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Article Excerpt
Wound healing is fundamental to surgical practice. The process of wound healing occurs through a cascade of interrelated intercellular and extracellular processes with the ultimate goal being tissue repair or functional integrity of the tissue. However, wound healing does not always proceed smoothly. Depending on the condition of the wound, the surgical wound healing process occurs in three phases: the inflammatory, proliferative, and maturation phases (Brunner & Suddarth, 2008). Different mechanisms of healing often are described in terms of intention, as primary, secondary, or tertiary. Primary intention, or primary union, begins when wounds are made aseptically with the opposing skin edges well approximated; healing occurs with minimal scar formation. Healing by secondary intention, or granulation, occurs when the skin edges are not well approximated as a result of loss of tissue or pus formation. During this stage, the cavity begins to fill with soft, red granulation tissue made of thin-walled capillaries and buds that later enlarge until they fill the area left by the destroyed tissue. Healing is complete when the epithelium completely covers the granulation tissue. Tertiary intention, also known as secondary suture or delayed healing, occurs when the two opposing granulation tissues brought together do not heal or are sutured later as a result of infection. During this phase, infection produces chemical enzymes that are damaging to the tissue and surrounding sutures (Brunner & Suddarth, 2008). Consequently, tissue damage can lead to wound dehiscence.
Wound dehiscence is the partial or complete disruption of the layers of the surgical wound (Doherty & Way, 2006). The reported incidence of dehiscence ranges from 0.5% (Pavlidis et al., 2001) to 6% (Hanif, Ijaz, Niazi, Zaidi, & Khan, 2000); international studies report an average incidence of 1%-2% (Van Geldere, 2000). In several studies, the morbidity rate associated with abdominal wound evisceration is high; the mortality rate ranges between 10% and 40% (Pavlidis et al., 2001), and can be as high as 44% for adults (Ghimenton, Thomson, Muckart, & Burrows, 2000). Additionally, patients with wound disruption spend an average of 53 days in the hospital (Van't Riet, De Vos Van Steenwijk, Bonjer, Steyerberg, & Jeekel, 2007), increasing length of stay by 9.4 days and resulting in $40,323 in excess health care charges (Zhan & Weingart, 2003). This also exposes patients to the risks of a second surgery and additional loss of work time. While any wound can develop dehiscence, abdominal wound complications occur an average of 7 days after surgery (Cigdem, Onen, Otcu, & Duran, 2006) and in particular are difficult to treat.
Dehiscence Risk Factors
Wound failure encompasses two basic elements: a decrease in the wound tensile strength and an increase in collagenolysis. Abdominal wound dehiscence is thought to result from cumulative predisposing demographic, systemic, and mechanical factors. Personal characteristics such as age over 65 and male gender are associated with wound disruption (Waqar et al., 2005). The older adult patient tends to be at greater risk for wound dehiscence because tissue becomes less resilient and regenerates more slowly with age. Hanif et al. (2000) and Waqar et al. (2005) identified advanced age in 50% of cases in wound dehiscence. Historically, however, research has shown that even middle-aged and younger patients are at risk, with age of dehiscence ranging from 43 (Tweetie & Long, 1954) to 56 (Riou, Cohen, & Johnson, 1992). Men are more likely to experience wound dehiscence than women, with the ratio of male predominance at 2:1 (Hanif et al., 2000; Waqar, 2005). These risk factors may serve to identify individuals in need of close monitoring for wound dehiscence.
Systemic factors may decrease the tensile strength of a healing wound (Hahler, 2006) and increase the patient's risk for wound dehiscence. Concomitant factors include smoking (Waqar et al., 2005), steroid use (Hahler, 2006; Riou et al, 1992; Sorensen et al., 2005), obesity, malnutrition, anemia, hypoproteinemia, hypoalbuminemia, uremia, wound infection, type of incision, and technique of wound closure (Eke & Jebbin, 2006). The clinical significance of these factors in predicting the development of dehiscence is undetermined, but there is general agreement on two points: good nutritional status is essential for wound healing, and infections at the surgical site may contribute to postoperative wound disruption (Brunner & Suddarth, 2008; Carlson, 1999; Pavlidis et al., 2001).
Mechanical factors are perhaps the most significant in predisposing the wound to disruption. Such risk factors include increased intra-abdominal pressure which may be the result of abdominal distention, heavy coughing, retching, or vomiting, or may be the result of pulmonary complications, such as obstructive airway disease, bronchitis, or atelectasis (Doughty, 2005; Eke & Jebbin, 2006; Hahler, 2006). In order for these factors to serve as useful risk indicators, they must be observed and documented because they are difficult...
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