B urst abdomen is a postoperative complication associated with significant morbidity and mortality. The risk factors for burst abdomen are patient- and surgery-related. The management of this complication is a relatively unexplored area within the field of surgery. Relevant surgical outcomes include recur- rence, mortality, and incisional hernia. A total number of 27 studies are identified that reported on at least one surgical outcome (recurrence, mortality, or incisional hernia rate) of at least 10 patients with burst abdomen. None of the identified studies were designed prospectively, and only a minority of studies report- ed surgical outcomes of considerable numbers of patients with burst abdomen. Reported conservative man- agement options included use of saline-soaked gauze dressings and negative pressure wound therapy. Operative management options included temporary closure options (open abdomen treatment), primary closure with various suture techniques, closure with application of relaxing incisions, use of synthetic (non- absorbable and absorbable) and biological meshes, and the use of tissue flaps. The treatment of burst abdomen is associated with unsatisfactory surgical outcome. Randomized controlled clinical trials are need- ed to provide the surgical community with a greater level of evidence for the optimal treatment strategy for burst abdomen and the various subtypes. Therapeutic Alternatives for Burst Abdomen ERASMUS UNIVERSITY MEDICAL CENTER DEPARTMENT OF SURGERY ROTTERDAM, THE NETHERLANDS - 111 - Hernia Repair SURGICAL TECHNOLOGY INTERNATIONAL XIX ABSTRACT GABRIËLLE H. VAN RAMSHORST , M.D., PH.D. FELLOW , RESIDENT IN TRAINING FOR SPECIALIST HASAN H. EKER, M.D. PH.D. FELLOW JORIS J. HARLAAR, M.D. PH.D. FELLOW KIRSTEN J.J. NIJENS, M.D. MEDICAL STUDENT JOHANNES JEEKEL, M.D. PROFESSOR JOHAN F. LANGE, M.D. PROFESSOR
Transcript
BBurst abdomen is a postoperative complication associated with significant morbidity and mortality. The
risk factors for burst abdomen are patient- and surgery-related. The management of this complication
is a relatively unexplored area within the field of surgery. Relevant surgical outcomes include recur-
rence, mortality, and incisional hernia. A total number of 27 studies are identified that reported on at least
one surgical outcome (recurrence, mortality, or incisional hernia rate) of at least 10 patients with burst
abdomen. None of the identified studies were designed prospectively, and only a minority of studies report-
ed surgical outcomes of considerable numbers of patients with burst abdomen. Reported conservative man-
agement options included use of saline-soaked gauze dressings and negative pressure wound therapy.
closure with various suture techniques, closure with application of relaxing incisions, use of synthetic (non-
absorbable and absorbable) and biological meshes, and the use of tissue flaps. The treatment of burst
abdomen is associated with unsatisfactory surgical outcome. Randomized controlled clinical trials are need-
ed to provide the surgical community with a greater level of evidence for the optimal treatment strategy for
burst abdomen and the various subtypes.
Therapeutic Alternatives for Burst Abdomen
ERASMUS UNIVERSITY MEDICAL CENTERDEPARTMENT OF SURGERY
ROTTERDAM, THE NETHERLANDS
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ABSTRACT
GABRIËLLE H. VAN RAMSHORST, M.D., PH.D. FELLOW, RESIDENT IN TRAINING FOR SPECIALIST
HASAN H. EKER, M.D.PH.D. FELLOW
JORIS J. HARLAAR, M.D.PH.D. FELLOW
KIRSTEN J.J. NIJENS, M.D.MEDICAL STUDENT
JOHANNES JEEKEL, M.D.PROFESSOR
JOHAN F. LANGE, M.D.PROFESSOR
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Burst abdomen is a serious complica-tion of abdominal surgery and could beconsidered as an acute postoperativehernia. Reported incidence rates varybetween 0.4% and 3.5%.1–15 Despiteadvances in perioperative care, surgicaltechniques, and materials, the incidenceof burst abdomen has remainedunchanged over the past few decades.16
In contrast to the large number of pub-lished articles to date on risk factorsassociated with burst abdomen, fewreports exist on the surgical outcome oftreated burst abdomen. In this chapter,the treatment options for burstabdomen and the surgical outcome willbe discussed.
