You are on page 1of 8

Clunie M.

Johnson

Development of Abdominal Wound Dehiscence After a Colectomy: A Nursing Challenge


Abdominal wound dehis cence is associated with pro longed hospitalization, high morbidity and mortality rates, an increase in health c a re costs, and risk of further surgery. A case of wound dehiscence in a patient fol lowing major abdominal sur gery is reviewed and a framework for understand ing wound complication as a challenge to nursing care is provided.

Clunie M. Johnson, MSN, MBA, RN, is Chief Nurse, U.S. Army Health Clinic, Hanau, Germany. Acknowledgment: The author thanks Dr. Amy Adler for her expertise and assistance with publishing this manuscript, and Mrs. Denise Sokolowski who helped tremendously with the literature review. Note: The opinions of the author contained herein are the private views of the author, and are not to be constru e d as official, or as reflecting true views of the Department of the Army or the D e p a rtment of Defense.

ound healing is fundamental to surgical practice. The process of wound healing occurs through a cascade of interrelated interc e l l ular and extracellular processes with the ultimate goal being tissue repair or functional integrity of the tissue. However, wound healing does not always proceed smoothly. Depending on the condition of the wound, the surgical wound healing process occurs in three phases: the inflammatory, proliferative, and maturation phases (Brunner & Suddarth, 2008). Different mechanisms of healing often are described in terms of intention, as primary, secondary, or tertiary. Primary intention, or primary union, begins when wounds are made aseptically with the opposing skin edges well approximated; healing occurs with minimal scar formation. Healing bysecondary intention, org r a n u l a t i o n, occurs when the skin edges are not well approximated as a result of loss of tissue or pus formation. During this stage, the cavity begins to fill with soft, red granulation tissue made of thin-walled capillaries and buds that later enlarge until they fill the area left by the destroyed tissue. Healing is complete when the epithelium completely covers the granulation tissue. Tertiary intention, also known as sec ondary suture or delayed healing, occurs when the two opposing granulation tissues brought together do not heal or are sutured later as a result of infection. During this phase, infection produces chemical enzymes that are damaging to the tissue and surrounding sutures (Brunner & Suddart h , 2008). Consequently, tissue damage can lead to wound dehiscence. Wound dehiscence is the partial or complete disruption of the layers of the surgical wound (Doherty & Way, 2006). The reported incidence of dehiscence ranges from 0.5% (Pavlidis et al., 2001) to 6% (Hanif, Ijaz, Niazi, Zaidi, & Khan, 2000); international studies re p o rt an average incidence of 1%-2% (Van Geldere, 2000). In several studies, the morbidity rate associated with abdominal wound evisceration is high; the mortality rate ranges between 10% and 40% (Pavlidis et al., 2001), and can be as high as 44% for adults (Ghimenton, Thomson, Muckart, & Burrows, 2000). Additionally, patients with wound disruption spend an average of 53 days in the hospital (Va n t Riet, De Vos Van Steenwijk, Bonjer, Steyerberg, & Jeekel, 2007), increasing length of stay by 9.4 days and resulting in $40,323 in excess health care charges (Zhan & We i n g a rt, 2003). This also exposes patients to the risks of a second surgery and additional loss of work time. While any wound can develop dehiscence, abdominal wound complications occur an average of 7 days after surgery (Cigdem, Onen, Otcu, & Duran, 2006) and in particular are difficult to treat.
MEDSURG NursingMarch/April 2009Vol. 18/No. 2

