How do you assess for fascial dehiscence?

Assessment of Fascial Dehiscence

Fascial dehiscence should be suspected clinically based on physical examination findings and confirmed through direct visualization or imaging, with the key understanding that in trauma patients, fascial dehiscence is a sign of underlying intra-abdominal infection in 71% of cases and requires aggressive investigation before simple wound management. 1

Clinical Presentation and Initial Assessment

Key Physical Examination Findings

The diagnosis of fascial dehiscence is primarily clinical and requires careful physical examination:

• Palpable fascial defect through the wound or incision site, often with visible or palpable bowel or omentum 2, 3
• Serosanguineous discharge ("salmon-colored" fluid) from the wound, which is a classic early warning sign occurring 5-8 days postoperatively 2
• Wound separation with visible fascial edges or evisceration of abdominal contents 4, 3
• Increased abdominal distention or pain disproportionate to expected postoperative course 2

Critical Clinical Context

In trauma patients specifically, fascial dehiscence must be viewed as a sign of possible underlying intra-abdominal infection rather than simple wound failure - 71% have concurrent intra-abdominal infection compared to only 4.6% of all trauma laparotomies. 1 This fundamentally changes the diagnostic approach.

Diagnostic Workup

Immediate Assessment Steps

When fascial dehiscence is suspected:

• Direct wound inspection by removing dressings and examining the fascial layer - the fascia should be directly palpated to assess integrity 4, 3
• Assess for signs of infection: purulent drainage, fascial necrosis, surrounding cellulitis, or systemic signs of sepsis 4
• Evaluate for evisceration: determine if bowel or other organs are exposed or protruding 3

Imaging for Underlying Pathology

Before managing the dehisced fascia, appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued to identify underlying intra-abdominal infection. 1 This is particularly critical because:

• Only 31% of fascial dehiscence patients with intra-abdominal infection underwent immediate laparotomy, while 69% received CT-guided percutaneous drainage followed by expectant management 1
• No clinical or laboratory factors reliably identify which fascial dehiscence patients have underlying intra-abdominal infection 1

CT imaging with IV contrast is the preferred modality when intra-abdominal infection is suspected, as it can identify:

• Fluid collections or abscesses requiring drainage 1
• Fascial defect size and extent 3
• Presence of bowel complications 1

Wound Assessment for Management Planning

Evaluate Wound Characteristics

Once fascial dehiscence is confirmed, assess:

• Presence of fascial necrosis: necrotic fascial edges require debridement and may preclude primary closure 4
• Infection status: bacterial cultures should be obtained from infected wounds (91 bacterial isolates were recovered in one series of infected fascial dehiscence) 4
• Size of fascial defect: extensive fascial resection may preclude tension-free closure and necessitate mesh placement 4, 3
• Timing: early dehiscence (within 7-10 days) suggests technical failure or infection; late dehiscence suggests underlying pathology 2, 3

Risk Stratification

Patients at highest risk for fascial dehiscence can be identified preoperatively using validated risk factors:

• COPD, immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight - scores above 3 predict 18% risk with 70% sensitivity and 80% specificity 5
• Local mechanical factors are more important than systemic factors: wound infections, abdominal distention, and pulmonary complications should be aggressively prevented or treated 2

Common Pitfalls to Avoid

• Do not assume fascial dehiscence is simply a wound problem - in trauma patients, it is a sign of intra-abdominal sepsis in the majority of cases and requires investigation before wound management 1
• Do not rely on clinical or laboratory parameters alone to exclude intra-abdominal infection in fascial dehiscence patients - imaging or direct visualization is required 1
• Do not attempt primary closure without adequate debridement of necrotic fascia, as this leads to treatment failure 4
• Do not overlook the need for bacterial cultures in infected wounds, as polymicrobial infections are common and may require tailored antibiotic therapy 4

Management Implications of Assessment

The assessment findings directly guide management:

• If intra-abdominal infection is identified: CT-guided percutaneous drainage or operative exploration with source control is required before definitive fascial management 1
• If extensive fascial necrosis is present: synthetic mesh placement may be necessary after debridement, even in the presence of infection 4
• If simple mechanical failure without infection: primary suture repair may be attempted, though synthetic mesh reduces incisional hernia rates from 30.7% to 11.1% 3