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