Wound Dehiscence
Pathophysiology and Prevention
A. Gerson Greenburg, MD, PhD; Richard P. Saik, MD; Gerald W.
\s=b\ A review of 32 abdominal wound dehiscences in a five-year
period shows an incidence of 0.51%. Important factors are
preexisting pulmonary disease, "malnutrition," intraoperative
contamination (often minimal), gastrointestinal distention, and
aggressive tracheobronchial toilet in the postoperative period.
Incision direction and type of closure have little influence on
dehiscence rates. Wound dehiscence results in a substantial
prolongation of hospital stay. Promptly recognized and treated,
wound dehiscence is no longer a highly lethal complication.
(Arch Surg 114:143-146, 1979)
As modern surgical techniques have evolved and surgical
-¿ .science has developed, the basis for wound dehiscence
has variously been attributed to systemic or local factors.1*5
This study was undertaken to define factors associated
with dehiscence in terms of systemic, local, and patient
management influences that might identify the patient at
high risk and thereby provide the basis for a rational
management approach.
DATA AND RESULTS
A restrospective review of 32 abdominal wound dehiscences
occurring at our two major teaching hospitals between January
1973 and January 1978 was accomplished. Only dehiscences occur¬
ring on the general surgical service were included. For our
purposes, wound dehiscence is defined as a wound disruption with
evisceration occurring in the immediate postoperative period
requiring closure to reduce the extraperitoneal bowel. During this
time, 6,250 intra-abdominal procedures were performed yielding
an incidence of dehiscence of 0.51%. There were 27 men and five
women in the series, with an average age of 60.68 ± 14.53 years
(range, 23 to 88 years). Indications for exploration were emergent
in 15 cases (47%) and elective in 17 (53%). The organs involved at
Accepted for publication July 12, 1978.
From the Departments of Surgery, Veterans Administration Hospital
and the University of California, San Diego.
Reprint requests to Department of Surgery, Veterans Administration
Hospital, 3350 La Jolla Village Dr, San Diego, CA 92161 (Dr Greenburg).
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Peskin, MD
primary surgical procedure are given in Table 1. The small bowel
or colon involved in 17 cases (53%). In reference to the original
was
operation, dehiscence occurred in eight "clean" cases (25%), 19
"clean-contaminated" cases (59%), and five "dirty" cases (16%). A
clean-contaminated case is one in which the gastrointestinal (GI)
tract is opened in a planned or unplanned fashion in what
otherwise is a clean case. For purposes of this study, electively
prepared colon resections are in this category.
Neoplasia was the primary pathology in six patients (19%),
primary inflammatory disease in seven (22%), trauma in two (6%),
acute GI bleeding in seven (22%), and some component of GI
obstruction was present in seven (22%). The associated diseases
were as follows: severe obstructive pulmonary disease, ten; obesi¬
ty, eight; hepatic insufficiency (cirrhosis), seven; malignancy, six;
cardiac, six; major weight loss (greater than 20%), five; and
diabetes, two. Two of the patients were operated on for morbid
obesity and two were receiving chronic steroid medications for
their pulmonary problems.
Midline incisions were used in 21 patients (66%) and transverse
in 11 (34%). This corresponds in distribution to incisions in general
use on our services. Four patients in each group had retention
sutures (25%), corresponding to the general incidence of use.
Primary fasciai closure was accomplished in all wounds using
nonabsorbable suture as indicated in Table 2. A running fasciai
closure was used in 18 (56%) and an interrupted closure in 14 (44%).
Table 2 gives the closures and represents essentially the distribu¬
tion of current practice in our institution.
No differences could be detected between elective and emergen¬
cy groups based on day of week or time of day. Mean duration of
surgery was identical for both groups, 2.9 hours. Intraoperative
antibiotics by irrigation were used equally in elective and emer¬
gency cases independent of classification. Postoperative antibiot¬
ics were used three times more frequently in emergency cases, yet
frank infection was present in only 16% at original procedure.
Recall, however, that 59% of the patients had their GI tract
opened, with only nine of 19 (47%) receiving antibiotics.
