Editing Fascial dehiscence


When abdominal wall tension is greater than tissue or suture strength or knot security.

* Complete dehiscence: full partition of fascia and skin, possibly involving evisceration
* Partial dehiscence: separation of fascial edges of the wound, without evisceration, but often with exposure of the underlying omentum or viscera

== '''Epidemiology''' ==

* Incidence is 3-3.5% after laparotomy
* Complete fascial dehiscence is associated with a mortality of 10% - this should not be interpreted as 'causative' though

== '''Risk factors:''' ==

* Patient:
** Age >70
** Obesity
** Smoking
** COPD
** Steroid use
** DM
** Malnutrition
** Ascites
** Previous laparotomies
* Disease:
** Abdominal trauma
** Ruptured AAA
** Retroperitoneal haematoma
** Pancreatitis
** Peritonitis/sepsis
** Bowel occlusion surgery with resection or suture
** Wound infection - more likely with fascial infection rather than superficial
** Wound class III or IV
** Presence of enterocutaneous fistula
** Synthetic mesh infection
** Necrotising fasciitis
** Abdominal wall defect >10cm width
** Incision length >18cm
* Can use Veterans Affairs Medical Center score or Rotterdam score to predict risk of suture complications

== '''Causes:''' ==

* Technical:
** Knot failure or inadequate strength of suture
** Fascial damage - tension, ischaemia, suture material failure
** Poor closure technique - in the majority of cases, sutures have pulled through rather than broken - either placed too close to fascial edge or under too much tension
*** Poor quality of tissue
*** Increased intra-abdominal pressure
*** Bites too big or small
* SSI/intra-abdominal abscess
* Increased intra-abdominal pressure

== '''Presentation''' ==

* Increased serosanguinous drainage from wound - 'moderate to large'
* Mostly 4-14 days post-op (mean 8 days)
* 'Popping' sensation
* Incisional bulge exacerbated by Valsalva manoeuvres
* Absence of a healing ridge by day 5

== '''Management''' ==

* Partial dehiscence
** Consider conservative management for small dehiscences if bowel is covered
** Carefully consider why it happened
*** Should get a CT to rule out an intra-abdominal cause of dehiscence
** Otherwise, to theatre for re-closure
* Complete dehiscence
** Initial:
*** Moist dressing over wound, taped securely to skin
*** Assess for factors that may have led to this including infection/IAH
** If superficial infection is present:
*** Drainage, antibiotics and local wound management then either
*** Option 1 - vac, then fix the incisional hernia later
*** Option 2 - debridement and delayed primary closure once the infection is resolved
** If deep infection is present, and the abdomen is inaccessible:
*** Treat the intra-abdominal infection
*** Planned ventral incisional hernia once the infection is resolved
*** Consider biologic mesh to breach the defect
** Early dehiscence with no infection:
*** Primary abdominal wall closure

== '''Operation''' ==

* Debride wound edges
* Look for signs of infection or other reasons for dehiscence
* Close wound again, if no infection, and wound can be safely closed
* Retention sutures not recommended by Sabiston/UTD
* Common option seems to be to add some interrupted 0 PDS or Nylon every 5cm

[[Category:Abdo wall and retroperitoneum]]
[[Category:Intern education]]