COMPLICATIONS OF ABDOMINAL INCISIONS:A REVIEW OF PREVENTION, DIAGNOSIS, AND TREATMENTBlaine Campbell, PGY3Grand RoundsKUMC – Wichita, Department of OBGYNMay 10, 2017

Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections

Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections

TerminologyWound classification:• Clean – uninfected; no encounter with potential infection source; no viscous entry

• Clean-contaminated – viscous is entered, but under controlled conditions

• Contaminated – fresh accidental wounds; major breaks in sterile technique; gross spillage;

non-purulent infection

• Dirty – grossly purulent, retained foreign body (trauma), devitalized tissue, fecal

contamination

Healing by:• Primary/first intent – surgical approximation of tissues

• Secondary intent – allowing the wound to close naturally

• Delayed wound closure – surgical closure of the wound after appearance of granulation

tissue

Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections

Complications• Collection of blood or serum• Asymptomatic; pain, drainage, swelling (fever, erythema, induration)• Predisposition to infection; impede wound healing

DIAGNOSIS• Inspection/palpation• Within a few days or delayed• CT or ultrasound

HEMATOMA/SEROMA

PREVENTION• Subcutaneous, retrofascial• Surgical technique

- Avoid excessive tissue handling and trauma- Fewest strokes/dissection possible- Decrease necrotic tissue and tissue ischemia- Scalpel vs electrocautery

*No benefit of one over other for both skin and subcutaneous incisions *Non-modulated (cutting) current similar tissue damage to scalpel [1]

HEMATOMA/SEROMA Complications

PREVENTION• Dead space as potential risk • Closure of subcutaneous tissue

*General surgery: no evidence to suggest increased incidence of wound complications if subcutaneous tissues not sutured [2]

*Cesarean section/hysterectomy: benefit in closure of Camper’s fascia [3,4]

HEMATOMA/SEROMA Complications

TREATMENT• Simple seroma/hematoma: expectant management• Large collections should be drained

Seromas: sterile needle aspiration (+/- ultrasound)Hematomas: partial or complete reopening (+/- OR)

- No evidence of infection = primary closure- (+) infection = debridement, irrigation, delayed closure or secondary intent

*Delayed closure significantly reduces healing time compared to secondary intent [5,6]

HEMATOMA/SEROMA Complications

TREATMENT• If lymphatic, serum, or blood collection anticipated (Ex: Maylard & oblique incisions,

accessing space of Retzius) -OR- chronic seroma formation- Consider drain placement- Puncture wound separate from primary incision- Open vs closed systems- Active vs passive systems

*Meta-analysis and RT have shownclosed systems do NOT significantlyprevent wound complications [7]

HEMATOMA/SEROMA Complications

Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections

• Disruption of fascial closure• Incidence 0.4-3.5% depending on type of surgery• Early (emergency) or delayed (incisional hernia)

- Mean 8 days postop

*Wounds have <5% of the tensile strength of unwounded tissue in the first postoperative week, thus wound security solely dependent on suture in healthy tissue

FASCIAL DEHISCENCE Complications

• *The knot is the weakest part of a suture- No benefit to using surgeon’s knot over square knot [8]

- Braided suture has better knot security compared with monofilament- Tying a single strand to a double strand of suture reduces knot security [9]

• Up to 95% of cases of abdominal wound dehiscence have intact knots and sutures, but suture has pulled through fascia [10, 11]

- Facial necrosis

ComplicationsFASCIAL DEHISCENCE

PREVENTIONTechnique, technique, technique!

Spacing: 1cm x 1cm- <5mm from tissue edge = risking nonviable or weak suture anchoring- >10mm from edge = increases compressive forces on bunched tissue [12]

- European Hernia Society

Length of suture: 4x length of incision; 4:1 recommended to reduce hernia [13]

ComplicationsFASCIAL DEHISCENCE

PREVENTIONTechnique, technique, technique!

Mass closure: Smead-Jones or continuous single- or double-loop closure- Significantly decreases dehiscence [14, 15]

Suture: slowly absorbable sutures [16]

Continuous closure: distributes tension evenly along incision; allows better perfusion; saves time; less knots. Downside is reoperation/removal

- Interrupted closure had significantly higher hernia rate regardless of type of suture [16]

ComplicationsFASCIAL DEHISCENCE

DIAGNOSIS• Clinical• “Pink lemonade” sign; copious serosanguinous• Popping sensation, incisional bulge increased with valsalva• Ultrasound or CT

TREATMENT• Wound exploration in OR• Until OR, can place moist dressing over incision and abdominal binder• +/- Retention sutures

ComplicationsFASCIAL DEHISCENCE

Overview• Terminology• Seromas/Hematomas• Fascial dehiscence • Surgical site infections

TerminologyGranulation tissue• Beefy, fleshy, red• Neovascularization• Tissue of healing Vs.

