A Prospective Study of Factors Influencing Wound Dehiscence after Midline Laparotomy

doi:10.4236/ss.2013.48070

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Surgical Science, 2013, 4, 354-358

http://dx.doi.org/10.4236/ss.2013.48070 Published Online August 2013 (http://www.scirp.org/journal/ss)

A Prospective Study of Factors Influencing Wound

Dehiscence after Midline Laparotomy

Kusum Meena1, Shadan Ali1, Awneet Singh Chawla2, Lalit Aggarwal1, Suhani Suhani1,

Sanjay Kumar1, Rehan Nabi Khan3

1Department of Surgery, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, India

2Department of Surgery, Safdarjung Hospital, New Delhi, India

3Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Email: [email protected]

Received May 22, 2013; revised June 23, 2013; accepted July 1, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Aim: To evaluate the factors influencing fascial wound dehiscence after midline laparotomy in the patients of perfora-

tion peritonitis with an emphasis on measurement of “intra-abdominal” pressure (IAP) and fascial transforming grow th

factor-beta (TGF-beta). Methods: Hundred eligible adult patients with the diagnosis of perforation peritonitis who u n-

derwent emergency exploratory laparotomy were prospectively recruited. Forty five patients who developed midline

abdominal wound dehiscence were compared with 55 patients without dehiscence. Results: The variables that were

significantly associated with wound dehiscence include anemia, hypo proteinemia, duration of surgery, prolonged

postoperative ileus, wound infection and postoperative pulmonary infection. Age, gender, jaundice, cause of peritonitis,

wound contamination and types of surgery were non significant variables. The mean IAP value in the patients with de-

hiscence was significantly higher than “non-dehiscence” group (p = 0.000). The patients with wound dehiscence

strongly expressed TGF-beta on the day of burst. Conclusion: The patients of peritonitis undergoing prolonged surgery

in the presence of risk factors like anemia, hypo proteinemia, postoperative ileus, wound infection and postoperative

pulmonary infection have high risk of abdominal wound dehiscence.

Keywords: Laparotomy; Perforation Peritonitis; Intra-Abdominal Pressure; Abdominal Wound Dehiscence;

Transforming Growth Fa ctor

1. Introduction

Of all the fall outs of abdominal surgery, dehiscence of

abdominal wound is easily the most notorious [1]. Pro-

foundly distressing both to the patient and the treating

surgeon, it is a common enough complication, with the

morbid consequences and at times, potentially dreadful

outcome [2]. Till recent, however, it has been a subject

little understood with little known about its exact etiopa-

thogenesis, there was little a surgeon could do to take

preventive steps [3].

The present study has endeavored to investigate the

events and contributory factors present in the pre-opera-

tive, per-operative and immediate post-operative period

that facilitate the mechanical forces of disruption and

impede the biological process of healing. While the dis-

ruptive mechanical forces can objectively be measured

by estimating the “intra-abdominal” pressure (IAP), the

impediment to the biological process of healing can be

estimated by the measure of transforming growth factor-

beta (TGF-beta) expression in the healing fascial wound

[4]. The purpose of this study was to evaluate the factors

influencing fascial wound dehiscence after midline lapa-

rotomy in the patients of perforation peritonitis with an

emphasis on measurement of IAP and fascial TGF-beta.

2. Methods

Hundred eligible adult patients with the diagnosis of

perforation peritonitis who underwent emergency ex-

ploratory laparotomy at university college hospital New

Delhi India were prospectively recruited (Table 1). Stan -

dard midline incision and continuous mass closure tech-

nique was used in each case. Based on outcome 45 pa-

tients with midline abdominal wound dehiscence (study

group) were compared with 55 patients without wound

dehiscence (control group). This study protocol was ap-

proved by the Institutional Ethical Committees of the

K. MEENA ET AL. 355

Table 1. Clinical characteristics of dehiscence and “non-

dehiscence ” group.

Characteristics Dehiscence

group

(n = 45)

“Non–dehiscence”

group (n = 55)

Age (year) mean (range) 33 (17 - 70) 29 (13 - 71)

Sex

Men 36 47

Women 9 8

Primary di ag nos is

Enteric perforation 32 24

Duodenal perforati on 8 14

Blunt abdominal trauma 2 7

Tubercular stricture perforation 1 2

Acute intestinal obstruction

with gangrenous bowel 0

Ectopic rupture 0 1

Appendicular perforation 2

hospital. All subject signed informed consent.

