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ORIGINAL ARTICLE
Frequency of abdominal wound dehiscence and role of
wound infection as a major causative factor
Mukhtiar Ali, Saeeda, Muhammad Israr, Hafiz Niamat-ullah

Abstract:
Objectives: To find the frequency of abdominal wound dehiscence and establish the role of
wound infection as a major causative factor in patients undergoing elective or emergency
laparotomy.
Methodology: This was a descriptive cross sectional study, conducted in the department of
Surgery Mardan Medical Complex and Teaching Hospital Mardan. Study duration was 12
months. Sampling technique was Consecutive (Non Probability) sampling. All male and
female patients above 18 years age who underwent diagnostic or therapeutic laparotomy
were included in the study. A pre-operative workup included history taking, thorough clinical
examination and routine laboratory investigations. Patients undergoing elective or emergency
laparotomy were prospectively followed for development of wound infection and any event of
wound dehiscence noted.
Results: Male to female ratio was 1.45:1. Mean age affected was 38.40 years. 144 (81.4%) patients were operated in emergency while 33 (18.6%) cases were operated electively. Out of 177
patients, abdominal wound dehiscence was seen in 26 (14.7%) patients. Overall 32 (18.1%)
patients developed wound infection. All of the patients having wound dehiscence had wound
infection. Presence of wound dehiscence was found significantly high (p= <0.05) in patients
operated in emergency as compared to elective cases. Wound infection was found to be statistically significant (p= <0.05) factor associated with wound dehiscence.
Conclusions: We conclude that frequency of wound dehiscence, burst abdomen is still very
high in this part of the world. Patients undergoing laparotomy for various emergency procedures like peritonitis, intestinal obstruction and trauma are at a particular high risk of developing wound dehiscence/ burst abdomen. Presence of wound is a significant factor contributing to development of wound dehiscence and burst abdomen. Wound dehiscence still
constitutes as a major cause of significant morbidity and mortality among patients undergoing
laparotomy. Some of the major factors like wound infection must be vigilantly looked for and
treated to prevent this catastrophic complication.
Mardan Medical
Complex Mardan.
M Ali
Saeeda
M Israr
H Niamat-ullah
Correspondence:
Dr Mukhtar Ali, District
Surgeon, Mardan Medical
Complex Mardan.
email: drmukhtarkhan1@
yahoo.com

Keywords: Wound infection, wound dehiscence, burst abdomen, laparotomy

Introduction:
Wound dehiscence/burst abdomen represents a
mechanical failure of wound healing of surgical
incision1.
Wound dehiscence/burst abdomen is a very
serious postoperative complication, associated
with high morbidity and mortality. It has significant effect on health care cost both for patient

and hospital2. Wound dehiscence continues to

be a major complication of abdominal surgery
despite significant progress in operative and per
operative care over the last few decades accompanied by high mortality and morbidity.
Abdominal wound dehiscence is defined as
post-operative separation of abdominal musculo-aponeurotic layers, which is recognized
Pak J Surg 2014; 30(1):4-8

Frequency of abdominal wound dehiscence and role of wound infection as a major causative factor

within days and requires some form of intervention3,4,5. It is a major catastrophe which can complicate any operation.3,6
Many different risk factors have been identified
leading to development of abdominal wound
dehiscence like advanced age, poor nutritional
status, obesity, anaemia, diabetes, irradiation,
drugs, malignancy and chronic airway diseases4,6
poor technique of wound closure, suture material, post-operative wound infection, prolonged
cough, constipation, vomiting, ascites and prolonged ileus. Of the most significant importance
is the development of wound infection which
remains highly prevalent due to factors like patients presenting in emergency with poor state
of health and nutrition and compounded by
presence of septic conditions like peritonitis.
This study aims to find the frequency of abdominal wound dehiscence and establish the role of
wound infection as the single most important
factor in its development. This study also highlights the importance of prevention or minimization of wound infection to reduce the already
very high rate of this dreadful complication.
Material and Methods:
This was a descriptive cross sectional study.
This study was conducted in the department of
surgery Mardan Medical Complex and Teaching Hospital Mardan. Duration of study was
12 months (From January 2012 to December
2012) Total number of patients studied was
177; sampling technique was consecutive (non
probability) sampling.