96

Dehiscence Risk Factors


Wound failure encompasses two basic elements: a decrease in the wound tensile strength and an increase in collagenolysis. Abdominal wound dehiscence is thought to result from cumulative predisposing demographic, systemic, and mechanical factors. Personal characteristics such as age over 65 and male gender are associated with wound disruption (Waqar et al., 2005). The older adult patient tends to be at greater risk for wound dehiscence because tissue becomes less resilient and regenerates more slowly with age. Hanif et al. (2000) and Waqar et al. (2005) identified advanced age in 50% of cases in wound dehiscence. Historically, however, research has shown that even middle-aged and younger patients are at risk, with age of dehiscence ranging from 43 (Tweetie & Long, 1954) to 56 (Riou, Cohen, & Johnson, 1992). Men are more likely to experience wound dehiscence than women, with the ratio of male predominance at 2:1 (Hanif et al., 2000; Waqar, 2005). These risk factors may serve to identify individuals in need of close monitoring for wound dehiscence. Systemic factors may decrease the tensile strength of a healing wound (Hahler, 2006) and increase the patients risk for wound dehiscence. Concomitant factors include smoking (Waqar et al., 2005), steroid use (Hahler, 2006; Riou et al, 1992; Sorensen et al., 2005), obesity, malnutrition, anemia , hypoproteinemia, hypoalbuminemia, uremia, wound infection, type of incision, and technique of wound closure (Eke & Jebbin, 2006). The clinical significance of these factors in predicting the development of dehiscence is undetermined, but there is general agreement on two points: good nutritional status is essential for wound healing, and infections at the surgical site may contribute to postoperative wound disruption (Brunner & Suddart h , 2008; Carlson, 1999; Pavlidis et al., 2001). Mechanical factors are perhaps the most significant in pre d i sposing the wound to disruption. Such risk factors include increased intra-abdominal pre s s u re which may be the result of abdominal dis-

tention, heavy coughing, retching, or vomiting, or may be the result of pulmonary complications, such as obstructive airway disease, bro nchitis, or atelectasis (Doughty, 2005; Eke & Jebbin, 2006; Hahler, 2006). In order for these factors to serve as useful risk indicators, they must be observed and documented because they are difficult to identify and diagnose. Some authors have suggested other mechanical factors as easier to identify but occur relatively infrequently. These factors include primary diseases or co-morbid complications, such as heart disease, hypert e nsion, diabetes mellitus, post-operative ileus, ascites, jaundice, drains, ostomies, abdominal malignancies (Waqar et al., 2005), previous radiation therapy (Dumanian & Denham, 2003), and use of anticoagulants (Brunner & Suddarth, 2008; Hahler, 2006). Lately, HIV infections and AIDS also have been regarded as strong predictors for wound dehiscence. Despite the demonstrated i m p o rt ance of demographic, systemic, and mechanical risk factors, there are conflicting data concerning the clinical significance of these risk factors for any one individual. The lack of substantiating each factors significance as a separate entity is controversial; rather, wound dehiscence re m a i ned a multi-factorial challenge (Waqar et al., 2005). Furthermore, few res ea rchers have examined the collective effect of demographic, systemic, and mechanical risk factors in wound ru p t u re incidence. In one of the early studies to examine cumulative effect, Pavlidis and colleagues (2001) re p o rted 40% risk of wound dehiscence when five separate individual risk factors were pre s e n t , reaching 100% risk for dying with eight or more factors (Waqar et al., 2005). In some cases, risk factors may emerge following surgery, or may take some time to develop during the re c o v e ry period. In other situations, clinical variables may be measured concurre n t l y only with the development of an infection at the wound site. Thus, the presence of these risk factors may emerge only over time. The patient in the case study had sev-

eral concurrent postoperative risk factors, such as wound infection, anemia, hypoproteinemia, hypoalbuminemia, a persistent dry hacking cough along with hiccups, and an ileus. While some factors are critical for identifying at-risk patients prior to surgery, the identification of risk factors postoperatively may alert medical staff to significant dehiscence. The pre sent study demonstrates the need for nurses to consider several factors simultaneously when assessing a patients risk for dehiscence. Nursing staff that focus only on pre-operative and immediate postoperative risk factors may misjudge the risk of dehiscence. Some patients may present with no significant risk factors preoperatively or peri-operatively. However, they still can dehisce postoperatively to a life-thre a t e ning extent. The case study re p o rted in this article describes a patient with no significant systemic or mechanical risk factors prior to surgery, during the perioperative phase, or in the immediate postoperative phase. In the patients case, dehiscence was evident 6 days after surgery and other risk factors emerged only later. This delay in risk factor development is a challenge to nursing care. This case also demonstrates the importance of recognizing cumulative risk factors and understanding their impacts in the re c o v e ry phase.