At the time of dehiscence, 22 of the patients (68%) had positive
cultures and ten of these were described as grossly purulent-45%
of positive and 31% of the total population. Clean-contaminated
cases demonstrated positive cultures in a ratio of 3:1 over the
 grossly contaminated cases. Recovered organisms were as epidural anesthesia have been used for this high-risk group,
follows: especially for elective procedures.
Escherichia coli 13 Prolonged hospitalization is the hallmark of the morbidity
Barteroides fragilis 12 associated with dehiscence. Ten patients (31%) required less than
29 days of total hospital stay, whereas 22 patients (69%) were
Staphylococcus aureus 5
Klebsiella 3 hospitalized for 30 days or more, mean stay, 45 days with a range
of ten to 90 days. There is one death attributed directly to the
Streptococcus faecalis 3
dehiscence complication occurring in a patient undergoing intesti¬
Salmonella typhi 1
7 nal bypass for morbid obesity (3.1%). Two other patients died of
"Mixed," more than three types
respiratory failure not at all related to the dehiscence or infection.
Dehiscence occurred between two and 11 days, mean, 7.03 days. Six Of the remaining 29 patients, 72% were known to be alive at the
dehiscences occurred at four or less days (19%), five at five or six time of review and eight have been lost to follow-up. Ventral
days (16%), and 21 at seven or more days (66%). hernias have been noted in three of the 21 patients available for
All dehiscences were reclosed in the operating room. Description evaluation and all have been repaired primarily. Interestingly, all
of the findings at that time showed intact sutures with fasciai three were in wounds closed by fasciai reapproximation and not
disruption in 22 patients (68%), necrotic infected fascia in six the through-and-through closure. In the latter group, no hernias
(19%), and a broken running suture in four (13%). The latter, three are yet apparent.
of four, occurred in less than four days. Dehiscence repair was with
through-and-through sutures in 25 patients (78%) and fasciai COMMENT
resuturing in seven (22%). The closures with through-and-through Abdominal wound dehiscence continues to haunt the
sutures were different in 70% from the original closure: 18 of 25
(72%) were wire and seven of 25 (28%) were nylon. Four wounds
general surgeon. With newer and more sophisticated pre¬
were reclosed with interrupted fasciai sutures and three with
operative evaluation and preparation techniques the inci¬
dence seems to have stabilized at about 0.5%. However,
running fasciai sutures, 57% exactly as the primary closure and
43% different. In none of these latter seven closures was gross since the report of Halasz1 in 1968, there seems to be no
purulence or necrotic fascia observed. substantial advance despite the availability of newer
Potentially important postoperative events are given in Table 3. suture material and a wide ranging retinue of closure
In the patients with GI distention, two had no nasogastric tube techniques.
and three had the tube discontinued at less than 36 hours Systemic and local factors seem to exert the same
postOperation. One patient had delirium tremens in the immediate influences now as they did ten years ago. The considerable
postoperative period. No patient's dehiscence was preceded by a decrease in mortality associated with dehiscence is proba¬
major wound infection. In those dehiscences associated with bly more a reflection of better perioperative and postoper¬
grossly purulent drainage, an intra-abdominal abscess was the ative care rather than technical advances in wound closure.
cause. Leakage of this serosanguinous ascites was noted in only six
The current study further indicates that it is exactly these
patients prior to presentation with a wound disruption.
Of importance in this series is the fact that all patients had their factors that may also contribute to the dehiscence rate.
operation under general endotracheal anesthesia despite the fact The need for and the implementation of assertive
that about one third of them had substantial obstructive pulmo¬ tracheobronchial toilet, including nasotracheal suction and
nary disease. Equal numbers of elective and emergency proce¬ intermittent positive pressure breathing with or without
dures were performed on these patients. In general, spinal or humidified air in the immediate postoperative period,
could be in part responsible for the wound's disruption.
More than one half of our patients were in this category.
Table 1.—Organs Involved at Primary Operation Increased intra-abdominal pressure, forced coughing, and
strain on abdominal wounds independent of direction
Site_Total_Elective_Emergency
Colon 11 secondary to these measures and accompanied by early
Small bowel ambulation can be viewed as factors contributing to dehis¬
Appendix cence. That is not to say these should be avoided. Rather,
Gastroduodenal the perioperative management of the patient at risk must
Biliary be perfect in every way so that should the problem of
Aorta dehiscence appear, its effects are minimized.