were operated on the main elective operation

list. Pre-operative workup included a detailed
history, a complete physical examination and
all relevant laboratory investigations and imaging studies. Patients were operated via midline
or paramedian incision and wound closure performed using polypropylene (prolene) No. 1
or polygalactin (Vicryl) No. 1 suture in either
continuous or interrupted manner. All patients
received third generation cephalosporin antibiotics and other supportive treatment in the
immediate post-operative period and continued for a variable period of time depending on
the condition of the patient. All patients were
closely observed for the development of wound
infection and subsequent presence of abdominal wound dehiscence during the entire hospital
stay as well as during the immediate follow-up
visits to outpatient department. All clinically relevant data was entered into a predesigned proforma. Results were analyzed at the end of study
and appropriate test of significance applied using SPSS version 17.
Results:
Total number of patients was 177. Gender distribution was as given in Figure 1, with a male
to female ratio of 1.45:1. Age distribution was
as given in figure 2. Minimum age recorded was
18 years and maximum age was 80 years with a
mean age of 38.40. Most frequent age group was
21-30 years (43 cases). Laparotomy was done
as emergency in 144 (81.4%) cases while it
was electively done in 33 (18.6%) cases. Out of
177 patients, wound dehiscence was observed
in 26 (14.7%). For descriptive purposes, all

Inclusion criteria: All male and female patients

above 18 years age who underwent emergency
or elective laparotomy.
Exclusion criteria: Patients with wound dehiscence at presentation; patients with severe malnutrition with body mass index <15; obesity
with body mass index >30.
A written informed consent was taken from all
the patients. Those patients needing emergency
laparotomy were operated in casualty department while those considered for elective surgery
Pak J Surg 2014; 30(1):4-8

Females
Males

72
105

Figure 1: Gender distribution (n=177)

M Ali, Saeeda, M Israr, H Niamat-ullah

50
40

Non burst

120

Burst

100

NON BURST
BURST

80

30

60

20

40

10

20

18-20 21-30 31-40 41-50 51-60 61-70 71-80

Figure 2: Age distribution (n=177)
cases were divided into group A- patients with
wound dehiscence and group B- patients without wound dehiscence. In group A, 15 patients
were male and 11 patients were female while in
group B, 90 patients were males and 61 patients
were females. In group A, 25 patients were operated as emergency while 01 patient was operated electively. In group B, 119 patients were
operated as emergency while 32 patients were
operated electively. Wound infection was observed in 32 (18.1%) cases, 26 in group A and
6 in group B. Presence of wound dehiscence was
found significantly high (p= <0.05) in patients
operated in emergency as compared to elective
cases. Wound infection and was found to be statistically significant (p= <0.05) factor associated
with wound dehiscence.
Discussion:
Acute wound failure has been discussed under
various names i.e. wound dehiscence, burst abdomen, wound disruption and evisceration1.
Despite increased knowledge and development
concerning wound healing and progress in perioperative and postoperative care and suture
materials, over the past few decades, wound
dehiscence after abdominal injury continues to
be a problem which considerably prolongs hospital stay and is associated with mortality rates
of 10-44%.7,8 Similarly, it has a significant impact
on health care cost both for the patient and the
hospital.9 Many trials and new techniques were
developed to prevent or at least reduce the risk
of wound dehiscence10-12 but burst abdomen
remains a formidable morbidity. This may be
attributable to increasing incidences of risk fac-