Etiology of Burst AbdomenBurst abdomen usually occurs during
the first two weeks after surgery.2,17–21 In23% to 84% of wounds, leakage ofserosanguineous fluid is observed beforedehiscence occurs.9,12,19,22–24 Patient- andsurgery-related factors may put a patientat increased risk of developing abdomi-nal wound dehiscence. Patient-related
variables that have frequently beenreported as risk factors include age,male gender, anemia, chronic pul-monary disease, poor nutritional status,emergency surgery, and wound infec-tion.1–11,14,25 Infections of the operationsite have been reported to be present inas many as 18% to 72% of patients withburst abdomen.2,6,9,11,12,23–28 Tillou et al.reported a trauma series with a 71%intra-abdominal infection rate in patientswith fascial dehiscence compared to4.6% in patients without.29 All fascialdehiscence patients with intra-abdomi-nal infections required laparotomy(31%) or computed tomography (CT)-guided percutaneous drainage support-ing routine evaluation forintra-abdominal infection in this patientgroup.29 Graham et al. diagnosed intra-abdominal infections in 47 out of 90patients (52%) operated upon for fascialdehiscence (32 patients with abscess, 15with anastomotic leakage).24 Fever andleucocytosis did not distinguish betweenpatients with intra-abdominal infectionscompared to those without. The pres-ence of intra-abdominal infection wasassociated with a significantly greatermortality rate of 44% versus 20% in
patients without intra-abdominal infec-tion.24
Surgical risk factors include the typeof suture material and surgical tech-nique.17 Brown and Goodfellow found atrend toward a lower incidence ofwound dehiscence with or without evis-ceration in transverse incisions com-pared to midline incisions in a systematicreview.30 Several studies have shown thatabsorbable fascial sutures are associatedwith an increased risk of developing anincisional hernia but found no associa-tion with burst abdomen.31–34 Onemeta-analysis by Weiland et al. found agreater incidence of wound dehiscence ifcontinuous absorbable closures or inter-rupted nonabsorbable closures wereused, but these findings were not con-firmed by two other meta-analyses byRucinski et al. and van ‘t Riet et al.35–37
Weiland et al. also reported lower inci-dences of dehiscence and hernia if massclosures were used compared to layeredclosures.35 A suture length to woundlength (SL:WL) ratio of less than 4:1 hasbeen associated with an increased inci-dence of incisional hernia, and may alsoexpose patients to an increased risk ofburst abdomen.38–41 A definitive answerto the question of whether the SL:WLratio is a relevant risk factor for burstabdomen can only be provided if theseratios are documented as part of thestandard abdominal closure procedure.
SURGICAL OUTCOME
The most frequent complications ofburst abdomen include recurrence,mortality, and incisional hernia. Anothercomplication is the occurrence of ente-rocutaneous fistula. Enterocutaneous fis-tula formation has only been reportedincidentally after burst abdomen andwill not be discussed in this chapter.42,43
RecurrenceThe technical failure of surgical
repair results in recurrences. Publishedrecurrence rates vary between 0% and35%.2,18–20,22,42,44,45,50 The fascia, whichhas already been damaged during the ini-tial (suture) repair and dehiscence there-after, may be more prone to tearingafter subsequent operative repair, espe-cially in the presence of increased intra-abdominal pressure. Increases inintra-abdominal pressure can occur inthe presence of abdominal distension as
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INTRODUCTION
Figure 1. Example of repeat dehiscence by tearing of polyglactin mesh.
SURGICAL OUTCOME
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a result of bowel edema, mechanicalobstruction, coughing, vomiting, or uri-nary retention.42 Tensile and burstingstrengths of fascia, subcutis, and skin areimpaired in cases of infection, tissuenecrosis, and poor nutritional status. Amesh repair can also result in recur-rence: Our prospective data include fourobservations of patients with burstabdomen who underwent polyglactinmesh repair and developed recurrencesdue to tearing of the mesh (Fig. 1).
MortalityReported mortality rates of burst
abdomen vary between 4% and 85%(Table 1). Cöl et al. reported a relationbetween the number of risk factors pre-sent for burst abdomen and the mortali-ty rate.11 Variables assigned as riskfactors in this study included hypopro-teinemia, nausea/vomiting, abdominaldistension, wound infection, two ormore drains, fever, an operation not per-formed by a senior surgeon, and woundclosure of all layers with interrupted silksutures. Mortality was found to be 30%for patients with seven risk factors and58% for patients with eight risk factors.Madsen et al. reported the causes ofdeath for 48 patients with burstabdomen, in order of frequency: car-diorespiratory insufficiency (n = 28),peritoneal sepsis (n = 7), primary dis-ease (n = 5), complicating illness(n = 3), hemorrhage (n = 2), andunknown cause (n = 3).22 White et al.reported the causes of death of 40patients: malignant disease (n = 12), res-piratory failure and pneumonia (n = 5),coronary occlusion (n = 4), renal failure(n = 3), pulmonary embolism (n = 3),peritonitis (n = 1), cardiovascular acci-dent (n = 1), and hematemesis (n = 1).20
Cardiac and respiratory complicationswere the most frequently reported caus-es of death in burst abdomen patients.
Incisional HerniaThe development of an incisional her-
nia is a frequent, late complication ofburst abdomen.18,44,46,47 If burst abdomenis treated conservatively, an incisional her-nia will develop in all cases. Reportedincidences of incisional hernia varybetween 6% and 48%, with a cumulativeincidence of 69% after 10years.18,20,22,44,45,48–50 The high incidence ofincisional hernia suggests that patientswho develop burst abdomen are moreprone to develop this late type of woundfailure than the average patient population.
SEARCH STRATEGY
PubMed-Medline, EMBASE, andthe Cochrane Library were searchedfor relevant publications and their ref-erences up to November 2009 usingthe keywords “abdominal wound dehis-cence,” “fascial dehiscence,” “eviscera-tion,” and “burst abdomen.” Searcheswere limited to studies in adults andelderly patients. Studies that reportedon at least one surgical outcome(recurrence, mortality, incisional her-nia) on 10 or more patients with burstabdomen are included in Table 1.
