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Burst Abdomen

Burst Abdomen. Presented by Dr. Saifuddin Ahmed. Definition. Post-operative separation of the abdominal musculo-aponeurotic layers. Mean time for dehiscence after 8 to 10 days. . Incidence . Incidence Historical 10%

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Burst Abdomen

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  1. Burst Abdomen Presented by Dr. Saifuddin Ahmed

  2. Definition • Post-operative separation of the abdominal musculo-aponeurotic layers. • Mean time for dehiscence after 8 to 10 days.

  3. Incidence • Incidence • Historical 10% • Recent study – 3.2% [Veterens Affairs Quality programme]

  4. Predisposing factors • 6S • Surgery • Surgeon • Sutures • Sepsis • Straining • Sick patient

  5. Predisposing factors • Surgery • Grossly contaminated surgery • Peritonitis • Biliary-fistula • Faecal-fistula

  6. Predisposing factors • Surgeon • Technique • Meticulous dissection • Haemostasis. • Gentle tissue handling • Tensionless sutures • Incision • Vertical incision worse than Transverse.

  7. Predisposing factors • Straining • Violent cough • Persistent vomiting • Distension • Paralytic ileus • Sepsis • Uncontrolled sepsis

  8. Predisposing factors • Sick patient • Malignancy • Jaundice • Obesity • Anaemia • Hypo-proteinemia • Uremia • Sutures • Prefer non-absorbable sutures

  9. Risk Factors

  10. Predisposing factors • Pre-operative • Cough • Anaemia • Hypo-proteinemia • Malnutrition • Steroid

  11. Predisposing factors • Post-operative • Cough • Abdominal distension • Ascitis • Vomiting • Bowel leakage • Wound infection • Haematoma • Uraemia • Jaundice • Electrolyte imbalance

  12. Mortality • Range • 9 to 43 % • Recent study • 16 % • Prevention is the cornerstone • With meticulous surgical technique

  13. Clinically • Pathognomonic feature • Sudden rush of copious serosanguinous discharge for the wound • Large subcutaneous hematoma • Herniated bowel under the skin • Tympanic boggy swelling

  14. Management • Basic principle • Resuture the wound edges • Replace the eviscerated organs • Prevent • recurrent dehiscence • Later development of ventral hernias • As soon as recognized • Protruding viscera - Warm NS bath • cover with large sterile dressing • Shift to OT

  15. Management • When there is Seepage of serosanguinous fluid through a closed abdominal wound, • Remove one or two sutures in the skin and • Explore the wound manually, using a sterile glove. • Look for any separation of the rectus fascia.

  16. Management • Operating room for primary closure. • Wound dehiscence may or may not be associated with intestinal evisceration. • When evisceration is present, the mortality rate is dramatically increased and may reach 30%.

  17. Management • If only very small area of the wound disrupted • That portion alone sutured • If more than half of the incision disrupted • Suture whole wound afresh

  18. Management • Small deficit • Conservative management • Packing with moist sterile dressing • Transverse elastic dressing • Abdominal binder • Avoid strenous activities • Secondary suturing/ natural healing

  19. Management Large deficit: • NG tube • GA • Lift up edges • Reposition of prolapsed bowel • Extract fragments of suture • Freshen the edges • Retention Suture • Strong monofilament non-absorbable • Continuous/ interrupted stitch.

  20. Retension Sutures • Strong monofilament Nylon • Thread through protective rubber tubing • 2.5 cm apart, 2.5 cm from margin. • All layers of the abdomen taken together. • Stitch off after 2 to 4 weeks.

  21. Retension Sutures Advantage • Reduce chance of evisceration. Disadvantage • Pain, discomfort • Types • Internal • External

  22. Comparison

  23. References GASTROENTEROLOGY 2003;124:1111–1134

  24. Thank You

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