Main exclusion criteria’s were: age less than 12 years,

patients on steroids/immunosuppressant or anticancer

therapy and patients on anticoagulant therapy

The patient’s nutritiona l status on admission was care-

fully determined. The patient’s were considered mal-

nourished if they had a serum protein level less than 60

g/l. Anemia was defined as hemoglobin level of less than

11 g/l. The presence of peritonitis was confirmed by

presence of clinical symptoms and signs and by the pu-

rulent exudates of abdomen.

The overall hospital stay, the underlying diseases, op-

eration time, the operative procedures performed, the

factors influencing intra abdominal pressure post opera-

tively and post operative mortality were also recorded.

2.1. Measurement of IAP

IAP was measured in all 100 patients from day 0 to day 8.

Readings were taken ever y eight hours.

IAP was first assessed clinically and was graded as

normal, moderate or markedly tense abdomen. Thereafter,

the IAP was measured indirectly by employing the saline

fluid column manometry technique through an indwell-

ing Foley’s catheter. First described by Sedark et al. in

2002, this procedure is easy, quick and inexpensive [5].

Sixty milliliter of saline was instilled into the urinary

bladder via the indwelling catheter. Zero-reference point

was taken at pubic symphysis, keeping Y of Foley’s at

the symphysis. Then Foley’s was connected with gradu-

ated transparent tubing. The distance at which the sterile

saline settles in the tubing was taken to b e the IAP in cm

of H2O.

The following grading was used to categorize the ele-

vated IAP [ 6].

Grade I: 15 - 18 cm H2O

Grade II: 18 - 22 cm H2O

Grade III: 22 - 25 cm H2O

Grade IV: 25 cm H2O or hig her

2.2. Measurement of TGF-Beta

TGF-beta was measured in the fascia from the biopsy

taken at the time of surgery and then on the day burst

abdomen occurred (Bancroft, JD) [7]. Expressed TGF-

beta protein levels were assessed as None (0) when none

of the cells stained, Mild (1+) less than 10% of the cells

stained, Intermediate (2+) 10% to 20% of the cells

stained and Strong (3+) when more than 20% to 25% of

the cells stained following the staining of tissue by im-

munohistochemical staining for TGF β-protein levels by

employing monoclonal antibodies using the Avidin bio-

tin complex technique. TGF-β was localized by means of

immunohistochemical reactions (Figure 1).

2.3. Follow up

All the patients without wound dehiscence were called

one month after discharge for clinical and ultrasono-

graphic scar evaluation.

2.4. Statistical Analysis

The statistical significance of these variables was deter-

mined using unpaired t test, repeated measured ANOVA

test and paired t test. P < 0.05 was considered significant.

3. Results

There were 100 patients in the study, 45 patients with

midline abdominal wound dehiscence and 55 patients

without wound dehiscence. Wound disruption occurred

Figure 1. Photomicrograph showing strong (3+) expression

of TGF-β in biopsy specimen of dehisced fascia.

K. MEENA ET AL.

356

on an average of 7 ± 2 days post operatively (range 6 to

9). This necessitated a prolonged hospital stay on part of

patients with wound dehiscence. While the stay in “non-

dehiscence” cases was of five to nine days, it ranged be-

tween 14 to 88 days in patients who had wound dehis-

cence. The mean stay in this group was 22 days. Wound

dehiscence also carried a significantly higher mortality

rate of 15% in comparison to that of 2% in the non de-

hiscence group.

IAP was assessed in each patient. The sensitivity,

specificity, positive pr edictive value and negativ e predic-

tive value of clinical examination for measurement of

IAP were found to be 86%, 52%, 88% and 47% respec-

tively. When clinical examination was used to assess

three categories of IAP range, viz. IAP between 15-18

cm H2O, 18 - 22 cm H2O and 22 - 25 cm H2O and was

correlated with IAP saline fluid column manometry, the

weighted kappa agreement score was 0.50. These result

showed that clinical method is not an accurate tool for

the assessment of IAP (Table 2).