Portal vein At obvious risk is the older man undergoing a colonie
Spleen
procedure or an emergency abdominal operation that is

Table 2.—Original Fasciai Closure Table 3.—Postoperative Events

Potentially Contributing to Dehiscence
Type Total Midline Transverse
Running Events _No. (%)
Polypropylene 17 12 On mechanical ventilator > 24 hr 13 (41)
Nylon Aggressive tracheobronchial toilet,
Interrupted nasotracheal suction,
Wire intermittent positive pressure breathing, etc 18 (56)
Polyester Pneumonia and atelectasis 10(31)
Polypropylene Ileus, gastrointestinal distention
_ _
7 (22)

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 complicated by or involves entrance into the GI tract. The
so-called "clean-contaminated" case must be recognized
and appropriate intraoperative irrigations used. This is
comparable to the information in the prospective report by
Goligher et alfi of 1975. There is little firm evidence to
support antibiotic irrigation as superior to balanced salt
solution. With the high incidence of infection in the
clean-contaminated cases, 15 of 19 cases (79%), it seems
reasonable to use antibiotic irrigation for this situation.
The patient with severe chronic obstructive pulmonary
disease obviously constitutes an increased risk and must be
managed more carefully. These patients often require
surgical intervention despite their high-risk status. Vital
to the success of the procedure is a well-organized, preoper¬
ative, perioperative, and postoperative management plan
designed to assure minimum compromise to respiratory
function. Recall that this group often uses the abdominal
muscles as accessory respiratory muscles and despite the
advantages of transverse incision on pulmonary function,
midline incisions should be considered.
Preoperative tracheobronchial toilet is mandatory for
this group of patients, particularly so in the elective
situation. Obviously, this is not always feasible in the
emergency situation. If at all possible, regional or conduc¬
tion block anesthesia should be used for elective and
emergency procedures. Many midabdominal and lower
abdominal procedures can be performed under adequate
spinal or epidural anesthesia. In fact, high thoracic contin¬
uous epidural anesthesia, if available, can be used for most
abdominal surgery with the catheter left in place for use in
postoperative pain management.
The patient with obstructive pulmonary disease should
avoid general anesthesia if at all possible. Allowing such
patients to breathe on their own and control pain provide a
mechanism for prevention of the pulmonary complications
that are associated with a large percentage of dehiscences.
We recognize this is not a clear cut management situation.
There are cases where the patient with severe pulmonary
disease also has cardiac compromise. In this subset of
patients, a general anesthetic with the attendant risks to
pulmonary function is preferable because the cardiovascu¬
lar system is under better control than it might be with a
regional anesthetic. We recognize the difference of opinion
and propose this management as a mode, not necessarily
the mode.
Malnutrition either as obesity or weight loss is yet
another factor to be dealt with in the area of prevention. If
one considers obesity as a form of malnutrition, then 13
patients (41%) of this series can be so classified. Converting
the wasted anorectic patient to positive nitrogen balance
preoperatively in the elective situation can only help
wound healing. The obese patient is a recognized risk for
wound infection and very little can be done to close the
huge dead space between skin and fascia. The use of
suction drains in this area seems to afford some degree of
protection in this situation.
That four of our dehiscences were associated with "bro¬
ken suture" material, three of which were polypropylene,
and that six dehiscences occurred between two and four
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days address the need for more attention to the technical
aspects of wound closure. Fasciai disruption with "intact
sutures" found in the absence of fasciai necrosis may also
be a technical problem related to poor suture placement.
One could argue that broken sutures or "pulled through"
running sutures would not occur if an interrupted closure
technique was adopted. That we have seen as many
disruptions with either technique tends to discount the
argument. Dehiscence is probably a function of more than
closure technique!
Failure to adequately decompress or maintain GI decom¬
pression is yet another aspect of management to be
considered. Gastric and small-bowel distention must be
decompressed if present to provide safe abdominal closure.