Case Study
The patient, age 48, noticed he had been passing blood in his urine for about 2 weeks. A CT scan d e t e rm ined the patient had divert iculitis. A colonoscopy was scheduled, but the severity of the diverticulitis obstructed the migration of the scope. As a result, the patient opted to have a colectomy, in which a part of the colon would be removed and the remaining ends rejoined by primary anastomosis. A prophylactic antibiotic was ordered on call to OR and given almost 2 hours before surgery. Postoperatively, the patient was taught to clean the wound site himself with normal saline prior to d i s c h a rge. His recovery was uneventful, and 5 days after sur-

MEDSURG NursingMarch/April 2009Vol. 18/No. 2

97

gery a follow-up appointment was scheduled. At that time, the only risk factors for wound dehiscence known to the operating team were his smoking (a pack of cigarettes each day) and his male gender. Two days after discharg e (postoperative day 7), the patient arrived in the emergency room. He stated the wound had begun to leak a pus-colored fluid and emit a foul odor. Physical examination showed that most of the staples located in the upper part of the wound had opened; the patient indicated he had observed this on postoperative day 6. Wound infection was diagnosed and the patient was re-admitted with a suspicion of wound dehiscence. The physician perf o rmed the initial wound cleaning; the next 4 days of nursing wound care consisted of frequent irrigation of the area with norm a l saline and a wet-to-dry packing of sterile gauze. Heparin was ordered to prevent deep vein thrombosis. The patient remained on bed rest but his condition deteriorated. On postoperative day 12, the patient returned to the operating room for debridement of necrotic fascia in the wound and around the edges. The wound was closed with staples and retention sutures were placed in a circle around the wound. Wet-to-dry dressing changes were ordered with normal saline three times per day. On postoperative day 15, the patient and the nursing staff noted a large amount of opaque pink drainage with a foul odor on the dressing. The patient complained of pain at the site. He also had a dry hacking cough and hiccups which had persisted for several days. He stated he felt a tearing sensation and something giving way when standing. Examination revealed continued wound dehiscence evidenced by loosened staples and enlarged openings between the staples and the wound fascia. Poor healing and a recurrence of necrotic tissues at the wound site also were noted. On postoperative days 17-21, the patient exhibited anemia (hemoglobin 6.5 g/dL/hematocrit 18.7%), hypoalbuminemia (albumin <3.5 g/dL), and a systemic infection (sepsis) due to persistent

Figure 1. Wound Dehiscence 4 Days after Presentation

The upper wound from below zyphoid to above umbilicus was approximately 8 inches long, 4 inches wide, and 1.5 inches deep. The wound was covered with a yellowish film in the center and was surrounded by beefy red tissue, with some serous-purulent drainage. The lower abdominal wound extending from below the umbilicus to above the symphysis pubis was 3 inches long, 3 inches wide, and 1.5 inches deep. The lower wound had a similar appearance as the upper wound. Only a few staples and the umbilicus separated the two wounds.

leukocytosis (white blood cells 24,400/ml), elevated temperature (range 101.8-103.0F), tachycardia ( h e a rt rate >112), and persistent low blood pressure (systolic <100 mmHg). Additionally, it was noted that the patient had a nutritional deficit with poor appetite (<15% intake/meal) since his admission, weight loss, an uncontrollable hacking cough, and an ileus (gastric tube placed for intestinal decompression). To meet his needs better, the patient was transferred to the intensive care unit of a tertiary facility. After admission to the tert i a ry facility, the patient was found to have an upper wound above the umbilicus and an inferior wound below the umbilicus with six retaining sutures (three on each side of the wound; see Figure 1). The upper wound was surrounded by beefy red tissue, with yellow and gray tissue inside; it had sero u s - p u ru lent drainage with a