EMERGENCY

ELECTIVE

Figure 3: Mode of presentation (n=177)

tors within patient populations outweighing the
benefits of technical achievements.
Wounds can become partially dehisced, involving the superficial layers of the skin, or completely dehisced with deeper tissue involvement.13
The frequency of wound dehiscence /burst abdomen varies from center to center worldwide.
Frequency of wound dehiscence or burst abdomen was 14.7% in this study. It proves high
when compared to western studies where its
frequency ranges from 1-3% 14,15 while it seems
comparable to results of some centers in India
with frequency of 10-30% 16,17, and even some
local studies with frequency of 5.9%. 18
Many risk factors are incriminated in development of burst abdomen. Some of the major independent risk factors that have been identified
are age, gender, ascites prolonged post-operative
abdominal distension or cough, anemia, peritonitis jaundice, emergency surgery and wound
infection5. Factors related to surgeon/experience are type of incision, suture material, drain,
and ostomy.19 Abdominal distension, vomiting,
and nausea are risk factors caused by increasing
intra-abdominal pressure.18,20
The number of patients with wound dehiscence
increases with an increase in the number of risk
factors, reaching 100 % for patients with 8 or
more risk factors.
Although as described above, many risk factors
have been studied and proved, this study focused on the presence and frequency of wound
Pak J Surg 2014; 30(1): 4-8

Frequency of abdominal wound dehiscence and role of wound infection as a major causative factor

infection as the cause of wound dehiscence in

patients undergoing laparotomy. Also taken into
account were age, gender, and mode of surgery
(emergency or elective)
In this study, the most common age group affected was 31-50 years (14 cases). Old age has
been found to be another independent risk factor for abdominal wound dehiscence.. Waqar et
al found 57% of their patients with wound dehiscence above the age of 5018. Hanif also showed
advanced age in 50 % of cases.20 The explanation
for this might lie in deterioration of the tissue repair mechanism in the elderly especially during
the first few days of the wound healing process,
the immune system plays a key role.
In our study, Males were more affected more
than females with male to female ratio being
1.36:1. Male predominance has been mentioned in many studies.4,21 Increased frequency
in males has been attributed to smoking as a possible confounder and its effect on tissue repair.
In this study, out of 26 cases with wound dehiscence, 25 (96.15%) cases were operated as
emergency as compared to only 1 (3.84%) case
operated electively. Wound dehiscence rate was
observed to be 12 % in emergency (5/62), and
4 % in elective laparotomies (2/55) by Waqar
et al,18 which is almost similar to that reported
by Hanif.20 Patients who undergo emergency
surgery are generally in worse condition and nutritional state, and the chance of contamination
of the surgical field is higher than in elective surgery. Moreover, the performance of the surgeon
might be affected at night, which could lead to
suboptimal closure of the abdomen at the end of
the operation. In our setup the emergency laparotomies are usually performed for acute abdomen cases which have been deteriorated due to
course of acute illness Most of the patients are already having complications like septicemia and
fluid and electrolytes derangements. Second factor responsible for this high incidence of wound
dehiscence especially in emergency cases may
be the lack of proper sterilization in an emergency setup. Third factor, which can also play a
major role in developing wound dehiscence, is
Pak J Surg 2014; 30(1): 4-8