Prevention of recurrent distention is crucial if one is to
prevent dehiscence. Enterotomy is not always necessary
for bowel decompression. A simple enterotomy can convert
a clean case to clean-contaminated and raise the risk of
dehiscence. Passage of a long tube from above or "milking"
contents retrograde to stomach or forward to the colon
often is feasible and effective decompression while obviat¬
ing an enterotomy. Maintenance of a nasogastric tube
postoperatively prevents swallowed air and gaseous disten¬
tion and is desirable.
The technique of abdominal incision, especially of the
fascia, is worthy of comment. In six of the eight most
recent dehiscences, the electrocautery in coagulation mode
was used in opening the fascia. In these six cases, there
was obvious fasciai necrosis without purulence where the
suture material had pulled through at reexploration occur¬
ring on day 6 or 7. Of interest is that all of these were
emergency procedures in younger patients than the series
as a whole and all had retentions placed. Whether the
dehiscence was due to fasciai necrosis secondary to cauter¬
ization or poorly placed sutures cannot be explicitly
stated.
There seems to be no difference in the rate of dehiscence
relative to incisional direction. Dehiscence occurs in
approximately the same ratio as these incisions are used.
Of interest is the total lack of paramedian incisions in the
series.
A large number of cases were either clean-contaminated
or dirty, 75%, and the incidence of infection at time of
dehiscence was 68%. Obviously, infection plays some role in
the pathogenesis of the dehiscence. The use of routine
irrigation with or without antibiotic irrigation in these
cases is advocated. Our preference is to use antibiotic
irrigation. In the patient with pulmonary compromise,
recent infection, substantial infection, or major blood loss,
special attention to wound closure details is in order. The
older patient with these factors present is at particular risk
for dehiscence, especially if pulmonary complications occur
and vigorous tracheobronchial toliet is required. If at all
possible the avoidance of general anesthesia is desirable
for it tends to exaggerate pulmonary difficulties.
Not surprising is that our results are quite similar to
those of Keills in that a single causative factor is difficult
to identify. The pathophysiology of wound dehiscence is no
doubt a combination of factors that, when taken together,
 produce the complication, whereas any one alone is not
quite sufficient to accomplish the deed.
In recent reviews, two factors seem to be of major
importance in wound dehiscence. These are infections as
noted by Halasz,' Higgins et al,4 and Reitamo and Möller,7
and postoperative pulmonary complications as emphasized
by various authors.3'7's Our data would support these
concepts.
We have no evidence to support a preference for midline
over transverse incisions nor can we implicate anemia or a
particular underlying cause. What we do recognize is the
patient at risk and the profile of this patient is as follows:
man, older than 60 years of age, malnourished, with
moderate to severe obstructive pulmonary disease who is
subjected to a colon operation or in whom the GI tract is
entered at emergency procedure. In this patient, develop¬
ment of considerable postoperative pulmonary complica¬
tions, pneumonia and atelectasis, requiring vigorous
tracheal-bronchial toilet is most frequently associated with
wound disruption.
Modern surgical management has made it possible to
treat effectively and efficiently a complication previously
associated with high mortality. Wound dehiscence, when
properly managed, is no longer a lethal situation.
CONCLUSION
Wound dehiscence most frequently in older male
occurs
abdominal
patients undergoing surgery for colon or small-
bowel problems who have associated chronic obstructive
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pulmonary disease and some degree of malnutrition. Open¬
ing of the GI tract in an otherwise clean case seems to be
an additional factor. The mode of closure and the direction
of incision seem to bear little influence on the problem.
Importantly, pulmonary complications and early removal
of GI decompression tubes correlate well with the occur¬
rence of dehiscence. Prolonged hospitalization is the main
morbidity, and mortality is low (3%), probably because of
improved management techniques. To the list of causes for
dehiscence we can add those related to management. It is
an enigma that techniques used for improving patient
survival also contribute to morbidity.
This research was supported in part by a grant from the Veterans
Administration Medical Research Service.
References
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1968.
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study of abdominal wound closure and dehiscence. Arch Surg 98:421-427,
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