RESULTS
A total number of 27 studies wereidentified. Data on applied techniquesand the associated surgical outcomeswere extracted (see Table 1). Treat-ment techniques for burst abdomenand the surgical outcomes associatedwith the applied techniques wereincomplete in the majority of thesereports. No prospective case series orrandomized studies were found.
Conservative ManagementNonoperative management is a
viable option for patients with smalldefects, in cases of a high risk of iatro-genic intestinal perforation due to vastadhesions, massive bowel edema, or ifthe general status of the patient doesnot allow for immediate surgery.17
Wounds can be covered with saline-soaked gauze dressings. Regular gauzedressings are inexpensive in terms ofdirect material costs but will requirefrequent dressing changes.
The use of negative pressure woundtherapy (NPWT) has been reported in13 patients with fascial dehiscence byHeller et al. and resulted in definitivefascial closure in 9 out of these 13patients.42 Subramonia et al. appliedNPWT in 9 patients with fascial dehis-cence and 42 patients with either alaparostomy (n = 10) or more superfi-cial types of abdominal wound dehis-cences (n = 32).43 The total group ofpatients showed a 29% mortality rateand 29% incisional hernia rate at amedian follow-up of 8 months. No sep-arate percentages were reported forpatients with fascial dehiscence. NPWThas been reported to promote the pro-
duction of granulation tissue and thereduction of wound volume, and can beused if direct contact with intra-abdominal organs is prevented.42 Ade-quate wound debr idement usuallyprecedes the placement of NPWTdressings. Granulated exposed bowelcan heal either by secondary intentionor by covering with split-thickness skingrafts, for instance, as part of a two-staged procedure or tissue flaps.42,51
Virtually every conservatively managedpatient who is denied operative repairwill develop an incisional hernia.
Operative ManagementA number of authors advocate
debridement of necrotic and infectedtissue, and exploration of the abdomenfor the presence of intra-abdominalabscess formation, (infected)hematomas, intestinal (anastomotic)leakage, and obstruction.17,18 It isunknown whether a local explorationof the dehisced fascia suffices in cases ofsmall defects in the absence of clinicalsymptoms of infection or whether theentire fascia needs to be opened (andre-closed).
Primary Suture ClosurePrimary closure can be performed
using a mass closure technique with aslowly absorbable running monofila-ment suture. Generally, a SL:WL ratioof at least 4:1 is advised.52 It is notknown whether traditional tissue bitesand suture distances of 1 cm should beused or small tissue bites with smallsuture distances of 0.5 cm, although useof the latter technique is supported byseveral clinical and experimental stud-ies.38,39,53,54 Primary closure withoutadditional measures is possible in half ofpatients with abdominal wall ruptureaccording to Fleischer et al.18 Abbott etal. reported a 56% success rate associat-ed with the primary closure of fascialdehiscence with or without retentionsutures in 27 patients.45 In selectedpatients, such as patients in whom tech-nical failure has resulted in dehiscencerather than patient-related risk factors(e.g., slipped knots), primary suturerepair may be successful.17,45
If the fascia is easily torn during ini-tial re-suturing, alternative closuremethods can be considered. In cases ofextensive debridement with the loss ofabdominal wall tissue, primary closurehas been reported to result in a 50%dehiscence rate.47
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SEARCH STRATEGY
RESULTS
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Table I Studies with Reports of 10 or More Patients with Burst Abdomen and Surgical Outcome
Author Year Type of Study
No. patients
Technique (Number of Patients and Specific
Aspects)
Recurrence Rate
Mortality Rate
Incisional Hernia Rate
Follow-Up (Range)
Reitamo23 1972 Retrospective 49 NR 10% 35% 10% NR
Keill9 1973 Retrospective 47 21 through-and-through retention sutures 12 one-layer fascial closure with wire 10 wire fascial closure with retention sutures 2 conservative treatment 2 NR
11% 30% NR NR
Grace48 1976 Retrospective 103 96 resuture with or without tension sutures 7 conservative treatment
2.1% 20% 48% NR
Sanders75 1977 Retrospective 11 NR NR 18% 60% NR (max 3 years)
Madsen22 1992 Retrospective 198 198 resuture with mass or retention sutures with nonabsorbable braided or monofile sutures, often using a plastic bridge or polyvinylchloride tube
5.6% 24% 23% NR
Wahl2 1992 Retrospective 30 27 resuture with interrupted sutures and two or three traction sutures 3 adapted wound edges, planned re-laparotomies
Van ’t Riet44 2004 Retrospective 168 Type of suture: 79 polyglactin 42 polydioxanone 9 polypropylene 9 polyglactin mesh 16 polypropylene mesh 1 polyester mesh 12 NR Type of technique: 70 interrupted 62 continuous 36 NR
9.5% 25% 44%† 37 months (3–146 months)
Heller42 2006 Retrospective 13 4 NPWT followed by no closure 4 NPWT followed by component separation 5 NPWT followed by delayed primary closure (including 3 polypropylene mesh repairs)
Relaxing IncisionsEsmat reported the use of relaxing
incisions in the transversus abdominisand internal oblique muscles (TI inci-sion), an additional incision in the exter-nal oblique muscle (TIE incision), oralso involving Scarpa’s fascia (TIES inci-sion).21 Eight patients with burstabdomen underwent a total of 15 inci-sions (2 TI, 9 TIE, 4 TIES) in this study.The mortality rate was 12.5%, norecurrences occurred, and incisionalhernias occurred at sites of TIES inci-sions only. Dietz et al. performed aninverting bilateral interrupted figure-of-eight suture (0 USP polypropylene) ofthe anterior and posterior rectus sheathin one patient, combined with relaxingincisions in the aponeuroses of theexternal oblique muscles and placementof a polypropylene mesh in sublay posi-tion.60 No incisional hernia was diag-nosed after 1 year of follow-up butnumbness of the skin in the right lowerabdomen was reported, which was pos-sibly due to a lesion of (part of) the ilio-hypogastric nerve.60 Relaxing incisionsin the transversus abdominis and inter-nal and external oblique muscles can beconsidered if primary closure cannot beperformed tension-free.
