Wound dehiscence surgical management - IJSER

International Journal of Scientific & Engineering Research Volume 8, Issue 12, December-2017 1933 ISSN 2229-5518

IJSER © 2017 http://www.ijser.org

Wound dehiscence surgical management

Abdulaziz Yarub Hassan Alali, Ahmed Yarub Hassan Alali, Omar Yarub Hassan Alali, Nawaf

Faisal Alharthi, Shelian Juweed Al Nomsi

Abstract:

In this review we discuss prevalence and incidence of SWD, early diagnosis methods for

prevention and surgical management approach. We conducted a comprehensive search for

articles published in English up to November, 2017. Search was performed through following

databases; MEDLINE, Current Contents, Web of Science, and PubMed with the terms

“wound dehiscence”, “prevention”, “surgical treatment”. Following surgery most surgical

wounds recover naturally without difficulties. Nonetheless, complications such as infection and

wound dehiscence could take place which may result in delayed healing or wound breakdown.

Postoperative wound healing plays an important function in promoting a patient's recovery and

recovery. Surgical wound dehiscence (SWD) influence on mortality and morbidity rates and

significantly contributes to prolonged hospital stays and related psychosocial stressors on people

and their families. Infected surgical wounds may consist of dead (devitalised) tissue. Removal of

this dead tissue (debridement) from surgical wounds will help to reduce bacterial burden in the

management of an SSI. Careful management and diagnosis in needed in case of wound

dehiscence.

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Introduction:

Timely and sustained postoperative wound recovery plays a significant role in optimising a

patient's postoperative healing and recovery. It has been established that surgical wound

dehiscence (SWD) contributes to enhanced morbidity and mortality rates, and implied and

specific expenses for individuals and health care providers [1], [2]. Specific prices result from

extended hospitalisation, the need for community nursing and support solutions and making use

of wound management consumables [3], [4].Social prices consist of hold-up in go back to work,

minimized capability to self-care and constraints on going back to previous social functions in the

area consisting of family support. SWD is defined as the rupture or splitting open of a formerly

closed surgical incision site. According to the Centre for Disease Control (CDC), a SWD can be

identified as either shallow or deep [5].A testimonial of the literature for aspects related to SWD

was performed in response to an identified rise in SWD referrals to a neighborhood nursing

solution in Western Australia, following either a cardiothoracic, orthopaedic, vascular or

abdominal surgical procedure. The goal of this evaluation was to identify inclining elements for

SWD and evaluation devices to help in the recognition of at-risk patients.

Wound dehiscence is a feasible complication adhering to any surgical procedure; nevertheless, a

lot of authors [6], [1], [2] report the event complying with orthopaedic, abdominal, cardiothoracic

and vascular surgical treatment. The literary works outlines some associations in between SWD

and patient comorbidities and the type of surgical wound closure [7].Nevertheless, the

recognition of these organizations as effective diagnostic predictors for SWD risk has been

inadequately studied throughout the majority of surgical domains.

In this review we discuss prevalence and incidence of SWD, early diagnosis methods for

prevention and surgical management approach.

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Methodology:

We conducted a comprehensive search for articles published in English up to November,

2017. Search was performed through following databases; MEDLINE, Current Contents, Web

of Science, and PubMed with the terms “wound dehiscence”, “prevention”, “surgical

treatment”. Furthermore, we searched the reference lists of articles identified by this search.

We restricted our search to articles with human subjects only.

Discussion:

• Prevalence and incidence of SWD

The occurrence of SWD following different surgeries has been reported as ranging in between

1,3 and 9,3% (Table 1). Among these researches, incidence data have been reported based on the

CDC SSI classification standards. The studies within the scope of the evaluation were categorised

into abdominal wound dehiscence, cardiothoracic, orthopaedic and vascular. For the purposes of

this evaluation, SWD is specified as the rupturing or splitting apart of the margins of a wound

closure [8].Wound dehiscence can be a superficial or deep tissue injury and according to the

CDC [9] wound dehiscence can be associated with SSI.

Table 1. Incidence of surgical wound dehiscence

Procedure Study Abdominal surgery—superficial dehiscence 2% and deep dehiscence 0·3%

Hadar et al. [11]

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Abdominal 1·3–4·7% Wounds West prevalence data (2007–2011) Caesarean section 3% De Vivo et al. [12] Sternal wound 3% John [14] Hip prosthesis 3% Smith et al. [10] Saphenous vein graft 9·3% (10/108 patients) Biancari and Tiozzo [13]

• Assesment

Clinicians ought to complete a holistic patient assessment to recognize elements that could

influence surgical injury healing in the pre-, intra- and post-operative stages. It is necessary to

keep in mind that reassessment should take place during the whole post-operative phase. The pre-

operative stage is an essential time, offering the possibility to create an atmosphere that prevents

surgical wound difficulties. Surgical injuries ought to be evaluated and the findings recorded

utilizing a standardized strategy.4 Assessment utilizing a comprehensive wound analysis tool

gives a standard and helps with the recognition of wound changes. This details helps with

determining either wound healing or degeneration and must guide recurring treatment choices.