foul odor. The lower wound had a similar appearance. Because the patients wound dehiscence was thought to be caused by multi-factorial microorganisms, he was prescribed metronidazole (Flagyl) for gram-negative cocci coverage and levofloxacin (Levaquin) for enterococcus. Daily laboratory studies consisted of 20-item chemistries and complete blood count. The patient received three units of packed red blood cells, which increased his hemoglobin to 11 g/dL and hematocrit to 33.4%. Pan-culture was done for elevated temperature. Antibiotic therapy was changed based on culture sensitivity. As a result of a nutritionist consultation, the patient began to receive total parenteral nutrition (TPN) and lipids with sliding scale insulin administration. TPN was indicated to meet the patients daily energy e x p e n d i t u re , correct hypoalbuminemia, and prevent weight loss. A l b u t e rol nebulizer tre a t m e n t s were prescribed to treat bilateral ronchi heard on auscultation. Incentive spiro m e t ry was used every hour while the patient was awake. Cough suppressant was given as ordered. In addition to treatments for factors associated with dehiscence, direct treatment of the wound also was provided. The surgeon perf o rmed daily bedside debridement of necrotic fibrinous tissues from the wound fascia and the edges. Wet-to-dry dre s s i n g changes were done with 0.25% Dakins solution, a powerful disinfectant, deodorant, and bleaching agent that is effective against vegetative bacteria, viruses, and, to some degree, spores and fungi (Gerbino, 2005). Dakins solution also exerts a germicidal action and dissolves necrotic tissue (Gerbino, 2005). The patients wound began to show good granulation. His bowel sounds returned and the gastric tube was discontinued. On postoperative day 22, the patient was taken out of bed as prescribed by the physician. After the patient was returned to bed, he developed supraventricular tachycardia (heart rate 195-200 BPM) confirmed on EKG, as well as a blood pressure of 96/58 mmHg. He was

98

MEDSURG NursingMarch/April 2009Vol. 18/No. 2

Figure 2. Postoperative Days 29-38: The Retention Sutures Were Removed; Depth of Wound Is Visible

Figure 3. Postoperative Days 29-38: Wound with Dressing Soaks of Dakin Solution

Figure 4. Postoperative Day 35: The Wound Appeared Pink, with Good Granulation Tissue

Figure 5. Two Months after Discharge: The Wound Continues to Heal

pale and diaphoretic. Adenosine (Adenocard) 6 mg and metoprolol (Lopressor) 5 mg were given intravenously with good result. His heart rate returned to baseline (108-116 BPM) with occasional pre-ventricular contractions noted. Arterial blood gas results included pH 7.445, PCO2 39.6 mmHg, PaO2 106.6 mmHg, HCO3 24.7, base excess 1.4, and SaO2 98.1 (patient receiving oxygen 2 L/minute). Cardiac enzymes were

within normal limits. Intravenous fluids were concentrated maximally to prevent fluid overload. Metoprolol 12.5 mg was ordered twice a day. On postoperative days 23 to 25, ibuprofen (Motrin) 400 mg was ordered to be alternated with acetaminophen (Tylenol) for fevers. TPN and lipids were discontinued. Fasting blood glucose was checked e v e ry 2 hours to prevent rebound hypoglycemia. The patients cen-

tral intravenous line was discontinued and the catheter tip sent to the laboratory for culture. The patient received cough suppressants as needed, and promethazine (Phenergan) was given for nausea. He was assisted to a chair for 10-15 minutes four times daily, and began a regular diet with nutritional supplements three times daily. An antacid was given for stomach upset. On postoperative day 26, the patient was stable hemodynamically and was transferred to the medical/surgical ward. Wound debridement continued at the bedside. In the patients upper lesion, a small amount of yellowish and necrotic coating remained, while his lower lesion was pinker. The patients retention suture holes had a scant amount of purulent drainage. On postoperative days 29 to 38, all six retention sutures were removed (see Figure 2) and the puncture sites were packed with dressing soaks of Dakin solution (see Figure 3). His wound continued to have a small amount of purulent drainage. However, his white blood count steadily decreased to 10,400/ml by day 34 and then normalized. On postoperative day 35, the patient continued to wear an abdominal binder when ambulating. He ate all meals and gained weight. His wound appeared smaller (see Figure 4), with a small amount of serous drainage. Arrangements were made for the patient to have all his dressing changes done at his local clinic. On postoperative day 40, the patient was discharged home with follow up scheduled 2 months later. Upon follow up, the patient had regained his pre-admission weight; he appeared relatively robust and re p o rted feeling healthy. His surgeon performed a dressing change. His wounds were smaller, with good granulation tissue (see Figure 5). Only a scant amount of serous drainage was noted around the wound. At the time, the physician identified a huge left abdominal hernia. The patient had a flap applied to the upper wound 25 days later, with skin for the flap taken from his upper anterior right thigh. His lower abdominal wound was well appro x i-