The mean IAP value in patients with dehiscence on

day 1 was 22.7 cm of H2O, on day 2 was 21.4 cm of H2O,

and on day 3 was 20.3 cm of H2O. The corresponding

readings for “non-dehiscence” group were 19.2, 17.4,

and 15.9 respectively. The difference is statistically sig-

nificant wi t h p v al ue of 0.000 (Table 3).

Table 2. IAP measurements.

Saline fluid column manometry Total number

of patients

Clinical

examination IAP > 18 cm of H2O IAP < 18 cm of H2O

Raised 70 9 79

Normal 11 10 21

Total 81 19 100

Table 3. Values of serial measurement of IAP in the two

group.

IAP Day 1 Number Of

patients Mean

(cm of water) Standard

deviation

Standard

deviation

mean

“Non-dehiscence”

group 55 19.200 2.4601 0.3317

Dehiscence group 45 22.7778 1.4443 0.2153

IAP Day 2

“Non-dehiscence”

group 55 17.4364 2.1323 0.2875

Dehiscence group 45 21.4222 2.4998 0.2236

IAP Day 3

“Non-dehiscence”

group 55 15.9455 2.3603 0.3183

Dehiscence group 45 20.3333 1.6652 0.2482

P = 0.000.

The variables that were significantly associated with

wound dehiscence include anemia (p = 0.001), hypo pro-

teinemia (p = 0.006), duration of surgery (0.003). The

additional postoperative factors that were found to be

significant were prolonged postoperative ileus (p =

0.003), wound infection (p = 0.000) and postoperative

pulmonary infection (p = 0.000). Age (p = 0.096), gender

(p = 0.470), jaundice (p = 0.644), cause of peritonitis (p

= 0.459), wound contamination (0.142) and types of sur-

gery (p = 0.261) were non significant variables (Table

4).

On Day 0, TGF beta was expressed in ten patients in

“non-dehiscence” group and eight patients of dehiscence

group. The p value obtain ed for this was 0.958. This sig-

nified the equivalence of baseline unexpressed TGF-beta

levels in these two groups on Day 0.

Forty one/forty five (91%) patients with wound dehis-

cence strongly expressed TGF-beta on the day of burst as

against mild presence in 8/45 patients on Day 0. The dif-

ference is statistically significant with p value of 0.000

(Table 5).

Wound dehiscence rate was 9% in the patients with

three or less significant risk factors, 46% in the patients

with four to seven risk factors and 100% in the patients

Table 4. Distribution of risk factors in the dehiscence and

“non-dehiscence” group.

Risk Factor Dehiscence

group “Non-dehiscence”

group P Value

Anemia 32 23 0.001

Jaundice 4 1 0.644

Total Protein mean

g/l (SD) 5.141 (0.461) 6.149 (0.393) 0.006

Operating time in

hours (SD) 2.2 (0.351) 1.9 (0.381) 0.003

Wound

contamination 39 18 0.142

Post operative ileus24 0 0.000

Post operative

pulmonary infection12 5 0.000

Table 5. Difference betw een TGF-beta on day 0 and on day

of burst in the wound dehiscenc e group.

TGF-beta expression Day 0 Day of burst

None (0) 37 3

Mild (1+) 8 1

Intermediate (2+) 0 21

Strong (3+) 0 20

Total 45 45

P = 0.000.

K. MEENA ET AL. 357

with eight or more risk factors. The difference is statistic-

cally significant with p value of 0.000.

Patients with seven risk factors had mortality of 25%,

with eight risk factors 40% and with nine or more risk

factors 1 00%.

Follow up

At one month follow up, on clinical and sonographic scar

evaluation none of the patients in the “non-dehiscence”

group developed incisional hernia.

4. Discussion

In the current study, out of 100 patients of generalized

peritonitis, 45 developed wound dehiscence. The vari-

ables that were significantly associated with wound de-

hiscence include anemia, hypo proteinemia and duration

of surgery. The postoperative factors that were found to

be significant were prolonged postoperative ileus, wound

infection and postoperative pulmonary infection. Age,

gender, jaundice, cause of peritonitis, wound contamina-

tion and types of surgery were non significant variables.