Assessment of the individual with a surgical wound starts quickly post-op, nevertheless most

surgical incisions are not generally analyzed up until 48 hours after surgery since, in most cases,

the original post-operative dressing remains in place for the initial 48 to 72 hours [15].

In addition to the wound analysis devices recommended in Wounds Canada's "Best Practice

Recommendations for the Prevention and Management of Wounds" 12 article, Pillen et al.

recognize 3 added tools for evaluation of surgical and general wounds: [16]

- The Barber Measurement Tool (BMT) makes use of the percent reduction in wound size in time

as a sign of healing but was not supported by information [17] .

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- The ASEPSIS tool was created to evaluate the effectiveness of antibiotic treatment on surgical

site infections by examining wound qualities. It was verified for high inter-rater integrity

however not examined for validity, intra-rate reliability or responsiveness [18].

- The Granulometer's function was to assess the condition of skin grafts and had interand intra-

rater reliability when used by surgeons to establish wound-healing progression. It was not

checked with various other health-care professionals. It had a non-significant anticipating ability

for graft take, recommending that it was not sensitive to small changes [19].

An extra evaluation tool, which has a section particularly for surgical wounds, is the Outcome

and Assessment Information Set-C (OASIS-C), an adjustment to the Outcome and Assessment

Information Set (OASIS) that home health agencies in the United States have to gather in order to

join the Medicare program (Wound, Ostomy and Continence Nurses Society). It provides

assistance regarding just what is and is ruled out a surgical wound. As well, Trexler supplies an

useful testimonial of how you can make use of the OASIS-C surgical wound thing M1342 to

classify surgical wounds [21].If the wound arises from an intervention that disrupts the intact

integumentary system (skin, hair, nails and sweat glands), it is a surgical wound. OASIS-C states

that surgery on a pre-existing wound or due to a terrible injury including the skin is not identified

as a surgical wound; nonetheless, surgery to repair or eliminate a damaged internal organ because

of trauma, where the skin was undamaged is taken into consideration a surgical injury. Likewise

according to OASIS-C, skin grafts over existing wounds are not surgical wounds, Foundations of

Best Practice for Skin and Wound Management yet benefactor sites are surgical wounds

[22].These meanings are open to conversation and interpretation and, generally, if a surgical

procedure is involved, any resulting laceration, injury or skin graft is considered either a surgical

incision or a surgical wound. If it is not healed in 30 days, it is still considered to be a surgical

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wound. It is very important that there is arrangement within each health-care organization about

what is and what is not classified as an open surgical injury.

In OASIS-C product M1342, "Status of Most Problematic (Observable) Surgical Wound," there are 4 possible choices, each with additional description (see Table 1): [23]

1. Newly epithelialized

2. Completely granulating

3. Early/partial granulation

4. Not recovery (may or may keep in mind be connected with infection).

For wounds healing by primary closure with well-approximated incisions, the close proximity of

the incisional edges leaves no locations for granulation to occur. For that reason, just the "newly

epithelialized" and "not healing" selections use. For wounds healing by secondary objective, all

four options would apply [21].This support relates to surgical wounds closed by either primary

intent (especially, approximated incisions) or secondary objective (specifically, open surgical

wounds).

Table 2: Surgical Wound Descriptions [23].

Newly epithelialized: • wound bed completely covered with new epithelium • no exudate • no avascular tissue (eschar and/or slough) • no signs or symptoms of infection

Fully granulating: • wound bed filled with granulation tissue to the level of the surrounding skin • no dead space • no avascular tissue (eschar and/or slough) • no signs or symptoms of infection • wound edges open

Early/partial granulation: • ≥ 25% of wound bed covered with granulation tissue • < 25% of wound bed covered with avascular tissue (eschar and/or slough) • no signs or symptoms of infection • wound edges open

Not healing:

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• wound with ≥ 25% avascular tissue (eschar and/or slough), OR • signs/symptoms of infection, OR • clean but non-granulating wound bed, OR • closed/hyperkeratotic wound edges, OR • persistent failure to improve despite appropriate comprehensive wound management

• Optimize the local wound environment through Cleansing

Wound cleansing at its best ought to eliminate foreign bodies such as organic or inorganic debris,

inflammatory pollutants such as devitalized tissue, bacteria and injury exudate without causing

trauma to healthy cells or introducing bacteria deeper into the wound [24].

Care of a post-operative injury recovery by primary intention must utilize a nontouch aseptic

method making use of sterile saline approximately 48 hours after surgical treatment. Showering

is permitted 48 hrs after surgery in most cases; however, the decision depends on the

participating in surgeon and will be tempered by factors such as drains, hardware and skin grafts.