Temporary ClosureOpen abdomen treatment is an alter-
native option if tension-free closure can-not be performed. One study reportedthe temporary closure of the abdomenwith a Bogota bag in one patient withburst abdomen, which enabled primaryclosure one month after placement.61
There are no studies found to date thathave compared the surgical outcomes oftemporary closure with other methodsof treatment for burst abdomen.
Synthetic MeshSynthetic mesh is often placed in
inlay position fixated to both fascialedges. There is no evidence to support apreference for either an inlay, onlay, orsublay position in the repair of burstabdomen. Material options includedabsorbable meshes such as polyglactinand nonabsorbable meshes such aspolypropylene. Polypropylene mesheshave been associated with high compli-cation rates in infected environments,especially in cases of placement in directcontact with intestines, leading to ente-rocutaneous fistula formation andintestinal adhesions.62–64 Van ‘t Riet etal. reviewed a group of 18 patients who
had undergone abdominal wound dehis-cence repair in the presence of intra-abdominal infection. All patientsdeveloped complications such as meshinfection (77%), enterocutaneous fistulaformation (17%), or migration of meshthrough the bowel (17%). Complica-tions had led to mesh removal in 8 outof 18 patients (44%) and at a mean fol-low-up of 49 months, incisional herniahad developed in 63% of patients.63
Other complications of nonab-sorbable meshes include bulging of themesh, which can mimic the clinical pre-sentation of incisional hernia, and meshrejection. McNeeley et al. reported theuse of nonabsorbable polypropylenemesh in 11 patients with fascial dehis-cence (7 Marlex®, CR Bard, MurrayHill, NJ; 4 Prolene®, Ethicon,Somerville, NJ). In three out of sevenpatients who underwent Marlex® repair,grafts were removed and abdominalscars were revised. There were noreported observations of enterocuta-neous fistula formation.49 We are notaware of any reports to date on the useof composite nonabsorbable meshes inthe acute treatment of abdominal burst.From a theoretical point of view, the useof this type of anti-adhesive meshescould be beneficial in terms of less adhe-sion formation than polypropylene meshand lead to a lower incidence of inci-sional hernia compared to absorbablemesh.
Polyglactin mesh is 100% absorbableand can be used in the presence of infec-tion. Repeated access to the abdomen iseasily acquired by opening and subse-quent closure of the mesh. However, thematerial can tear and thereby result inrepeat evisceration and an indication forreoperation.65 Covering the mesh withsaline-soaked gauzes or NPWT is oftenused until granulation tissue is formedon the bowel and can be covered withsplit-thickness skin grafts. Removal ofmesh due to rejection may be necessaryat an outpatient clinic during the monthsfollowing mesh repair. McNeeley et al.used polyglactin mesh in seven patientswith fascial dehiscence, one of whomrequired mesh removal.49 Moreover, theuse of polyglactin mesh without directcontact between fascial edges inevitablyresulted in incisional hernia over time.Abbott et al. reported a 100% successrate for primary polyglactin mesh repairin 7 out of 37 patients. Closure withpolyglactin mesh required 12 subse-quent operations (1.71 operations per
case), compared to 39 operations in 27patients (1.56 operations per case) forprimary fascial repair.45 Buck et al.reported the use of polyglycolic acidmesh (Dexon™, Mansfield, MA) inseven patients with wound dehiscence,all of whom developed incisional her-nias.66
Biological MeshIn recent years, various types of bio-
logical meshes have been developed andbecome commercially available. Biologi-cal meshes consist of cross-linked ornon-cross-linked extracellular matrixwithout cellular components, derivedfrom porcine dermis collagen, porcinesmall intestine submucosa, or cadaverichuman dermis.67 The high biologicalcompatibility is generally seen as a greatadvantage in comparison with syntheticmaterials, especially in infected surgicalfields.68 Tissue ingrowth in the meshwill eventually create a new abdominalfascia, thereby preventing incisional her-nia formation unless the mesh is degrad-ed by collagenases in cases of (severe)infection. Few publications are availableon the use of biological mesh in burstabdomen patients. Bounovas reportedthe implantation of porcine dermal col-lagen under local anesthesia in one caseof infected abdominal wound dehiscenceafter hysterectomy. After a follow-upperiod of 9 months, no incisional herniaoccurred.69 Chuo et al. described theuse of a biological mesh, derived fromporcine dermis, in combination withNPWT in a patient with abdominaldehiscence and exposed bowel.70 Onereport has been published by Wotton etal. who described a case of a patientwith burst abdomen in whom severerejection of a biological mesh, derivedfrom porcine dermis, occurred.71 Thelimited number of studies published todate on this topic inhibits any substanti-ated advice on the use of a specific typeof biological mesh (cross-linked versusnon-cross-linked, human versusporcine) or on optimal mesh position.