lack of experience on part of the surgeon. The

emergency laparotomies are performed most of
the time by surgical residents.
In this study wound infections were present in
all 26 (100%) cases of wound dehiscence making it the most predominant risk factor causing
burst abdomen. As most of the patients were
operated in emergency with acute conditions
like peritonitis, gangrenous or obstructed bowel
with a contaminated abdominal cavity, which
led to inevitable development of wound infection. Waqar et al found wound infection in all
7 cases with dehiscence.18 Col and Soran also
reported wound infection as an important risk
factor for wound dehiscence15.
Conclusions:
It is clear from this study that the frequency of
wound dehiscence/ burst abdomen is still very
high in this part of the world. Patients undergoing laparotomy for various emergency procedures like peritonitis, intestinal obstruction and
trauma are at a high risk of developing wound
dehiscence/ burst abdomen. Presence of wound
is a significant factor contributing towards the
development of wound dehiscence. Wound
dehiscence still constitutes a major cause of
significant morbidity and mortality among
patients undergoing laparotomy. Some of the
major factors like wound infection must be vigilantly looked for and treated to prevent this catastrophic complication.
References:
1. Spiliotis J, Tsiveriotis K, Datsis A, Vaxevanidou A, Zacharis
G,Giafis K, et al. Wound dehiscence; is still a problem in the
21th century; a retrospective study. World J Emergency Surg
2009;4:12.
2. Lotfy W. Burst abdomen: it is a preventable complication .
Egyptian journal of surgery 2009 july;28(3):128-32
3. Sheikh MS, Shaikh SA, Shaikh BA, Abro A, Sikandar S. Abdominal wound dehiscence, frequency and risk factors. J Surg
Pak. 2005;10(4):30-33.
4. Kihara A, Kasamaki S, Kamano T, Sakamoto T, Tomiki Y. Abdominal wound dehiscence in patients receiving long term
steroid treatment. Journal of international medical research
2006;34:223-30
5. Begum B, Zaman R, Ahmad MU, Ali S. Burst abdomen- a preventable morbidity. Maymunsingh Med J 2008; 17(1):63-6
6. Khan MNS, Naqvi AH, Irshad K, Choudry AR. Frequency and
risk factors of abdominal wound dehiscence. J Coll Physicians
Surg Pak 2004;14:355-7.
7. Afzal S, Bashir M. Determination of wound dehiscence
in abdominal surgery in public sector hospital. Annal
2008;14(3):110-15

M Ali, Saeeda, M Israr, H Niamat-ullah

8. West J,Gimbel M. Acute surgical and traumatic wound healing.
In Acute and chronic wounds:Nursing management Edited
by: Brayant.St.Louis Mosby;2005:189-96.
9. Sorensen LT, Hemingsen U, Kallehave F, Risk factors for tissue and complications in gastrointestinal surgery.Ann Surg
2005;241:654-8
10. Menke NB,Ward KR,Witten TM,Impaird woung healing.Clin
Dermatol 2007;25:19-25.
11. Broughton G II,Janis JE,Attinger CE.Wound healing: an overview. Plast Reconstre Surg 2006:177:1e-S-32e-S.
12. Gabrielle H ,Ramshort, Nieuwenhuizen J, Wim CJ, et al. Abdominal wound dehiscence in adults: Development and validation of a risk model. World J Surg 2010;34:20-7.
13. Burger JW,Van t Riet M, Jeekel J. Abdominal incisions: techniques and post operative complications . Scand J Surg
2002;91:315-21.
14. Wilson JA, Clark JJ. Obesity: impediment to wound healing.
Crit Care Nurse Q 2003;26:119-32.
15. Col C, Soran A, Col M. Can postoperative abdominal
wound dehiscence be predicted? Tokai J Exp Clin Med
1998;23(3):123-27

16. Makela JT, Kiviniemi H . Factors influencing wound dehiscence after midline laparotomy . Am J Surg 1995;170:387-90
17. Lazarus GS, Cooper DM. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol
1994;130:489.
18. Waqar, S, Malik, Z., Razzaq, A., Abdullah ,M ., Shaima, A.,
AND Zahid, M. Frequency and risk factors for wound dehiscence/burst abdomen in midline laparotomies. Journal Ayub
Medical College Abottabad, 2005;17(4):70-73
19. Richard NM, Ramzi SC. Repair; cell regeneration, fibroses and
healing. In :Vinay K, Ramzi SC, Stanley LR. Basic Pathology.
6th ed. Philadelphia: WB Saunders; 1997.56.
20. Hanif N, Ijaz A, Niazi U.E, Akhtar , I, Zaidi AA, and Khan,
M.M. Acute wound failure in emergency and elective laparotomies. Journal of College of Physician and Surgeons Pakistan,
2000;11:23-26.
21. Vanlt Riet M, de vos van Steenwijk PJ, Bonjer HJ, Steyerberg
EW, Jeekel J. Mesh repair for postoperative wound dehiscence
in the presence of infection: is absorbable mesh safer than
non-absorbable mesh. Hernia 2007; 11:409-13

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