing factors
SurgeryGrossly contaminated surgeryPeritonitisBiliary-fistulaFaecal-fistula
Predisposing factors
Surgeon Technique
Meticulous dissection Haemostasis. Gentle tissue handling Tensionless sutures Incision Vertical incision worse than
Transverse.
Predisposing factors
StrainingViolent coughPersistent vomitingDistension
Paralytic ileusSepsis
Uncontrolled sepsis
Predisposing factors
Sick patientMalignancyJaundiceObesityAnaemiaHypo-proteinemiaUremia
SuturesPrefer non-absorbable sutures
Risk Factors
Predisposing factors
Pre-operative Cough Anaemia Hypo-proteinemia Malnutrition Steroid
Predisposing factors
Post-operativeCoughAbdominal distensionAscitisVomitingBowel leakageWound infectionHaematomaUraemiaJaundiceElectrolyte imbalance
Mortality
Range 9 to 43 % Recent study
16 %
Prevention is the cornerstone With meticulous surgical technique
Clinically Pathognomonic feature
Sudden rush of copious serosanguinous discharge for the wound
Large subcutaneous hematoma Herniated bowel under the skin
Tympanic boggy swelling
Management
Basic principleResuture the wound edges
Replace the eviscerated organs Prevent
recurrent dehiscenceLater development of ventral hernias
As soon as recognizedProtruding viscera - Warm NS bathcover with large sterile dressingShift to OT
Management When there is Seepage of
serosanguinous fluid through a closed abdominal wound, Remove one or two sutures in the
skin and Explore the wound manually, using a
sterile glove.
Look for any separation of the rectus fascia.
Management Operating room for primary closure.
Wound dehiscence may or may not be associated with intestinal evisceration.
When evisceration is present, the mortality rate is dramatically increased and may reach 30%.
If only very small area of the wound disruptedThat portion alone sutured
If more than half of the incision disruptedSuture whole wound afresh
Management
Management
Small deficit Conservative management
Packing with moist sterile dressingTransverse elastic dressingAbdominal binderAvoid strenous activitiesSecondary suturing/ natural healing
Large deficit: NG tube GA Lift up edges Reposition of prolapsed bowel Extract fragments of suture Freshen the edges Retention Suture Strong monofilament non-absorbable Continuous/ interrupted stitch.
Management
Retension Sutures
Strong monofilament Nylon Thread through protective rubber
tubing 2.5 cm apart, 2.5 cm from margin. All layers of the abdomen taken
together. Stitch off after 2 to 4 weeks.
Retension SuturesAdvantage
Reduce chance of evisceration. Disadvantage Pain, discomfort Types
InternalExternal
Comparison
References
GASTROENTEROLOGY 2003;124:1111–1134
Thank You
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