Tissue FlapsTissue flaps have been used most fre-
quently for delayed repair of abdominalwall defects, for instance, after abdomi-nal wound dehiscence. However, Jeon etal. reported the use of a pedicled rectusfemoris muscle flap for a completelyeviscerated renal allograft in a 66-year-old man after development of a perigrafthematoma. The rectus femoris flap
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became dehiscent. After additional localtissue rearrangement and a perforator-based cutaneous advancement flapreconstruction, no incisional herniaoccurred within the first two years aftersurgery.72
Closure of the Skin andSubcutaneous Tissue
Subcutaneous (multifilament) suturesinitiate a foreign-body reaction andpotential bacterial colonization. In a rel-atively clean environment, the skin canbe closed with monofilament interrupt-ed sutures or staples. If drainage ofinfected material through the wound isexpected, the skin should be left openor approximated at intervals with staplesor interrupted monofilament sutures toallow for sufficient drainage. Chen-drasakhar described the bedside staplingof Vicryl mesh to the skin as a sole pre-ventive measure against evisceration intwo patients with abdominal wounddehiscence. Skin grafts were placed afteringrowth of the mesh with granulationtissue, thereby avoiding major surgeryand accepting incisional hernia forma-tion.73
Postoperative PeriodWound healing should be promoted
by achieving adequate tissue perfusionand oxygenation and by creating an opti-mal wound environment. The nutrition-al status should be checked andoptimized by resuming enteral feedingas soon as possible, preceded by admin-istering total parenteral nutrition if nec-essary. Postoperative intestinal paralysisshould be minimized to prevent abdomi-nal hypertension and thereby stress onthe wound. Pulmonary inhalers and res-piratory exercises under the guidance ofa physiotherapist may assist in the pre-vention of pulmonary infection and fre-quent coughing, which can result insudden peaks in intra-abdominal pres-sure. There is no evidence to supportthe use of restraining cotton sheets orabdominal binders to prevent burstabdomen, a further increase in the gapbetween both fascial edges, recurrences,or incisional hernia.
Treatment of RecurrenceAbbott et al. reported the largest
series of treated recurrence patients(n = 12). Polyglactin mesh was used intwo patients, both resulting in subse-quent incisional hernia repair. Repeatfascial closure was performed in the
remaining 10 patients, 3 of whomrequired additional operative interven-tions (70% success rate). Recurrence isoften combined with additional damageto the fascia and adjacent tissues and is arelative contraindication for suturerepair. Torn mesh can be repaired bysutures with or without bridging of themesh or by applying two sheets of meshin a double layer for extra support.
DISCUSSION
The evidence regarding the manage-ment of burst abdomen is extremelypoor. Our review of managementoptions has revealed that none of the
studies found in the literature to datewere designed prospectively, and only aminority of studies have reported surgi-cal outcomes of considerable numbersof patients. The level of evidence there-fore does not exceed 2b (individualcohort studies). Any advice on the man-agement of burst abdomen should there-fore be interpreted with caution.
Based on the available evidence fromcase series, conservative managementmay be reserved for patients whose gen-eral health status does not allow forimmediate surgery. In clean and clean-contaminated wounds, primary sutureclosure could be attempted (e.g., in caseof failed suture technique), although thisrepair has been associated with consider-able recurrence rates and the develop-
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Figure 2. Example of patient with fascial necrosis, exposed abdominal content, and concurrent intra-abdominal infection.
DISCUSSION
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ment of incisional hernia in a number ofstudies.2,8,9,20,22,44,48,50 If intra-abdominalpressure (IAP) levels are high, primarysuture repair will presumably be associ-ated with an even worse surgical out-come. The high recurrence andincisional hernia rates following treat-ment of burst abdomen could be consid-ered as a support of mesh repair,especially in these patients. In cleanwounds, polypropylene or compositemeshes could be used, depending onwhether or not contact with abdominalcontents can be avoided; intraperitonealplacement of polypropylene is associatedwith high complication rates after subse-quent surgical interventions.74 A biolog-ical mesh repair could be considered inclean-contaminated wounds as an alter-native for a two-staged repair with tem-porary closure of the abdomen (with orwithout NPWT) or open abdomentreatment.