MEDSURG NursingMarch/April 2009Vol. 18/No. 2

99

Table 1. General Risks Factors of Wound Dehiscence


Factors Gender Obesity Anemia Hypovolemia/ hemorrhage Steroid use Wound/systemic infection Abdominal complications (vomiting, heavy straining, abdominal distention, ileus) Pulmonary complications (cough, atelectasis, bronchitis) Hypoproteinemia/ hypoalbuminemia Nutritional deficits Amino acids are needed for collagen synthesis, fibroblast proliferation, and scar remodeling. Diet containing enough fats and carbohydrates supplies the extra energy needed to prevent protein breakdown. A lack of certain vitamins and minerals can prolong healing. Increased bile in the system causes portal and systemic endotoxemia that can create a pro-inflammatory state which delays healing. Decreased/altered amounts of insulin in the blood delays wound healing Rationale Males are more prone to dehisce than females. Excess weight is associated with technical difficulties in closing the wound and an increase in the infection rate. Reduced hemoglobin leads to a decreased release of oxygen at the tissue level. Reduced blood volume leads to vasoconstriction and inadequate tissue oxygenation, affecting healing. Steroid use causes immunosuppression and may mask the presence of infection by impairing normal inflammatory response. Bacterial colonization leads to an increased release of proteolytic enzymes, free radicals, and inflammatory mediators, which then cause further tissue breakdown. These can cause increased intra-abdominal pressure, producing more tension on wounds.

Jaundice Diabetes

Sources: B runner & Suddarth, 2008; Hahler, 2006; Riou et al., 1992.

mated with staples. Iodoform gauze was used in between staples for serous drainage. The lower wound was healed completely in 3 weeks. His hernia was repaired several months later.

Discussion
Although some factors such as age and gender are unchangeable, some patient-related risk factors should be predicted early to decrease their number and, obviously, the incidence of wound failure. In the case study described in this article, several risk factors highlighted by previous authors were identified (see Table 1 for a general overview of risk factors of wound dehiscence and their rationale). Yet, this case illustrates the importance of recognizing that some risk factors emerged only during the postoperative phase after the wound dehisced and that re c o v e ry may be complicated further by additional related

factors such as an ileus (see Table 2 for identified risk factors in the case study) or hernia. Consistent with an algorithm offered by Pavlidis and colleagues (2001), the presence of more than five factors placed the patient at substantial risk for wound dehiscence. Furthermore, studies indicate that wound dehiscence occurs more often after emergent than elective surgeries (Pavlidis et al., 2001; Webster et al., 2003). Other re c u rrence of abdominal wound dehiscence can result in incisional hernia (Sukumar, Shaharin, Razman, & Jasmi, 2004; Va n t Riet et al., 2004). Although, no single etiologic factor can be shown to increase the patients risk for dehiscence, many authors re p o rt a higher incidence associated with upper compared to lower midline incisions (Eke & Jebbin, 2006). Some authors have implicated abdominal complications related to increased intraabdominal pressure as the cause for

dehiscence, while others have associated primary disease, such as diabetes, malignancy, or other co-morbid conditions with the incidence of dehiscence (Eke & Jebbin, 2006; Hahler, 2006; Waqar et al, 2005). As the risk factors for dehiscence increase, nurses must be able to identify susceptible patients. While the suture materials and procedures used in the patients initial surg e ry may not be typical of modern suturing standards, the risk of dehiscence remains a major catastrophe in medical care and postoperative re c o v e ry . Providing adequate rest and nutritional support, maintaining wound cleanliness, and positioning the patient influenced the outcome of rapid healing. A malnourished patient has a greater tendency to experience a delay in wound healing; when combined with a co-morbid state, the immediate postoperative morbidity and mortality rate increases twofold. Other specific nursing interventions include assessment and care of the wound to prevent infection (Brunner & Suddarth, 2008). Surgical site infection remains one of the most common nosocomial infections in the postoperative patient, as well as one of the most significant factors in wound dehiscence. The patients case demonstrates the importance of administering timely prophylactic antimicrobials and ensuring the patient and family fully understand how to care for wounds at home while observing for indicators necessitating further education. Additionally, antimicrobial prophylaxis should be e ffective against organisms characteristic of the operative site and should be in adequate concentration throughout the peri-operative period when bacterial invasion is likely to establish an infection (Wolf et al., 2008). Improper timing of antimicrobial administration is one of the most common problems in many surgical settings. For example, some authors found that parenteral antimicrobials given more than 2 hours pre-operatively were ineffective in preventing infection (Classen et al., 1992). Likewise, antimicrobial prophylaxis administered after 3 hours of surgical incision was ineffective against bacterial colonization (Wolf et al., 2008). Current

