Wound dehiscence is where a wound fails to heal, often re-opening a few days after surgery (most common in abdominal surgery). It can be divided into two clinical entities:
- Superficial dehiscence – the skin wound alone fails, with the rectus sheath remaining intact
- Often occurs secondary to local infection, poorly controlled diabetes mellitus, or poor nutritional status
- Full thickness dehiscence – the rectus sheath fails to heal and bursts, with protrusion of abdominal content (often termed a “burst abdomen”)
- This may occur secondarily to raised intra-abdominal pressure (e.g. patients with an ileus), poor surgical technique (e.g. poor suture technique or poor suture choice), or if the patients is critically unwell
Wound dehiscence is a costly post-operative complication and thus identification and appropriate management of the condition is key.
Figure 1 – Schematic demonstrating layers involved in (A) Superficial Dehiscence (B) Full Thickness Dehiscence
Aetiology
The most common cause of wound dehiscence is infection (see surgical site infection). Risk factors can be divided into patient, intra-operative, and post-operative factors (Table 1)
| Patient Factors | Intra-Operative Factors | Post-Operative Factors |
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Table 1 – Risk Factors for Wound Dehiscence
Clinical Features
The most evident feature of wound dehiscence is the visible opening of the wound (Fig. 2), healing poorly following the operation; this typically happens around 5-7 days post-operatively.
A classic sign of deep / full thickness dehiscence (where the skin can be intact) is new bulging of the wound and seepage of pink serous or blood-stained fluid from the wound. A sudden increase in wound discharge should be considered as deep dehiscence until proven otherwise*.
*Such a presentation will mandate removal of the skin clips / sutures at the area of maximal leakage and physically examining the rectus sheath with your finger to check it is still intact
Figure 2 – A large superficial wound dehiscence
Investigations
The diagnosis of wound dehiscence is clinical. For cases with concurrent surgical site infection, wound swabs should be taken for culture at the wound site.
Management
Superficial dehiscence usually just requires washing out the wound with saline and then simple wound care (e.g. packing the wound with absorbent ribbon gauze).
The patient should be advised the wound will now be required to heal by secondary intention and that this can take several weeks. More extensive wounds may be treated with a Vacuum-Assisted Closure device to speed healing.
Management of Full Dehiscence
In the event of a sudden full dehiscence of a wound (or “burst abdomen”), provide suitable analgesia and start broad spectrum intravenous antibiotics as a priority.
Cover the wound in saline-soaked gauze and arrange urgent return to theatre for re-closure of the wound.
For the majority of patients, closure is usually done in theatres with large interrupted sutures, avoiding excessive tension. In small number of cases, closure is inappropriate or unsafe (e.g. gross abdominal sepsis, necrotising fasciitis of abdominal wall), and can be managed as an open abdomen (e.g. using a vacuum dressing), or using a bridging mesh.
Prevention
Optimisation of co-morbidities and treating any surgical site infections is key in the prevention of wound dehiscence. Avoiding heavy lifting and encouraging adequate post-operative nutrition will reduce the risk further.
Key Points
- Wound dehiscence is the failure of a wound to close properly, divided into either a simple dehiscence or a burst abdomen
- Most cases of simple dehiscence are due to infection, however several risk factors can increase the risk of it occurring
- Wound dehiscence may require a return to theatre, although some cases can managed with closure by secondary intention
- A burst abdomen warrants an urgent return to theatre