In contaminated-dirty wounds, treat-ment should be aimed at identifying thesource of infection, for example, intra-abdominal abscess or anastomotic leak-age. This type of patient is illustrated inFigure 2: Progressive necrosis of the fas-cia resulted in exposure of the abdomi-nal content, and intra-abdominalinfection was found at re-laparotomy.We discourage primary suture repair inpatients with obvious tissue (fascial)necrosis and considerable loss of theabdominal wall due to high reportedrates of treatment failure.47 Surgeonscan choose open abdomen treatment(with or without NPWT) or closure ofthe abdomen with absorbablepolyglactin or biological mesh repair.Due to lack of evidence, none of thesetechniques can be considered themethod of first choice. Absorbablepolyglactin meshes can be used to bridgeabdominal wall defects but will eventu-ally lead to incisional hernia forma-tion.44,45,66 Tension-free applicationallows for a certain safety window incases of expansion of abdominal con-tents during the postoperative phase.Biological meshes have demonstratedhigh biocompatibility in infected fieldsand should be considered a closureoption for burst abdomen. Closure withbiological mesh may be associated with alower incidence of incisional hernia, butthere are no case series of patients withburst abdomen available with long-termfollow-up. Until evidence is availablethat the use of biological mesh results inimproved surgical outcome in this
patient group, its widespread use will berestrained by greater material costs.
CONCLUSIONS
Current surgical closure techniquesare associated with unacceptably highrates of recurrences and incisional her-nia. The overall lack of evidence to dateon this topic mandates well-designedrandomized controlled trials. Conserva-tive and operative management optionsshould be compared for short-term andlong-term surgical outcomes to providesurgeons with a greater level of evidenceregarding the optimal treatment strategyfor burst abdomen. We propose thatdistinctions are made between treat-ment options for patients with clean andclean-contaminated wounds on onehand and patients with contaminated-dirty surgical sites on the other, andbetween patients with normal versusraised intra-abdominal pressure. A pos-sibly relevant characteristic of affectedpatients in view of surgical outcome isthe initial calculated risk of developingburst abdomen. The size of the defectand presence of evisceration should alsobe taken into consideration as presumedrisk factors for the development of anincisional hernia.
REFERENCES
1. Webster C, Neumayer L, Smout R, et al.Prognostic models of abdominal wound dehis-cence after laparotomy. J Surg Res2003;109:130-7.2. Wahl W, Menke H, Schnütgen M, et al.Die Fasciendehiscenz- Ursache und Prognose.Chirurg 1992;63:666-71.3. Gislason H, Grönbech JE, Söreide O. Burstabdomen and incisional hernia after major gas-trointestinal operations-comparison of threeclosure techniques. Eur J Surg 1995;161:349-54.4. Armstrong CP, Dixon JM, Duffy SW, et al.Wound healing in obstructive jaundice. Br JSurg 1984;71:267-70.5. Penninckx FM, Poelmans SV, KerremansRP, et al. Abdominal wound dehiscence ingastroenterological surgery. Ann Surg1979;189:345-52.6. Pavlidis TE, Galatianos IN, Papaziogas BT,et al. Complete dehiscence of the abdominalwound and incriminating factors. Eur J Surg2001;167:351-4.7. Humar A, Ramcharan T, Denny R, et al.Are wound complications after a kidney trans-plant more common with modern immuno-suppression? Transplantation 2001;72:1920-3.
8. Mäkelä JT, Kiviniemi H, Juvonen T, et al.Factors influencing wound dehiscence aftermidline laparotomy. Am J Surg1995;170:387-90.9. Keill RH, Keitzer WF, Nichols WK, et al.Abdominal wound dehiscence. Arch Surg1973;106:573-7.10. Niggebrugge AH, Hansen BE, Trimbos JB,et al. Mechanical factors influencing the inci-dence of burst abdomen. Eur J Surg1995;161:655-61.11. Cöl C, Soran A, Cöl M. Can postoperativeabdominal wound dehiscence be predicted?Tokai J Exp Clin Med 1998;23:123-7.12. Riou JP, Cohen JR, Johnson H Jr. Factorsinfluencing wound dehiscence. Am J Surg1992;163:324-30.13. Swaroop M, Williams M, Greene WR, etal. Multiple laparotomies are a predictor offascial dehiscence in the setting of severe trau-ma. Am Surg 2005;71:402-5.14. Van Ramshorst GH, Salu NE, Bax NM, etal. Risk factors for abdominal wound dehis-cence in children: a case-control study. WorldJ Surg 2009;33(7):1509-13.15. Halasz NA. Dehiscence of laparotomywounds. Am J Surg 1968;116:210-4.16. Van Geldere D. One hundred years ofabdominal wound dehiscence and nothing haschanged. Hernia 2000;4:302-4.17. Cliby WA. Abdominal incision woundbreakdown. Clin Obs Gyn 2002;45:507-17.18. Fleischer