The mean IAP value was significantly higher in the de-

hiscence group while strong expression of TGF-beta

level was observed in the healing fascial wound on the

day of burst.

In our study, wound dehiscence rate was 45%. While

some retrospective studies have reported these rates be-

tween 0.2% and 10%, their rates derive from patient

group where few underwent emergency surgery [8,9].

Makela et al. reported an incidence of 10%; their series

include 30% patients operated emergently [10]. Riou et

al. found that 16 (51.6%) of their 31 dehiscence patients

had an emergency surgery [11]. Wound dehiscence is

associated with considerable mortality. While Madson et

al. and Greenberg et al have reported mortality rate in the

range of 10% - 30%, the current study had a mortality of

15% (7/45) in the burst group and 2% (1/55) in the non

burst group [2,3]. Time to dehiscence following surgery

may vary considerably. The reported range is 1 to 28

days with mean of 7 days [2,10,11]. Abdominal wound

dehiscence is associated with a prolonged hospital stay.

Studies report an average stay of 45 days with a range 20

- 90 days in patients managed conservatively [3]. The

mean hospitalization time was only reduced marginally

to 22 ± 10 days and 25 ± 15 days, when wounds were

reclosed following disruption [2,10]. In our study, the

mean period of hospital stay of wound dehiscence pa-

tients was 22 days, with a range between 14 - 88 days.

Currently preferred surgical closure technique is by a

continuous running polypropylene suture using Jenkin’s

technique because of its simplicity, speed, low rate of

wound dehiscence, and its superiority in an infected set-

tings [12,13]. We also follow Jenkin’s technique. In this

series, we did not have a knot slippa ge or suture breakage

in any of our patients. However, cutting through the tis-

sue was a common problem. While a poor application of

technique may be culpable, several studies emphasize the

role of mechanical or biological factors operating at the

wound site in causation of burst [14-16].

Measurement of IAP is critical while studying the ro le

of mechanical factors in wound dehiscence. W e tried two

different approaches: clinical examination and saline

fluid column manometry. The second a more objective

method; allowed us to assess the accuracy of first. Girth

and tenseness of the abdomen, two clinical determinant

of IAP, have however been discounted by several studies

[17,18]. They fared no better in present study. Unlike the

result of Sugrue et al. (weighted kappa agreement 0.70,

we did not observe a significant improvement (weighted

kappa agreement 0.50) despite adding a third category of

IAP in clinical examination [19].

Anemia and hypo proteinemia are known to impair

wound healing [20 ]. Wound infection is a major risk fac-

tor for wound dehiscence [11,12]. Prolonged ileus and

pulmonary infections are known to increase the IAP

[11,21,22]. Both played a significant role in our series.

Patients with wound dehiscence strongly expressed

TGF-beta on the day of burst as against mild presence on

Day 0. Franz et al. and Mustoe et al. have also shown a

peak of TGF-beta expression on five to seven day at

wound site. Therefore, the wound failure in our patients

is not actually a scar matrix failure [23,24]. We also at-

tempted to correlate the fascial TGF-beta expression with

IAP in dehiscence group. The mean expression of TGF-

beta was found to be 2.53 in dehiscence patients with

IAP < 20 cm of H2O, and 2.48 in dehiscence patients

with IAP > 20 cm of H2O (p value 0.786). Thus, wound

failure occurs in the biochemically active zone adjacent

to the acute wound edge where the sutures are placed. It

this process that is accountable for cutting through of

sutures, and was the factor responsible for wound dehis-

cence in the present series.

Multiple factors contributing to increase in disruptive

mechanical forces were primarily responsible for ab-

dominal wound dehiscence as the biological healing

process of having scar matrix in place was found intact

by revealing the strong expression of TGF-beta in the

specimens of facial biopsies. A preventive attitude to-

wards every risk factor responsible f or wound breakdown

at every stage before, during and after surgery should go

a long way in reducing the incidence of wound dehis-

cence.

Limitations of the present study were small sample

size and single institutional study.

5. Conclusion

The patients of peritonitis undergoing prolonged surgery

K. MEENA ET AL.

358

in the presence of risk factors like anemia, hypo pro-

teinemia, postoperative ileus, wound infection and post-

operative pulmonary infection have high risk of abdomi-

nal wound dehiscence.

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