BURST ABDOMEN and it’s MANAGEMENT

1. BURST ABDOMEN and it’sMANAGEMENT Melina Desalphine 2002 MBBS

2. ACUTE WOUND HEALING Stage 1 -EARLY WOUND HEALING 1.ACHIEVEMENT OF HEMOSTASIS 2.ONSET OF INFLAMMATION rubor, dolor, calor, tumor

3. Stage2-INTERMEDIATEWOUND HEALING 1. MESENCHYMAL CELL MIGRATION AND PROLIFERATION 2. ANGIOGENESIS 3. EPITHELISATION

4. Stage 3-LATE WOUND HEALING 1. COLLAGEN DEPOSITION 2. WOUND CONTRACTION

5. Stage 4-FINAL WOUND HEALING/ SCAR REMODELLING 1.NEWER COLLAGEN REPLACES OLDER COLLAGEN 2. INCREASED COLLAGEN CROSS-LINKS

6. Timing of wound healing HEALING BY PRIMARY INTENTION Direct approximation of wound margins. 1.Clean with no infection 2.Less than 6 hours old e.g surgical wounds

7. HEALING BY SECONDARY INTENTION/ SPONTANEOUS HEALING Wounds which are left open & allowed to close by epithelisation and contraction. 1. contaminated /infected 2. more than 6 hours old

8. HEALING BY TERTIARY INTENTION OR DELAYED PRIMARY CLOSURE Management of heavily contaminated - not suitable for primary closure after 4-5 days- wound edge clean and well vascularized for approximation

9. Healing more rapid than secondary intention More safer than primary intention

10. BURST ABDOMEN Syn:Abdominal wound disruption and evisceration Post operative dehiscence of abdominal wound Post operative eventration

11. WHAT IS BURST ABDOMEN/ EVISCERATION? DEFINITION: Following any abdominal surgery an abdominal wound bursts open due to rupture of all layers of the abdominal wall with or without extrusion of viscera.

12. INCIDENCE: varies between 0-2 % figures much higher - high no. of undiagnosed cases.

13. PARTIAL DISRUPTION: 1 or more layers have separated incisional hernia 2. COMPLETE DISRUPTION / BURST ABDOMEN: All layers of the abdominal wall have separated

14. As a RULE ~ cause is MULTI-FACTORIAL. - Emergency laparotomy - Re- opened laparotomy wounds ETIOLOGY

15. AGE & SEX 1. ELDERLY PATIENTS: much common above 60yrs 2. SEX : male: female ~ 4:1

16. TYPE OF ANESTHESIA EQUAL FREQUENCY WITH LOCAL, SPINAL AND INHALATIONAL ANESTHESIA. BADLY ADMINISTERED INHALATIONAL ANESTHESIA: Post operative straining/struggling Hasty suturing under tension

17. FAULTY TECHNIQUES OF WOUND CLOSURE 1. TECHNICAL ERRORS • Hastily closed wound 2. Suture breaks, cuts out of tissues, knots undo 3. Insufficient no. of sutures 4. Too small bites of suture material

18. 2. CORRECT CHOICE OF SUTURE MATERIAL Short-lived absorbable sutures e.g. chromic catgut unacceptably high incidence of wound disruption

19. A.TENSILE STRENGTH OF SUTURE MATERIAL NON-ABSORBABLE SUTURES (N.A.S) frequently used now Retain their tensile strength

20. STEEL WIRE: excellent result but is difficult to use • 2. MONOFILAMENT NYLON,POLYPROPYLENE • 3. BRAIDED SILK

21. MONOFILAMENT NYLON • extremely unreactive • does not favour growth of micro organism • healing occurs even with gross infection & suppuration.

22. Satisfactory Alternative LONGER LASTING ABSORBABLE SUTURES POLYDIOXANONE(PDS), POLYGLYCONATE. retains strength during initial week of healing used for suturing abdominal aponeurosis which is slow to heal.

23. B.STRETCHING AND KNOTTING PROPERTIES OF SUTURE: BRAIDED SILK forms secure knots high incidence of wound infection. MONOFILAMENT NYLON needs careful handling loses strength when kinked with instrument

24. 3. CORRECT TECHNIQUE OF SUTURING The sutures cut through tissues 1. Placed too close to wound margin 2. Excessive weakening of tissues – jaundice, uremia, protein depletion & most importantly sepsis. 3.Associated abdominal distension, coughing and straining.