SURGICAL SITE INFECTION

• 4% of clean and 35% of dirty wounds• Superficial, deep, organ/space• Risk factors: DM, obesity, immunosuppression, smoking, cancer, previous surgery,

malnutrition, prior irradiation

PREVENTION• Sterile technique• Irrigation• Prophylactic antibiotics

Complications

Antibiotic Prophylaxis for Gynecologic ProceduresACOG Practice Bulletin 104, reaffirmed 2016

Prophylaxis Regimens by Procedure

ComplicationsSURGICAL SITE INFECTION

DIAGNOSIS• Erythema, induration, fluctuance/purulence discharge, fever, wound separation

- Necrotizing fasciitis• Culture and sensitivity

TREATMENT• Conservative vs reexploration

1. Exploration: - Anesthesia needs on a case-by-case basis- Fascial involvement requires the OR

ComplicationsSURGICAL SITE INFECTION

TREATMENT2. Debriding:- Mechanical vs enzymatic- Remove all devitalized tissues- Debride until level of granulation tissue or uninvolved tissue is reached

Sharp excisional debridement of chronic wounds decreases bacterial load and stimulates wound contraction/epithelialization [17]

ComplicationsSURGICAL SITE INFECTION

TREATMENT3. Irrigation:

- Pressurized vs passive- Isotonic solution preferred (saline)- Tap water in ambulatory setting- Addition of iodine or antiseptic solutions may impede wound healing [18, 19]

4. Antibiotics:- Targeted treatment according to potential contamination source and cultures

ComplicationsSURGICAL SITE INFECTION

• Delayed closure:- Secondary intent used to be standard of care - Delayed closure safe & effective; only 5% incidence of re-exploration for reinfection- Ideally between day 3-5, no later than day 10*Significantly decreases healing time over secondary intent

ComplicationsSURGICAL SITE INFECTION

DRESSINGS• Significant effect on speed of healing, wound strength, skin function, and cosmetics• Adjusted in case-by-case basis

- Some impede some aspects of healing (ex: silver dressings)- Charts available, providing visual description of wound and recommended dressing- In general:

Hydrogels for debridement stageLow-adeherent & moisture retentive for granulationLow-adherent for epithelialization (i.e. “let it breathe”) [20]

• Dressing changes daily or every other day • Initial bandage removal in first 48 hours after procedure

SURGICAL SITE INFECTION

WOUND PACKING• Wounds with large soft-tissue defects (tunneling, undermining) need packing• Document accurate depth of wound and its dimensions

• Wet to Dry packing- Used in healing by secondary intent or delayed closure- Contaminated wounds, or incision after debridement/reoperation- Wet gauze packed into incision; removal of necrotic tissue as dry out and changed

(up to 2-3x daily)- Discontinuation when granulation tissue is noted

*Chronic wounds should never be closed primarily

SURGICAL SITE INFECTION

WOUND VAC

Decreases surrounding edemaIncreases circulationIncreases granulation

QUESTIONS/COMMENTS?

REFERENCES

1. Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011; 253:8

2. Paral J, Ferko A, Varga J, et al. Comparison of sutured versus non-sutured subcutaneous fat tissue in abdominal surgery. A prospective randomized study. Eur Surg Res 2007; 39:350.

3. Del Valle GO, Combs P, Qualls C, Curet LB. Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption? Obstet Gynecol 1992; 80:1013.

4. Naumann RW, Hauth JC, Owen J, et al. Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Obstet Gynecol 1995; 85:412.

5. Dodson MK, Magann EF, Meeks GR. A randomized comparison of secondary closure and secondary intention in patients with superficial wound dehiscence. Obstet Gynecol 1992; 80:321.

6. Walters MD, Dombroski RA, Davidson SA, et al. Reclosure of disrupted abdominal incisions. Obstet Gynecol 1990; 76:597.

7. Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery--a metaanalysis. Am J Obstet Gynecol 2007; 197:229.

REFERENCES

8. van Rijssel EJ, Trimbos JB, Booster MH. Mechanical performance of square knots and sliding knots in surgery: comparative study. Am J Obstet Gynecol 1990; 162:93.

9. Muffly TM, Boyce J, Kieweg SL, Bonham AJ. Tensile strength of a surgeon's or a square knot. J Surg Educ 2010; 67:222.

10. Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 2005; 62:220.

11. Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations. Cochrane Database Syst Rev 2013; :CD010424.

12. Cengiz Y, Gislason H, Svanes K, Israelsson LA. Mass closure technique: an experimental study on separation of wound edge. Eur J Surg 2001; 167:60.

13. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015; 19:1.

14. Seid MH, McDaniel-Owens LM, Poole GV Jr, Meeks GR. A randomized trial of abdominal incision suture technique and wound strength in rats. Arch Surg 1995; 130:394.

15. Meeks GR, Nelson KC, Byars RW. Wound strength in abdominal incisions: a comparison of two continuous mass closure techniques in rats. Am J Obstet Gynecol 1995; 173:1676.

16. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg 2010; 251:843.

17. Brem H, Stojadinovic O, Diegelmann RF, et al. Molecular markers in patients with chronic wounds to guide surgical debridement. Mol Med 2007; 13:30.

18. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.

19. Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med 1998; 5:1076.

20. Paddle-Ledinek JE, Nasa Z, Cleland HJ. Effect of different wound dressings on cell viability and proliferation. Plast Reconstr Surg 2006; 117:110S.

21. https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html

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