A-nnals of the Royal College of Surgeons of England (1977) 1i01 59

ASPECTS OF TREATMENT*

Abdominal wound dehiscence

A io-year
survey

from

district general hospital

H White Mch FRCS

Senior

Registrart

J Cook

BM BCh House Surgeon

MI Ward BM BCh
House Surgeon, North Middlesex Hospital, London Nil

Summary

istics of the group of patients who suffered The incidence of abdominal wound dehiscence abdominal wound dehiscence. at a district general hospital was found to be about I.5%. Analysis of a group of I23 Metlhods patients with dehiscence in 3 separate years Abdominal wound dehiscence wvas defined as during a Io-year period confirmed that dis- disruption of an abdominal wound that reruption most commonly occurs during the quired resuturing and was found at operation second postoperative week. The suture to involve all layers of the wound, including material used for primary closure appeared the peritoneum, whether or not viscera proto have no influence on subsequent dehiscence. truded. Initially all the case notes of those After resuture the recorded incidence of in- patients with abdominal wound dehiscence ct;sional herniation was I9% and the mortal- were requested from the central registry. Howity was 24%. Patients who survived resuture ever, errors of coding made this methoid of remained in hospital for a prolonged period. search valueless. Consequently a search was made through all the operating theatre records for io years. Even this method of retrieving Introduction A variety of factors has been accepted as cases tends to underestimate the incidence as predisposing to abdominal wound dehiscence reported in other series3' '. In order to assess -hasty suture, infection, persistent coiugh, the incidence every operation in which the abdominal distension, leakage of pancreatic peritoneum was oipened through an anterior enzymes, and delayed healing in malignancy abdominal approach was recorded in the first, have all been incriminated. Estimates. of the middle, and last year of the period of the surincidence vary from nil' to 3%2'5* Most series vey. A loin approach to the kidney in which reported have been from teaching centres and the perito,neum was inadvertently opened was it seemed appropriate to examine the records not included. An inguinal incision for of a large district general hospital over a iO- herniorrhaphy in which the sac was routinely year period. Our main object was to assess opened before ligation was excluded. An occawhether the incidence fell within the previously sional dehiscence following appendicectomy reported range and to analyse the character- was found and therefore appendicectomy cases tPresent appointment: Consultant Surgeon, Royal were incltuded in assessing the incidence of dehiscence. Marsden Hospital, London SW3
*Fellows and Members interested in submitting papers for consideration wvith publication in this series should first write to the Editor.
a

vicw

to

338

H Whifte, J Cook, and AM WVard

TABLE I Inicidencc of abdonminal wounld dehiscence over a Io-year period.
Year
I 962 1967
1971

Dcspite the limitations of a retrospective study it was felt that this would yield wvorthwhile information about incidence and also allow us to analyse certain characteristics of the group of patients who suffered abdominal wound dehiscence. Results The incidence of abdominal wound dehiscence during the 3 years analysed is set out in Table I. The lower incidence in the first year of the survey is probably a result of inadequate records and poor retrieval despite a thorough search rather than the introduction of bolder surgery during the i o years of the survey on an older hospital population. The avcrage incidence of dehiscence in the present series was therefore probably about I.5%/,. It was not possible to retrieve the case records of all patients who returned to the theatre for resuturing of an abdominal wound dehiscence. However, those cases of abdominal wound dehiscence during the Io-ycar pcriod of which the records co-uld be found (I23) have been analysed. Eighty-two (67%) of these patients were undergoing elective surgery and 41 ('3%) were emergency cases. The age distribution is shown in the figure. The patients who suffered abdominal wounil dehiscence are grouped in io-year cohorts, the greatest incidence being between the ages of 51 and 8o years, with a peak incidence between 6i and 70. There were 75 males and 48 females in the group studied, which gives a male: female ratio of I.6 : i. The incidence of dehiscence was highest in the months OctoberDecember and was 25% lower during the rest of the year. Dehisccnce occurred within 2 weeks of the operation in over go9/% of cases and the majority of these (87) were in the second postoperative week. The suture material used to close the peritoneum and the muscle sheath at the original operation was recorded in only 37% of the cases. However, the routine procedure of alI but one of the surgeons concerned (and their registrars) was to close the peritoneum and muscle sheath with continuous catgut. The his remaining surgeon (together with registrar) used continous nylon to close the muscle sheath in the last 2 years of the survey, having previously used interrupted stain-

