What is the medical management for a burst abdomen?

Medical Management of Burst Abdomen

Immediate surgical repair is the primary management for burst abdomen, with specific techniques chosen based on tissue viability and patient condition to reduce morbidity and mortality.

Burst abdomen (abdominal wound dehiscence) is a serious postoperative complication requiring prompt intervention. The management approach must be systematic and decisive to prevent further complications.

Initial Assessment and Stabilization

• Assess hemodynamic status immediately
• Cover exposed viscera with sterile, saline-soaked gauze to prevent desiccation
• Correct fluid and electrolyte imbalances
• Initiate broad-spectrum antibiotics to prevent or treat infection
• Optimize nutritional status with parenteral nutrition if enteral feeding is contraindicated

Surgical Management Options

Primary Surgical Repair

For most cases of burst abdomen, surgical intervention is necessary. The approach depends on several factors:

1. Temporary Closure Options (Open Abdomen Treatment):

   • Indicated when primary closure would cause excessive tension
   • May be necessary in cases with significant edema or risk of abdominal compartment syndrome

2. Primary Closure Techniques:

   • Mass closure with non-absorbable continuous sutures at 1-cm intervals 1
   • Suture length to wound length ratio of 4:1 or more to prevent recurrence 1
   • Inverting bilateral figure-of-eight suture of the rectus sheath may be used in cases with destruction of the linea alba 2

3. Mesh Reinforcement:

   • Synthetic (absorbable or non-absorbable) or biological meshes
   • Particularly useful when tissue quality is poor or tension would be excessive with primary closure 3
   • Can be placed in sublay position to reinforce the repair 2

4. Tissue Flap Techniques:

   • For cases with significant tissue loss or poor quality local tissue 3

Conservative Management

In select cases where surgery is contraindicated or as a bridge to definitive repair:

• Saline-soaked gauze dressings with frequent changes 3
• Negative pressure wound therapy (NPWT) to promote granulation and reduce edema 3

Post-Repair Management

• Continuous monitoring in ICU for at least 24-48 hours 4
• Serial clinical examinations every 4-8 hours 4
• Laboratory monitoring (CBC, inflammatory markers) every 24 hours 4
• Measures to prevent increased intra-abdominal pressure:
  • Avoid coughing, vomiting, and abdominal distension 5
  • Consider prophylactic antiemetics and stool softeners
  • Early ambulation as tolerated

Risk Factor Management

Address underlying factors that may impair wound healing:

• Control infection with appropriate antibiotics and wound care
• Optimize nutrition (protein supplementation for hypoproteinemia) 6
• Manage comorbidities (diabetes, jaundice, malignancy) 5, 6
• Correct anemia if present 5

Monitoring for Complications

• Monitor for signs of abdominal compartment syndrome
• Regular wound assessment for signs of infection
• Follow-up imaging if clinical deterioration occurs
• Long-term follow-up to monitor for incisional hernia development, which occurs in 10-40% of cases 3

Prevention Strategies for Future Surgeries

• Consider transverse incisions when possible (lower dehiscence rates than vertical incisions) 5
• Proper closure technique with appropriate suture material
• Attention to risk factors: malnutrition, obesity, infection, coughing, vomiting 6

The management of burst abdomen remains challenging with high morbidity and mortality rates. Early recognition, prompt intervention, and addressing underlying risk factors are crucial for improving outcomes.