GM, Renner A, Rühmer M. Dieinfizierte Bauchdecke und der Platzbauch.Chirurg 2000;71:754-62.19. Helmkamp BF. Abdominal wound dehis-cence. Am J Obstet Gynecol.1977;128(7):803-7.20. White H, Cook J, Ward M. Aspects oftreatment Abdominal wound dehiscence A 10-year survey from a district general hospital.Ann Royal Coll Surg Engl 1977;5:337-41.21. Esmat ME. A new technique in closure ofburst abdomen: TI, TIE and TIES incisions.World J Surg 2006;30(6):1063-73.22. Madsen G, Fischer L, Wara P. Burstabdomen-clinical features and factors influenc-ing mortality. Dan Med Bull 1992;39(2):183-5.23. Reitamo J, Möller C. Abdominal wounddehiscence. Acta Chir Scand1972;138(2):170-5.24. Graham DJ, Stevenson JT, McHenry CR.The association of intra-abdominal infectionand abdominal wound dehiscence. Am Surg1998;64(7):660-5.25. Van Ramshorst GH, Nieuwenhuizen J,Hop WCJ, et al. Burst abdomen in adults:development and validation of a risk model.World J Surg 2010;34(1):20-7.26. Haddad V, Macon WL IV. Abdominalwound dehiscence and evisceration: contribut-ing factors and improved mortality. Am Surg1980;46(9):508-13.27. Greenburg AG, Saik RP, Peskin GW.Wound dehiscence. Pathophysiology and pre-vention. Arch Surg 1979;114(2):143-6.28. Irvin TT, Vassilakis JS, ChattopadhyayDK, Greaney MG. Abdominal wound healingin jaundiced patients. Br J Surg 1978;65:521-2.29. Tillou A, Weng J, Alkousakis T, VelmahosG. Fascial dehiscence after trauma laparotomy:
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REFERENCES
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CONCLUSIONS
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a sign of intra-abdominal sepsis. Am Surg2003;69(11):927-9.30. Brown SR, Goodfellow PB. Transverseverses midline incisions in abdominal surgery(review). Cochrane Database of SystematicReviews 2005, Issue 4, Art. No. CD005199.DOI: 10.1002/14651858.CD005199.pub2.31. Iwase K, Higaki J, Tanaka Y, et al. Run-ning closure of clean and contaminated abdom-inal wounds using a synthetic monofilamentabsorbable looped suture. Surg Today1999;29:874-9.32. Seiler CM, Bruckner T, Diener MK, et al.Interrupted or continuous slowly absorbablesutures for closure of primary elective midlineabdominal incisions: a multicenter randomizedtrail (INSECT: ISRCTN24023541). Ann Surg2009;249(4):576-82.33. Wissing J, van Vroonhoven TJ, Schat-tenkerk ME, et al. Fascia closure after midlinelaparotomy: results of a randomized trial. Br JSurg 1987;74(8):738-41.34. Hodgson NCF, Malthaner RA, Ostbye T.The search for an ideal method of abdominalfascial closure. Ann Surg 2000;232(3):436-42.35. Weiland DE, Bay RC, Del Sordi S. Choos-ing the best abdominal closure by meta-analy-sis. Am J Surg 1998;176:666-70.36. Rucinski J, Margolis M, Panagopoulos G,Wise L. Closure of the abdominal midline fas-ciae: meta-analysis delineates the optimal tech-nique. Am Surg 2001;67(5):421-6.37. van 't Riet M, Steyerberg EW, NellensteynJ, et al. Meta-analysis of techniques for closureof midline abdominal incisions. Br J Surg2002;89(11):1350-6.38. Israelsson LA, Jonsson T. Suture length towound length ratio and healing of midlinelaparotomy incisions. Br J Surg1993;80(10):1284-6.39. Israelsson LA, Jonsson T. Incisional herniaafter midline laparotomy: a prospective study.Eur J Surg 1996;162(2):125-9.40. Millbourn D, Israelsson LA. Wound com-plications and stitch length. Hernia2004;8(1):39-41.41. Kendall SW, Brennan TG, Guillou PJ.Suture length to wound length ratio and theintegrity of midline and paramedian incisions.Br J Surg 1991;78:705-7.42. Heller L, Levin SL, Butler CE. Manage-ment of abdominal wound dehiscence usingvacuum-assisted closure in patients with com-promised healing. Am J Surg2006;191(2):165-72.43. Subramonia S, Pankhurst S, Rowlands BJ,Lobo DN. Vacuum-assisted closure of postop-erative abdominal wounds: a prospectivestudy. World J Surg 2009;33:931-37.44. Van 't Riet M, De Vos van Steenwijk PJ, etal. Incisional hernia after repair of wounddehiscence: incidence and risk factors. AmSurg 2004;70:281-6.45. Abbott DE, Dumanian GA, Halverson AL.Management of laparotomy wound dehis-cence. Am Surg 2007;73(12):1224-7.46. Poole GV Jr. Mechanical factors in abdom-inal wound closure: the prevention of fascial