100

MEDSURG NursingMarch/April 2009Vol. 18/No. 2

Table 2. Selected Fa c t o rs Influencing Dehiscence Severity in Cited Case


Association with Increased Risk of Dehiscence Increased with advanced age Occurs more often in males Yes Yes 48 Male Altered hemoglobin and hematocri t Consistent low blood pressure as defined by systolic blood pressure <100 mmHg Dry, uncontrollable hacking cough; t e a ring sensation when standing Elevated white blood cell count, temperat u r e, and heart rate Post-operative day 12 Throughout post-operative period Case Study Application

Factors Age Gender Anemia Hypovolemia

Timing of Onset Dehiscence can occur in middle age.

Cough, vomiting, heavy stra i ning, abdominal distention Wound/systemic infection Steroids use Hypoproteinemia/ hy p oalbuminemia Nutritional deficits/weight loss Ileus

Increased intraabdominal pressure

First noted on postoperative day 15 and continued throughout his recovery phase Post-operative days 7-35

Yes (leading predisposing factor) Yes Decrease

A l bumin and total protein decreased Poor appetite (<15%/meal) Weight loss >20 lbs in 3 we e k s Abdominal distention, bowel sounds absent

Post-operative day 15

Yes

Post-operative days 15-37

Yes

Post-operative days 17-21

Sources: B runner & Suddarth, 2008; Hahler, 2006; Riou et al., 1992.

guidelines indicate that the first dose is to be infused within 60 minutes prior to surgical incision, and the prophylactic antimicrobial agent discontinued within 24 hours of the end of surg e ry (Bratzler & Houck, 2005). Nurses thus must optimize the timing of antimicrobial prophylactic administration to minimize the risk of post-operative surgical wound infection. Furthermore, institutional policies and pro c edures should minimize the use of on call to the operating room orders. Instead, orders should be written with a specific interval time most appropriate for the agent being used and timing also should coincide with the initiation of the operative procedure. In other instances, the hallmark presentation of wound dehiscence was that of serosanguinous drainage from the wound site. Signs of wound infection usually appear at least by postoperative day 5

(Brunner & Suddarth, 2008); the patient in the case study noted this drainage on postoperative day 7. Because most patients are discharged from the hospital by that time, the importance of patient education re ga rding wound care is underscored. Perhaps the patients failure to perform adequate self-care led to infection. Requiring the patient and family members to verbalize repeatedly their understanding of the need for wound care and perform several return demonstrations prior to discharge may help reduce the risk of infection. Current nursing standards advocate patient teaching and return demonstration as part of the re co ve ry process. Thus, this case confirms previous re p o rts that infection and wound disruption were associated with a higher risk of re-operation, prolonged hospitalization, and increased resource utilization. The nursing challenge is not