No of patients undergoing abdominal operation

I I67 I 208
I I I8

No with wound dehiscentce

7 20

(o.6%) (1.7 %) I4 (1-3%)

less steel wire. As i 8 cases of dehiscence were recorded in which nylon had been used it would appear that abdomens closed with this material during the last 2 years of our survey were just as likely to disrupt as those in which absorbable catgut had been used. Some cases of dehiscence were also found in patients whose abdomens had been closed with interrupted steel wire. In resuture deep tension slutures were almost invariably employed and a tvolayer closure was used whenever possible. The numbers of upper and lower abdominal incisions were almost identical (59 uppler, 64 lower) and the majority (i I 6) were vertical incisions. Fifty-seven patients (46%) were found at the original laparotomy to be suffering from primary or secondary malignant disease affecting some part of the abdominal cavity. Of the 66 patients who, were not suffering from malignant disease, 28 were anaemic (haemoglobin concentration in females below I I.5 g/dl and in males below 13.5 g/dl7). Twelve of the I23 patents (io%) had been treated for cardiac failure before the operation, i i (io%) had chronic bronchitis, 6 (5s/%) had peripheral arterial di"ease with at
40
34

22

8
6
2

0 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 - 80 81 - 90 Age

Age distribution of wound dehiscence.

123 patients with abdominal

Abdominal wound dehiscence

TABLE II Deaths after resuture in patients undergoinzg 'curative' surgery for malignant disease
Age (years) 77 Day after resuture that patient died 5 Original condition requiring surgery Cause of death

339

73 63 77 54 75

3 2
II 10

Ca. stomach anid haematemesis Ca. stomach Ca. rectum Ca. uterus Ca. rectum Ca. sigmoid

Respiratory failure and pneumonia

Pulmoniary embolism ,, Peritonitis

least one absent peripheral pulse, and 3 (2.4%) of resuture. Of these, I8 were suffering from were jaundiced at the time of laparotomy. malignant disease and I 2 from benign conThe most common consequence of de- ditions. Only 6 of the patients with malignant hiscence was a prolonged stay in hospital. After disease were thought to be free from metaa laparotomy a patient can expect to be dis- stases at the time of the original laparotomy charged at the end of the second post- and had consequently undergone 'curative' operative week. However, after resuture of surgery. The details of these patients are rea dehiscenec 34 patients (28%) remained in corded in Table IL. Details of those patients hospital for 3 weeks and a further 39 (32%) with benign conditions who died after resuture arc recorded in Table III. for 4 or more weeks. Incisional hernia was recorded in i 8 (I'9%/O) of the 93 patientss who survived resuture of Discussion the abdomen. Wound infection following The incidence of abdominal wvound deresuture was recorded in 17 patients (i8%). hiscence in our series falls vithin the range Further dehiscence occurred in only one case. reported from various centres during the i o This wound had incidentally become infected years preceding our study5 5-13. Our survey following secondary suture. is from a busy district general hospital where Thirty patients (24%) died within 4 wveeks a significant amount of the surgery (especially
TABLE III Deaths after resuture in patienlts with benign disease Age Day after resuture Cause of death Original condition requiring surgery (years) that patient died
75
7

7I
82 88
7 3 2 3
I0

65
68

8i
70 68

76
86

27

3
IO

69

Pnieumnoniia Adhesions and obstruction Perforated duodenal ulcer ,, Volvulus of sigmoid Renal failure Perforated duodenal ulccr Ulcerative colitis (colectomy) Perforated gastric ulcer Coronary occlusion Volvulus of ileum Cholelithiasis Gastric ulcer and hacmaternesis Iliac artery occlusion Cerebrovascular accident Pelvic abscess Pulmonary embolism Perforated duodenal ulccr Haematemesis
.,
.,J

340

H W'hite, J Cook, (land M Ward

emergency laparotomy) is performed by young and relatively inexperienced surgeons in training. Although it is disappointing that the figures apparently have not improved in recent years, we must remember that the hospital population and those subjected to laparotomy are generally older than io years agol. The average age of those patients suffering abdominal dehiscence in Hartzell and Winfield's series in I 9393 was 44 years and in Wolff's series in I9504 it was 50 years; in our series it was 70 years for males and 65 years for females. This is a very different age group and perhaps there is some consolation to be gained from the fact that the incidence of dehiscence has remained fairly constant despite bolder surgery on an ageing hospital population. Dehiscence in the age group (5 i-6o years) in which Mann et al5 found the greatest incidence was only 50% of that which occurred a decade later (61-70 years) in our series. Although we do not know the age distributioin of all patients subjected to laparotomy in the 0o-year period covered by our survey, the rise in the age of peak incidence of dehiscence probably reflects an increase in the number of laparotomies in this age group. Wolff' found that age had a significant effect on the incidence of disruption in patients over 40 years old. The male: female ratio of i.6: I is in keeping with that reported by Meleney and Howes' and by Hartzell and Winfield3. We do not have details of the sex ratio of all the patients undergoing laparotomy in our series and the limitations in interpreting this ratio arc similar to those of the previously reported series" Although there was an apparent small increase in dehiscence during the winter months, the notes do not give enough clinical details to judge whether this dehiscence resulted from an increase in respiratory infection. The time at which dehiscence became evident was most commonly during the second postoperative week. Undoubtedly the deeper layers had often given way some time earlier and either a serosanguineous leak or pain was sometimes recorded during the days preced&ng dehiscence. The time of dehiscence agrees with that in other series3'6. The extent of the deep dehiscence may become evident only