dehiscence. Surgery 1985;97:631-40.47. Carlson MA. Acute wound failure. SurgClin North Am 1997;77:607-36.48. Grace RH, Cox S. Incidence of incisionalhernia after dehiscence of the abdominalwound. Am J Surg 1976;131(2):210-2.49. McNeeley SG Jr, Hendrix SL, BennettSM, et al. Synthetic graft placement in thetreatment of fascial dehiscence with necrosisand infection. Am J Obstet Gynecol1998;179(6 Pt 1):1430-4.50. Gislason H, Viste A. Closure of burstabdomen after major gastrointestinal opera-tions-comparison of different surgical tech-niques and later development of incisionalhernia. Eur J Surg 1999;165(10):958-61.51. Baker S, Millard DR Jr. Two-stage abdom-inal-wall reconstruction of sepsis-induceddehiscence. Plast Reconstr Surg1995;96(4):898-904.52. Jenkins TPN. The burst abdominal wound:a mechanical approach. Br J Surg1976;63:873-76.53. Harlaar JJ, Van Ramshorst GH, Nieuwen-huizen J, et al. Small bites with small suturedistances increase laparotomy closure strength.Am J Surg 2009;198(3):392-5.54. Millbourn D, Cengiz Y, Israelsson LA.Effect of stitch length on wound complicationsafter closure of midline incisions. Arch Surg2009;144(1):1056-9.55. Dare FO, Bako AU, Ezechi OC. Burstabdomen following caesarean section: a pre-ventable surgical complication. J Obs Gyn2000;20(6):612-13.56. Abbasoglu O, Nursal T. Surgical techniquefor closure of difficult abdomen. Acta ChirBelg 2003;103:340-41.57. Thome C, Brechet E, Bernard A, et al.Prevention of postoperative dehiscence. Com-parative study of polyglactin 910 mesh andtotal reinforced extraperitoneal sutures. AnnChir 1991;45(6):513-6.58. Rink AD, Goldschmidt D, Dietrich J, etal. Negative side-effects of retention suturesfor abdominal wound closure. A prospectiverandomised study. Eur J Surg2000:166(12):932-37.59. Van Geldere, D. Abdominal WoundDehiscence. In: Bendavid R, Abrahamson J,Arregui ME, et al. (eds), Abdominal WallHernias: Principles and Management. NewYork: Springer-Verlag, 2001, pp 569-76.60. Dietz UA, Debus ES, Thiede A, Kuhfuss I.Inverting bilateral figure-of-eight suture of therectus sheath after burst abdomen with destruc-tion of the linea alba: a new technique. J PlastReconstr Aesthet Surg 2007;60(4):389-92.61. Sukumar N, Shaharin S, Razman J, JasmiAY. Bogota bag in the treatment of abdominalwound dehiscence. Med J Malaysia2004;59(2):281-3.62. Brandt CP, McHenry CR, Jacobs DG, etal. Polypropylene mesh closure after emer-gency laparotomy: morbidity and outcome.Surgery 1995;188(4):736-40; disc. 740-1.63. Van 't Riet M, de Vos van Steenwijk PJ, etal. Mesh repair for postoperative wound dehis-
cence in the presence of infection: isabsorbable mesh safer than non-absorbablemesh? Hernia 2007;11(5):409-13.64. Jones JW, Jurkovich GJ. Polypropylenemesh closure of infected abdominal wounds.Am Surg 1989;55(1):73-6.65. Schachtrupp A, Fackeldey V, Klinge U, etal. Temporary closure of the abdominal wall(laparostomy). Hernia 2002;6:155-62.66. Buck JR, Fath JJ, Chung SK, et al. Use ofabsorbable mesh as an aid in abdominal wallclosure in the emergent setting. Am Surg1995;61(8):655-7.67. Ansaloni L, Catena F, Coccolini F, et al.New "biological" meshes: the need for a regis-ter. The EHS register for biological prostheses.Hernia 2009;13:103-8.68. Patton JH Jr, Berry S, Kralovich KA. Useof human acellular dermal matrix in complexand contaminated abdominal wall reconstruc-tions. Am J Surg 2007;193(3):360-3.69. Bounovas A, Antoniou GA, Laftsidis P, etal. Management of abdominal wound dehis-cence with porcine dermal collagen implant:report of a case. Ostomy Wound Mgmt2008;54(9):44-8.70. Chuo CB, Thomas SS. Absorbable meshand topical negative pressure therapy for clo-sure of abdominal dehiscence with exposedbowel. J Plast Reconstr Aesthet Surg2008;61(11):1378-81.71. Wotton FT, Akoh JA. Rejection of Perma-colÒ mesh used in abdominal wall repair: acase report. World J Gastroenterol2009;15(34):4331-33.72. Jeon H, McHugh PP, Ranjan D, et al. Suc-cessful management of eviscerated renal allo-graft with preservation of function. Am JTransplantation 2008;8(5):1067-70.73. Chendrasakhar A. Bedside placement ofpolyglycolic acid mesh: a novel treatment ofuncomplicated abdominal wound dehiscence.WV Med J 1996;92:136-7. 74. Halm JA, de Wall LL, Steyerberg EW, etal. Intraperitoneal polypropylene mesh herniarepair complicates subsequent abdominalsurgery. World J Surg 2007;31(2):423-9;disc. 430.75. Sanders RJ, DiClementi D. Principles ofabdominal wound closure. II. Prevention ofwound dehiscence. Arch Surg1977;112(10):1188-91.76. Stone HH, Fabian TC, Turkleson ML,Jurkiewicz MJ. Management of acute full-thickness losses of the abdominal wall. AnnSurg 1981;193(5):612-8.77. Paye F, Rongere C, Gendreau D, LenriotJP. Intraperitoneal resorbable mesh in the pre-vention of postoperative wound dehiscence. Acomparative study. Ann Chir 1992;46(6):518-22.78. Hendrix SL, Schimp V, Martin J, et al.The legendary superior strength of the Pfan-nenstiel incision: a myth? Am J ObstetGynecol 2000;182(6):1446-51.79. Fackeldey V, Höer J, Klinge U. Fascialhealing and wound failure. Chirurg2004;75(5):477-83.
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Hernia RepairSURGICAL TECHNOLOGY INTERNATIONAL XIX
