Burst abdomen (abdominal wound dehiscence)
Burst abdomen denotes postoperative disruption of abdominal wound healing with loss of continuity of the abdominal wall layers, most critically the fascia, occurring after prior approximation of wound edges and allowing progression to evisceration in complete fascial failure. [1,2] This condition is part of the broader spectrum of wound dehiscence, in which dehiscence represents partial or total separation of previously approximated wound edges due to failure of proper wound healing. [1]
Classification types
Burst abdomen is clinically characterized by increasing depth and severity of failure. [1,2]
- Superficial dehiscence: separation limited to superficial wound layers with wound-edge separation. [1]
- Fascial dehiscence: separation of the underlying fascial closure, which is a surgical emergency because progression to evisceration can occur. [1,2]
- Evisceration: herniation of intraabdominal organs through a completely dehisced wound. [1]
Clinical features
Dehiscence commonly occurs during the early postoperative healing window. [1,2]
- Dehiscence typically develops around postoperative days 5 to 8, during early healing stages. [1]
- Fascial dehiscence is frequently heralded by sudden drainage. [2]
- Fascial dehiscence can be suspected with a classic “salmon-colored” drainage (serosanguinous fluid) leaking through the incision. [2]
- A new abdominal wall bulge or increased wound drainage suggests fascial dehiscence. [2]
- Evisceration is a sign of complete wound dehiscence requiring emergent management. [1,2]
Investigations
Clinical assessment for depth of failure and complications determines the diagnostic pathway. [2]
- In stable patients without evidence of evisceration, CT abdomen/pelvis with contrast is recommended to evaluate the size of the fascial defect and detect associated pathology such as abscesses and herniation of abdominal contents. [2]
- Bedside findings suggesting fascial dehiscence include increased drainage and focal abdominal wall bulging. [2]
- Incision opening to probe the wound is not recommended because doing so may convert fascial dehiscence to evisceration requiring emergent operative intervention. [2]
Pathogenesis
Burst abdomen results from impaired wound-healing processes with failure of fascial closure under physiologic and local stressors. [1,2]
- Dehiscence is driven by factors that impair healing such as ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. [1]
- Fascial dehiscence can result from inadequate resolution of surgical site infection with inflammatory and bacterial effects on healing. [2]
- Hypoalbuminemia is associated with fascial dehiscence. [2]
- Chronic steroid use inhibits tissue repair and increases risk of wound-healing failure. [2]
- Technical closure failure contributes to fascial dehiscence, including loose knots, tissue strangulation, or inadequate incorporation in suture bites. [2]
- Increased intraabdominal pressure increases risk of fascial closure breakdown. [2]
Pathology
The operative field in fascial dehiscence may show tissue viability failure related to infection and impaired perfusion. [2]
- Surgical exploration can reveal frankly contaminated or necrotic tissue. [2]
- Necrosis and inflammatory tissue deterioration may coexist with fascial breakdown in the setting of infection or critical illness. [2]
Recommended surgical treatment
Management depends on the presence of evisceration, ischemia/strangulation, obstruction, and undrained infection. [2]
- Evisceration: the herniated bowel should be wrapped with gauze moistened with warm saline to prevent fluid losses, followed by preparation for emergent abdominal exploration with return of bowel to the abdominal cavity and closure. [2]
- Fascial dehiscence without evisceration in a stable patient: nonoperative management can be considered when the skin overlying the fascial defect remains closed to prevent evisceration. [2]
- Indications for operative intervention include evisceration, bowel strangulation/ischemia, bowel obstruction, or undrained infectious collection. [2]
- Operative management requires return of herniated bowel to the abdomen. [2]
- Operative management requires drainage and irrigation of superficial, deep, or organ-space infections. [2]
- Nonviable tissues require debridement, and bowel resection can be necessary when bowel segments are irreversibly ischemic. [2]
- Closure of the fascial defect can be performed with primary closure when the defect is minor and the fascia is healthy after debridement of nonviable tissue. [2]
- Mesh augmentation is considered to improve outcomes and reduce recurrence when appropriate. [2]
- Mesh should be avoided in infected cases or when bowel resection is required, with biologic mesh repair considered reasonable when mesh is needed in such circumstances. [2]
- Large defects that do not approximate can be managed with progressive closure strategies, including open abdomen management using vacuum therapy, sequential tightening of progressive closure devices such as a Wittmann patch, or creating a planned ventral hernia with cutaneous flaps closed over the defect. [2]
- When open abdomen is managed with negative-pressure wound therapy, negative pressure wound therapy for laparostomy is used for open abdominal wounds with exposed intraperitoneal organs. [3]