only to prevent the development of wound infection and educate the patient in appropriate wound cleaning procedures, but also to monitor the potential risk factors associated with wound dehiscence even days after surg e ry . Traditional risk factors, such as poor nutrition, weight loss, anemia, hypovolemia, infection at the wound site, coughing, hypo-albumenemia, and ileus, combine to create an environment in which wound dehiscence can be severe and life threatening. Continued, careful monitoring of blood chemistries in the postoperative period is imperative to identify potential hazards to the patient. In addition, some signs and symptoms may be less easily identified. Only c a reful nursing observation and documentation can mitigate these risks. For example, the patient in the case study complained of a dry hacking cough and hiccups throughout the day, and indicated he felt a tearing sensation and something give away when standing. These remarks should be documented and must be re p o rted as a possible first indication of wound dehiscence or evisceration. Similarly, abdominal pain, inflammation, serosanguinous drainage, or fever may be a prelude to wound disruption. As a patient advocate, the nurse must know normal pathophysiology of the wound healing p rocess, factors contributing to wound dehiscence, and immediate nursing interventions required when wound disruption is suspected to help reverse this process and stabilize a deteriorating patient (Brunner & Suddarth, 2008). Some risk factors of wound dehiscence are avoidable and should be predicted early to decrease their number immediately before or after surg e ry . When these factors are identified after dehiscence is diagnosed, their individual clinical significance becomes less clear. In this patients case, the nurse only could use the risk factors as indicators that the dehiscence was likely to get worse, not that it would emerge in the first place. Risk factors thus become important not only in predicting the development of dehiscence, but also in estimating dehiscence severity. The patient identified as at high risk may benefit

MEDSURG NursingMarch/April 2009Vol. 18/No. 2

101

he case study demonstrates the enormous significance of early recognition of cumulative patient risk factors.
from close observation and early aggressive intervention. tors. Future research should define the role of each risk factor during the entire peri-operative experience. It should include collection of data from the patients perspective in order to identify additional risk factors and potential wound management problems leading to dehiscence. Additionally, development of a reliable and precise instrument to measure wound area is crucial; staff education on instrument use is imperative. In the meantime, wound dehiscence continues to offer a tremendous challenge to the nursing field. Only through vigilance and early, aggressive treatment can the nurse help the patient and family overcome this challenging complication and prevent a potentially fatal outcome.
References
Bratzler, D.W., & Houck, P.M. (2005). Antimicrobial prophylaxis for surgery : An advisory statement from the National Surgical Infection Prevention Project. The American Journal of Surgery, 189(4), 395-404. Brunner, L.S., & Suddarth, D.S. (2008). Postoperative nursing wound management (pp. 449-451). In Textbook of med ical-surgical nursing (6th ed.). Philadelphia: J.B. Lippincott Company. 20, 449-451. Carlson, G.L. (1999). The influence of nutrition and sepsis upon wound healing. Journal of Wound Care, 8(9), 471-474. Cigdem, M.K., Onen, A., Otcu, S., & Duran, H. (2006). Postoperative abdominal evisceration in children: Possible risk factors. Pediatric Surgery International, 33, 677680. Classen, D.C., Evens, R.S., Pestotnik, S.L., Horn, S.D., Menlove, R.L., & Burke, J.P . (1992). The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. The New England J o u rnal of Medicine, 326, 281-286. Doherty, G.M. & Way, L.W. (2006). Postoperative complications (pp. 21-34). In Current surgical diagnosis & treatment (12th ed.). New Yo rk : Lange medical Books/McGraw Hill. Doughty, D. (2005). Preventing and managing wound dehiscence. Advances in Skin and Wound Care, 18(6), 319-322. Dumanian, G.A., & Denham, W. (2003). C o m p a rison of repair techniques for major incisional hernias. The American J o u rnal of Surgery, 185, 61-65. Eke, N., & Jebbin, N. (2006). Abdominal wound dehiscence: A review. International S ur g e ry , 91, 276-287.

Limitations and Recommendations


The chart review was conducted retrospectively, a month after the patient was discharged and subsequently readmitted, resulting in a potentially biased selection of variables previously associated with dehiscence risk factors. However, some of the chart entries were made at the time of observation and the risk factors selected for re p o rting were previously identified in the literature. Second, management of a dehisced wound requires some type of dressing to maintain its physiological integrity and promote healing. The case study is based on older surgical protocols for dehisced wound management. For example, retention sutures and wetto-dry gauze packing were used compared to a modern style of closure and treatment. Additionally, the wide-ranging therapeutic benefits of certain types of contemporary wound treatment modalities, such as vacuum-assisted-closure, alginate, and hydrogel products, may alter the degree to which various postoperative risk factors may contribute to dehiscence. Third, consistent use of one technique for wound measurement as well as the precise time of the surgical incision after the administration of prophylactic antimicrobial could not be validated. Finally, management of a deep cavity wound as in this case is demanding and taxing to nursing staff as well as costly to the organization because rapid healing rarely occurs and diff e rent treatment modalities or additional surgery may be required.