when the skin sutures are removed4' ". Although vertical incisions disrupted far more commonly than transverse incisions, this almost certainly reflects the greater frequency with which a vertical incision was employed. The introduction of non-absorbable suture material does not appear significantly to have altered the incidence of disruption in our series. The number of cases of dehiscence that occurred after continuous nylon was used to close the muscle layer was of the same order as that observed with absorbable sutures. Therefore it appears that the introduction of nylon did not confer any particular benefit. It has sometimes been claimed that interrupted stainless steel wire sutures prevent abdominal wound dehiscence. This appears to be a surgical myth. Primary one-layer closure was not employed in our series and accordingly no comparison can be made with the findings of Kirk"3. Malignant disease has often been said to predispose towards wound dehiscence2' 3, 145. However, Wolff4 concludes that cancer by itself does not predispose to wound disruption, although the number of patients over 45 with cancer gives this false impression. If malignancy does predispose to dehiscence one might expect a difference in the average ages of the patients with cancer and those with benign conditions who suffer dehiscence. The average ages of the two groups in our series were almost identical-64 and 6o years respectively. Nearly 6o% of patients stayed in hospital for at least 3 weeks after resuture of a dehiscence, which represents a high cost in bed occupancy. The recorded incidence of incisional herniation was 19%. That recorded by Mann et al5 was 28% and by Wolff4 31.6%. As Akman'7 recorded an incidence of incisional hemiation of 22% after right lower paramedian incisions and 9.6% after right upper paramedian incisions in the absence of disruption the incidence in our series following disruption does not appear remarkable. The mortality of 24% is of the same order as that found by Mann et al5 (23%) and lends support to the view expressed by Skidmore"8 that wound disruption should be regarded in a serious light. It is interesting that 67% of those who died after resuture had malignant

A bdominal wound dehiscence

341

disease whereas the incidence of malignancy in the whole group was only 46%. It is only with a detailed prospective study that the questions that have remained unanswered for so many years will be answered. Such a prospective study would be both interesting and a valuable medical audit for large surgical centres.
We would like to express our thanks to Mr R A Payne for suggesting this study and for his help and encouragement in the preparation of this paper. All cases were from the North Middlesex Hospital and we are grateful to all consultant surgeons for their permission to report this series of cases. We would also like to thank Mrs Maureen Reynolds at the North Middlesex Hospital for her help in retrieving the case notes and MIrs Trudy Tyler and Mrs Lisa Wakeling for typing this paper.

References
25, 7-

I Baldwin, J F

(I934) American

Journal of Suirgery,

3 Hartzell, J B, and Winfield, J M (I939) International Abstracts of Surgery, 68, 585.

2 Starr, A, and Nason, 1, H (I933) Journal of the American Medical Association, IOO, 3IO.

4 Wolff, W I (i950) Annals of Surgery, 131, 534. 5 Mann, L S, Spinazzola, A J, IAndesmith, G G, Levinc, M J, and Kuczerepa, WV (I962) Journal of the American Medical Association, i8o, 1021. 6 Meleney, F L, and Howes, E L (i934) Annals of Surgery, 99, 5. 7 Dc Gruchy, G C (1972) Clinical Haematology in Medical Practice, 3rd edn, ) 45. Oxford, Blackwell. 8 Schiebel, H M, and Creech, B (I953) American Surgeon, I9, 318. 9 Marsh, R L, Coxe, J W, Ross, W L, and Stevens, G A (1954) Journal of the American Medical Association, I55, 1197. io Standeven, A (955) Lancet, I, 533. ii Del Junco, T, atnd Lange, H J (I956) American Journal of Surgery, 92, 271. 12 Bettman, R B, and Kobak, M W (I960) Journal of the American Medical Association, I72, 1764. I3 Kirk, R M (1972) Lancet, 2, 352. I4 Colp, R (I934) Annals of Surgery, 99, I4. 15 Glen, F, and Morre, S W (I941) Surgery, Gynecology and Obstetrics, 72, 1941. i6 Everctt, W G (I974) Annals of the Royal College of Surgeons of England, 55, 31. 17 Akman, P C (I962) Journal of the International College of Surgeons, 37, 125. i8 Skidmore, F D (I973) British Journal of Surgery,
6o, 1.