Successful Management of Infected Widely Dehisced Wound Using Progressive Tension Sutures: Case Report

Introduction

Surgical wound dehiscence (SWD) is the separation of the margins of a closed surgical incision in skin, with or without exposure or protrusion of underlying tissue, organs, or implants.¹ Broadly, SWD could be a partial or total separation of previously approximated wound edges due to failure of wound healing.^2–4 In partial dehiscence, only the superficial layers or part of the tissue layers reopen, but in complete wound dehiscence, all layers of the wound thickness are separated.^5,6 If the intestine protrudes through the separated wound, the term evisceration (burst abdomen) is used.⁴ The dehisced incision may or may not be associated with clinical signs and symptoms of infection. Depending on the presence of infection and depth of separation, SWD has four grades (Table 1). In the majority of patients, SWD occurs between the fifth and 14^th postoperative day.^3,4,7,8 SWD is rare, with a frequency of 0.06% and 7%. Nonetheless, the reported mortality rate reaches as high as 45%.^3,6–9

Table 1 Sandy Classification System of the World Union of Wound Healing Societies (WUWHS, 2018)

The major risk factors for SWD include post-operative wound infection, older age, hypoproteinemia, emergency surgery, duration of surgery, obesity (BMI exceeding 30), chronic obstructive pulmonary disease (COPD), smoking, diabetes, malnutrition, radiation, and poor perfusion.^1,4,6,9,10 Hematoma or seroma at the incision site, described in 2–5% of women after CS, has been known to act as a predisposing factor to wound infection and subsequently to wound dehiscence.⁸ Abnormal wound healing, untying of the suture knots, and mechanical stress can also lead to SWD.^6,10–12 Various surgical interventions are used to address SWD, some of which include tension suturing, Mesh repair, Bogota bag, and vacuum-assisted closure.³ Here, we report a case of complete wound dehiscence successfully managed by progressive approximation of widely separated wound edges by tension sutures.

Case Report

A 35-year-old Para-VII Eritrean woman was referred to Orotta National Referral Teaching Hospital as a case of intractable wound dehiscence. She was a postpartum patient on day 30 who delivered by caesarean section for a prolonged second stage and fetal distress. The membrane ruptured during the active phase of labor and was meconium-stained. On postoperative day 5, the patient developed a surgical site infection, complicating wound dehiscence. Consequently, the patient had a fever and occasional diarrhea that subsided after five days of broad-spectrum antibiotic treatment. Following two failed attempts at dehisced wound closure at an interval of one week, the patient was referred to Orotta National Referral Hospital for further treatment.

On arrival at our hospital, she was chronically ill-looking and emaciated with normal vital signs. She had pink conjunctivae and nonicteric sclera. The abdomen was moderately distended with a longitudinal midline incision below the umbilicus. The size of the wound bed was 20 cm by 18 cm, and protruding abdominal contents through the dehisced wound, but covered by the peritoneum (Figure 1a). On vaginal examination, the cervical os was closed, without discharge or bleeding. Transabdominal ultrasound revealed an empty uterus without any collection of intra-abdominal fluid or abscess. The complete blood count, liver function test, and renal function test were all within normal range. But the serum albumin was low (hypoalbuminemia). Under general anesthesia, thorough debridement was done; the patient was started on broad-spectrum antibiotics, followed by daily wound dressing with normal saline. Eventually, the wound slowly started to granulate (Figure 1b).

Figure 1 (a) Dirty wound with purulent discharge and widely separated wound edges upon hospital admission. (b) Clean wound with some granulation tissue after a week of dressing and antibiotic treatment, and the arrow shows the separated edge of the rectus sheath muscle.

With the dressing and wound healing, the wound contracture began to approximate the wound edges (Figure 2a). Progressive approximation of the wound edges using tension sutures was performed at an interval of three weeks under spinal anesthesia (Figure 2b). The through-and-through retention sutures with Vicryl number 2 passing through a sterile intravenous set (tube) were placed at a distance of 2 cm from the skin through all layers of the wound to strengthen the tension (Figure 2b). After 3 weeks, the tension sutures were removed, and the wound base decreased to a width of 3 centimeters.

