Wound Evisceration and Wound Dehiscence - Causes, Risk Factors, and Prevention

Introduction:

Wound dehiscence and evisceration are surgical complications in which the approximated edges get separated, which occurs due to ischemia, infection, smoking, hypoalbuminemia, malnutrition, exposure to radiation, pressure on the sutures, diabetes, obesity or long-term use of corticosteroids. In severe cases, the internal organ shows through the incised wound. This complication occurs due to multiple factors such as infection, low blood supply, malnutrition, radiation therapy, and systemic factors like diabetes, low protein levels, and low carbohydrate levels. These can be prevented by taking appropriate measures.

What Is Wound Dehiscence?

It is a surgical complication where the approximated wound edges are separated completely or partially. This occurs in the early stage of surgery, around 5 to 6 days. As a result, the site may show symptoms of bleeding, broken sutures, open wounds, swelling, redness, and pain. Superficial dehiscence occurs when the edges of the wound separate due to increased bleeding or drainage. This can occur due to various causes such as ischemia, infection, smoking, hypoalbuminemia, malnutrition, exposure to radiation, pressure on the sutures, diabetes, obesity, or long-term use of corticosteroids. It can be managed with the help of abdominal binders that reduce strain on the wound and prevent further dehiscence. In contrast, deep dehiscence should be closed surgically because this can lead to evisceration.

What Is Wound Evisceration?

Wound evisceration is when the internal organs push out through the dehisced wound. This condition requires emergency treatment. This may occur from the omentum or the internal organs through the separated fascia.

What Are the Stages of Wound Healing?

Wound healing is a natural reaction to injury to the tissue. It involves many cells, such as the vascular system, cytokines, and mediators. It consists of four stages

• Hemostasis Phase: Platelet aggregation and vasoconstriction of blood vessels to control bleeding.

• Inflammatory Phase: This consists of hemostasis (cessation of blood), chemotaxis, and increased vascular permeability, which limits the damage by closing the wound and removing bacteria and cellular debris; it lasts for several days.

• Proliferative Phase: Granulation tissue is formed, and neovascularization and re-epithelialization occur.

• Maturation and Remodeling Phase: Maximum strength is achieved by the wound.

What Are the Causes of Wound Dehiscence and Wound Evisceration?

The causes include:

• Ischemia: It is a condition where the blood flow is reduced, resulting in low oxygen, which hampers wound healing.

• Infection: The wound gets stuck in the inflammation phase and cannot achieve the end stage of healing.

• Smoking: It causes vasoconstriction (narrowing blood vessels), which results in low blood flow.

• Hypoalbuminemia: It is a condition of decreased albumin protein, and protein is essential for collagen synthesis, fibroblast proliferation, and angiogenesis. Therefore, without adequate amounts of protein, it can lead to delayed wound healing.

• Malnutrition: Decreased carbohydrate levels can cause protein catabolism (breakdown of protein) and wound breakdown. Decreased zinc and vitamin C can hamper wound healing.

• Radiation: It causes microvascular obliteration, increased fibrosis, and altered cellular replication, which leads to delayed wound healing.

• Pressure on the sutures or incorrect sutures or tight sutures.

• Weak muscles and tissues in the wound area.

• Diabetes mellitus (a metabolic disease that causes increased blood sugar levels).

• Obesity.

• Long-term use of corticosteroids.

What Are the Risk Factors for Wound Dehiscence and Wound Evisceration?

The risk factors include:

• Increasing age.

• Wound infection.

• Hypoalbuminemia.

• Emergency surgery.

• Cancer at the site.

• Anemia (low hemoglobin levels).

• Jaundice (increased bilirubin in the body causes yellowing of the skin, sclera, and mucous membrane).

• Chronic obstructive pulmonary disease (chronic inflammation of the lungs that obstructs airflow).

• Presence of necrotic tissue in the flap.

• Hyperglycemia (high blood sugar levels).

• Excess tension on the wound.

• Presence of scar at the wound.

• Increased abdominal pressure (severe coughing, straining, vomiting, and fluid buildup).

• Early exercise or lifting heavy objects.

What Is the Diagnosis of Wound Dehiscence and Wound Evisceration?

The diagnosis includes:

• Clinical observation of the wound.

• Fluids from the wound are taken to identify the type of infection.

• Blood tests to identify the infection.

• In case of deep dehiscence, doctors can do an X-ray, ultrasound, and CT (computed tomography) scan.

• In the case of wound evisceration, the abdominal content or bowel loops are visible through the wound. There is fascial separation, blood, serous, and suppurative fluid discharge.

What Is the Treatment of Wound Dehiscence and Wound Evisceration?

The treatment includes:

• Antibiotics should be administered if an infection is present, and doctors should remove the damaged, infected tissue. New sutures should be placed, or a mesh should be placed to close the wound.

• The wound dressings should be changed often, and the wound should be left open in a sterile environment to speed up the healing process and allow tissue growth.

• Negative pressure wound therapy causes the removal of fluids and infection from the wound with the help of a vacuum attached to it.

• Wound dehiscence, with exposed omentum (a peritoneal fold that covers the stomach and other abdominal organs), is managed by skin grafting; if necessary, hernia repair is done.

• In case of evisceration, mesh reconstruction is done, and an absorbable or nonabsorbable mesh can be used. Polypropylene mesh gives permanent results. After the mesh's granulation, bipedicle flaps (receive blood supply from two pedicles) are used for closure.

How to Prevent Wound Dehiscence and Wound Evisceration?

The preventive measures include:

• The surgeon should use proper suture material (Monofilament, large caliber, non-absorbable sutures) and specific closure techniques. Suturing should be done carefully, the wound area should be maintained clean, and light pressure should be applied to the wound while dressing.

• Excess tension on the wound should be avoided. Advanced techniques such as small 'pie-crust' incisions and using attachment plates can reduce wound tension.

• Antibiotics should be given before and after the surgery to avoid infection.

• Retention sutures can reduce evisceration risks.

Conclusion:

Therefore, wound dehiscence and evisceration can cause delayed wound healing. Therefore, before the surgery, the causes and risk factors should be considered, and appropriate preventive measures should be taken, which should include the use of proper suture material and suture technique, avoiding excess tension on the wound, and providing antibiotics prior to the treatment.