Efforts to cleanse a primary incision in beginning could disrupt the pathogenic microorganisms

along the suture line [25].Many surgical incisions do not require cleansing, [26] however

cleansing might add to patient comfort and remove any products that may postpone the healing

procedure [27].

Cleansing of surgical injuries that dehisce, are to heal by secondary objective or have an

increased bacterial load require clinical analysis and consideration of the kind of cleaning agent

and technique to be used. Each of the choices could have clinical advantages as well as

preventative measures. The NICE guidelines suggest that faucet water be utilized for injury care

after 48 hrs if the incision has separated or has been surgically opened to help with the water

drainage of pus. The Joanna Briggs Institute cautions that faucet water for post-operative wounds

should not be utilized if it has been stated non-potable [28].If used, the faucet must be run for 15

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secs before use, and safety and security of the tap water need to be guaranteed in rural areas. The

selection of solution must reflect patient choice and a formal economic assessment. Boiled and

cooled water is an appropriate service in the absence of safe and clean tap water, although in the

writers' experience, lots of health-care specialists still like to use sterile normal saline in their care

of dehisced incisions, risky injuries and especially when vascular grafts or hardware are included.

• Surgical management

Debriding

The elimination of necrotic tissue will help to minimize bacterial burden in the management of an

SSI. In collaboration with the surgeon, clinicians have to identify what method of debridement is

most proper: debridement with speed (surgical debridement done by the surgeon), conventional

sharp wound debridement (CSWD) of necrotic tissue by a proficient doctor, nurse or

physiotherapist; mechanical debridement, using irrigation with forces of 7 to 15 pounds per

square inch (psi), adequate quantity of solution, or compresses; autolytic debridement with

mindful dressing selection or a mix of approaches [30].The team has to decide who is the most

proper health-care professional to execute debridement of the necrotic tissue. Policies, treatments

and experienced professionals have to remain in area for reliable conventional sharp wound

debridement [29].Much more considerable debridement must be executed only by the medical

team or by persons with the proper skill degree. Sharp debridement needs that ideal analgesia be

offered to the patient in the past, throughout and after the procedure, which the setup allow for

the achievement of hemostasis [30].According to the NICE standards, eusol (hypochlorite bleach)

in gauze, damp cotton gauze or mercuric antiseptic remedies ought to NOT be utilized to take

care of surgical wounds that are healing by secondary intention. There is not enough high-grade

proof to sustain eusol versus that of alginates, so the problem is not that it triggered harm. The

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toxicity index would certainly depend on the quantity of dilution made use of. There are newer,

safer antiseptic solutions for usage when injuries have bacterial biofilm, localized infection,

debris or necrotic tissue. These consist of a non-toxic, pH-balanced, hydrochlorite 1:1000 and

hypochlorous acid solution being made use of for debridement and odour management, and a

polyhexamethylene biguanide (polyhexanide or PHMB) solution that decreases surface tension,

help removal of debris, bacteria and biofilm, and can be utilized adhering to sharp debridement.

Skin graft and donor sites

Skin grafts are a section of epidermis and dermis that has been totally separated from its blood

supply in one part of the body (donor site) with the objective of transplanting it to an additional

location of the body (recipient site) [31].

Although the OASIS device does not consider skin grafts to be surgical wounds if done to repair

an existing wound, donor sites and skin grafts are the result of surgical interventions. Full-

thickness skin grafts are used for little areas. Skin can be acquired from the pre-and post-auricular

region, the neck, upper and lower extremities, groin and abdomen. Split-thickness grafts use the

epidermis and a portion of the dermis. This skin is gathered from any kind of body location,

however the thigh is most typical. Grafts may be non-meshed or meshed. If fit together, after that

it is developed by pie-crusting with a scalpel or with a mesher that produces fenestrations at

equivalent distances. The purpose of meshing is to create a larger surface area from a smaller

sized graft. It additionally permits drainage of liquid from the wound to prevent hematoma or

seroma formation [31].

Donor site injury care requires the application of moist wound healing concepts. There are

several industrial dressings offered to sustain moist wound healing [32].Donor sites recover by

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re-epithelialization usually needing transparent dressings or fine mesh gauze [32].The donor site

can be more agonizing compared to the graft site and needs protection and patient education to

heal [31].

Conclusion:

Following surgery most surgical wounds recover naturally without difficulties. Nonetheless,

complications such as infection and wound dehiscence could take place which may result in

delayed healing or wound breakdown. Postoperative wound healing plays an important function

in promoting a patient's recovery and recovery. Surgical wound dehiscence (SWD) influence on

mortality and morbidity rates and significantly contributes to prolonged hospital stays and related

psychosocial stressors on people and their families. Infected surgical wounds may consist of dead

(devitalised) tissue. Removal of this dead tissue (debridement) from surgical wounds will help to

reduce bacterial burden in the management of an SSI. Careful management and diagnosis in

needed in case of wound dehiscence.

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Wound dehiscence surgical management - IJSER