Figure 2 (a) After 2 weeks of wound dressing, wound contracture started to approximate the wound edges. (b) Further approximation of wound edges using tension sutures.

Finally, after the removal of the tension sutures, the patient was taken to the operating room for the third time, and the ragged and scarred wound edges were debrided, and the closure was left to heal by third intention. Another set of tension sutures was placed at two sites to be removed after two weeks (Figure 3a–c).

Figure 3 (a) Removal of ragged and scarred wound edge with closure by tertiary intention. (b) Tension sutures at two sites during tertiary intention, and (c) finally, the successfully treated wound.

Discussion

Surgical wound dehiscence is a serious postoperative complication where management poses a clinical challenge.³ Surgical wound dehiscence occurs when the wound does not gain sufficient strength to withstand the strains placed on it.^3,6 It is less common (0.1% to 0.7%) in gynecologic abdominal procedures. SWD incurs high healthcare expenditures due to increased rates of reoperations and extended hospital stay.^6,10,13 SWD also contributes significantly to dissatisfaction and related psychosocial stress in patients and their caregivers. In our case, the length of hospital stay could have been reduced if the wound breakdown had been recognized early, and the two initial trials of closure had been deferred. Unfortunately, it was identified when full-blown purulent discharge developed.

The risk factors and causes of SWD are similar to the causes of SSI.¹⁰ Good knowledge of the risk factors is of paramount significance for the prevention of wound dehiscence using prophylaxis.⁹ Factors such as excessive wound tension, choice of suturing material, and quality of tissue influence the risk of dehiscence.¹³ In our case, prolonged labour, the materials used in their first trial, and wound tension might have predisposed her to the recurrent wound dehiscence. Proper selection of suture material is critical in preventing wound dehiscence. If a suture has too little initial tensile strength or it is absorbed too quickly before the wound regains enough strength to resist normal stress.⁴ A surgeon’s expertise and surgical techniques also play a key role in preventing wound dehiscence.^1,3 For high-risk groups, an interrupted far-far, near-near mass closure technique is preferred.⁴ In our patient, the initial surgery was performed in another hospital. Thus, we have no knowledge of the sutures used. During our progressive wound closure, we used the number 2 Vicryl tension sutures.

Low transverse incisions are 30 times stronger than midline incisions; they are also less painful, and result in less interference with postoperative respirations compared to mid-longitudinal line incisions.⁴ In our patient, the mid-longitudinal line incision was preferred, for fast entry for fetal distress, a decision which predisposed her to recurrent wound dehiscence. The key factors that must be considered are the timely identification of risk factors, early detection of the signs and symptoms of SWD, accurate assessment and categorization of the type of wound dehiscence, and, more importantly, prompt management.^1,3 Primary SWD closure is the most common practice, unless there is no significant tissue tension. Furthermore, it is better suited for patients whose wound dehiscence is due purely to technical failure.³ In our case, the two previous attempted closures possibly failed due to incomplete tissue granulation and surgical techniques in the approximation of the edges of the wound.

Thorough wound cleaning was done to remove foreign bodies, devitalized and dead tissue, and bacteria. Complete removal of necrotic tissue minimizes bacterial burden. Debridement also removes migrated leukocytes that have phagocytized the bacteria.¹² Supportive measures such as nutritional support, regular ambulation with control of infection, speed up the recovery.³ In our case, wound debridement was done once with normal saline, and wound dressing was done daily to avoid disruption of the wound response.

The use of prophylactic antibiotics can reduce the risk of infection and subsequent dehiscence.^1,5,9 Emergency laparotomies have an increased risk of delayed healing, mainly due to increased contamination and inadequate preparation for surgery.^1,9 In our case, the surgery was performed after a prolonged second stage of labor and fetal distress. Poor quality of wound closure, leading to inadequate tissue perfusion and thus tissue ischemia, can hinder wound healing and contribute to wound dehiscence.¹³ Proper postoperative wound care with appropriate wound dressing, prophylactic antibiotics, and vigilant monitoring of the surgical site are of utmost importance in preventing wound dehiscence.

Conclusion

Complete wound debridement, followed by progressive approximation of wound edges using tension sutures at the interval of two to three weeks, increases the success rate of dehisced surgical wound closure without using a Mesh in resources limited areas.