Conclusion
Wound dehiscence remains a potentially serious postoperative complication for the patient following major abdominal surg e ry . The case study demonstrates the enormous significance of early recognition of cumulative patient risk fac-

Gerbino, P.P . (2005). Remington: The science and practice of pharmacy (21st ed.). Philadelphia: Lippincott Williams & Wilkins. Ghimenton, F., Thomson, S.R., Muckart, D.J., & Burrows, R. (2000). Abdominal content containment: practicalities and outcome. B ritish Journal of Surgery, 87, 106-109. Hahler, B. (2006). Surgical wound dehiscence. MEDSURG Nursing, 15(5), 296-300. Hanif, N., Ijaz, A., Niazi, U.F., Zaidi, A.A., & Khan, M.M. (2000). Acute wound failure in emergency and elective laparotomies. J o u rnal of College of Physicians and Surgeons Pakistan, 11, 23-26. Pavlidis, T.E., Galatianos, I.N., Papaziogas, B.T., Lazaridis, C.N., Atmatzidis, K.S., M a k ria, J.D., et al. (2001). Complete dehiscence of the abdominal wound and i n c riminating factors. European Journal of Surgery, 157, 351-355. Riou, J.P .A., Cohen, J.R., & Johnson, Jr., H. (1992). Factors influencing wound dehiscence. A m e rican Journal of Surgery, 163(3), 324-330. Sorensen, L., Hemmingsen, U., Kallehave, F., Wllie-Jorgensen, P., Kjoergaard, J., Moller, L., et al. (2005). Risk factors for tissue and wound complications in gastrointestinal surgery. Annals of Surgery, 241(4), 654-658. Sukumar, N., Shaharin, S., Razman, J., & Jasmi, A.Y. (2004). Bogota bag in the treatment of abdominal wound dehisc e n c e. Medical Journal of Malaysia, 5 9(2), 281-283. Tweetie, F.J., & Long, R.C. (1954). Abdominal wound dehiscence. Surgical & Gynecological Obstetric, 99, 41. Vant Riet, M., De Vos Van Steenwijk, P.J., Bonjer, H.J., Steyerberg, E.W., & Jeekel, J. (2004). Incisional hernia and repair of wound dehiscence: Incidence and risk factors. The American Surgeon, 70, 281286. Vant Riet, M., De Vos Van Steenwijk, P.J., Bonjer, H.J., Steyerberg, E.W., & Jeekel, J. (2007). Mesh repair for postoperative wound dehiscence in the presence of infection: Is absorbable mesh safer than non-absorbable mesh? Hernia, 11(5), 409-413. Van Geldere, D. (2000). One hundred years of abdominal wound dehiscence and nothing has changed. Hernia, 4(4), 302-304. Waqar, S., Malik, Z., Razzaq, A., Abdullah, M., Shaima, A., & Zahid, M., (2005). Frequency and risk factors for wound dehiscence/burst abdomen in midline laparotomies. Journal Ayub Medical College Abottabad, 17(4), 70-73. Webster, C., Neumayer, L., Smout, R., Horn , S., Daley, J. Henderson, W., et al. (2003). Prognostic models of abdominal wound dehiscence after laparotomy. J o u rnal of Surgical Research, 109, 130-137. Wolf, J.S. Jr., Bennett, C.J., Dmochowski, R.R., Hollenbeck, B.K., Pearle, M., & Schaeffer, A. (2008). Best practice policy statement on urologic surgery antimicrobial prophylaxis. The Journal of Urology, 179(4), 1379-1390. Zhan, C., & We i n g a rt, S.N. (2003). Some medical injuries in hospitals pose significant threat to patients, substantial costs to society. The Journal of the American Medical Association, 10(290), 18681874.
MEDSURG NursingMarch/April 2009Vol. 18/No. 2

102

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

You might also like