25. Sutures should be • Placed at least 1 cm from wound margin due to collagenolysis • Tight enough for secure approximation of wound edges • Sutures should be placed no more than 1 cm apart to prevent herniation of viscera b/w sutures.

26. JENKIN’S RULE • Length of suture material : length of wound is 4:1. • Interrupted suturing is more reliable. • Continuous suturing is often used but compromises the whole wound.

27. 4.TYPES of INCISIONS

28. 5.USE OF COLOSTOMY/ ILEOSTOMY STOMA DEFINITELY increases risk Stoma – should be fashioned through a separate small incision.

29. 6. ABDOMINAL DRAINAGE To a lesser extent drainage DIRECTLY through wound- higher incidence of burst abdomen must be done through a separate incision.

30. 7.TECHNIQUE OF LAPAROTOMY CLOSURE 1.INTERUPTED MASS CLOSURE DEEP TO SKIN: extremely encouraging results Mass closure with interrupted N.A.S All layers of abdomen incorporated except skin peritoneal layer- can be left open.

31. Wide bites- 1-1.5 cm from wound margin. • Closely placed sutures-interval of at least 1 cm • Skin sutured separately with interrupted N.A.S- monofilament nylon.

32. FAR AND NEAR TECHNIQUE Smead and Jone’s (U.S ,1941) • very low incidence of burst abdomen • far and near sutures put using interrupted mass closure technique.

33. 2. RUNNING CLOSURE: • Monofilament non-absorbable sutures • Increase in suturing speed • Decrease in no. of knots • Jenkin’s rule followed

34. Skin has a different tensile strength than other abdominal layers - necrosis and scar formation. • Deep tension sutures should also not be used.

35. 8.POOR HEALING OF TISSUES • Wound Infection/ hematoma & sepsis 2. Increased intra abdominal pressure 3. Operations on pancreas, obstructed cases.

36. 9. GENERAL CONDITION OF PATIENT 1. UREMIA 2. JAUNDICE 3. VIT.C DEFICIENCY. post-operative fall in serum vit.C due to blood transfusion.

37. Prevention Depends on 1.Anesthetist 2.Surgical procedure 3.Nature of disease 4.Patient’s diet

38. CLINICAL FEATURES OF WOUND DISRUPTION 1. PINK SEROSANGUINOUS DISCHARGE PATHOGNOMICof wound dehiscence. Large subcutaneous hematoma Soft and boggy swelling

39. Burst Abdomen with fecal fistula patient of typhoid perforation following laparotomy

40. 2. FOLLOWING EXCESSIVE STRAIN – SUDDEN PAINLESS“ GIVE” IN THEWOUND with or without pink discharge. wound completely torn apart bowel prolapsed shock - rare

41. EXPLORATION OF WOUND IN OPERATING ROOM 1. 1-2 stitches removed 2. Edges of wound gently separated. 3. Deeper layers inspected to determine satisfactory union.

42. PROGNOSIS GOOD • detected as early as possible • clean cases with partial dehiscence • complete dehiscence with no visceral prolapse

43. BAD • extensive suppuration • general peritonitis MORTALITY RATE : 9% to 44 % Average is 18 %.

44. TREATMENT 1. NON-OPERATIVE MANAGEMENT: packing and strapping • OPERATIVE MANAGEMENT: a. temporary packing and strapping & re-suturing b. immediate re-suturing

45. GENERAL PROCEDURE • Reassure patient • Start i.v line immediately • Cover wound skin intact- dry dressing gut prolapsed-saline soaked gauze pads

46. Apply adhesive strapping • Advise against coughing and straining

47. TECHNIQUE OF STRAPPING 1. i.m morphine/pethidine given. 2. Wound cleaned with warm normal saline. 3. Minor visceral protrusion- replaced carefully. Excessive prolapse -relaxant anesthetist & replaced.

48. 4. Wound edge sprayed with polybactrin. 5. Bulky dry gauze dressing applied. 6. Generous strips of elastoplast/ velcro abdominal belt applied transversely.

49. NON- OPERATIVE TREATMENT INDICATIONS: • Patient in critical state 2. Patient seen late - omentum and gut adherent 3. Presence of infection and gross suppuration. • Associated fistula of small or large bowel. • No gross prolapse of the viscera.

50. PROCEDURE 1. All sutures removed & wound opened completely. 2. Wound cleaned with normal saline 3. 3-5 layers of saline soaked pad applied 4. dry wool applied over pad & wound secured with adhesive plaster.