What is the management of wound dehiscence?

Management of Wound Dehiscence

For wound dehiscence, immediately assess for infection and wound characteristics, then pursue conservative management with secondary intention healing for small dehiscences (<6mm) or negative pressure wound therapy (NPWT) for larger fascial dehiscences, reserving immediate surgical re-closure only for clean wounds within 7-10 days that can be closed without tension. 1, 2

Immediate Assessment Protocol

When wound dehiscence occurs, perform a focused examination looking for:

• Infection signs: erythema extending beyond wound margins, warmth, purulent drainage, increased pain, fever, or elevated inflammatory markers 3, 1, 2
• Wound depth: determine if dehiscence is superficial (skin/subcutaneous only) versus fascial involvement with potential bowel exposure 4
• Tissue viability: assess for healthy granulation tissue, adequate blood supply to wound edges, and presence of necrotic debris 1, 2
• Timing context: dehiscence within days of suture removal suggests premature removal or inadequate wound tensile strength 1

If infection is present, immediately remove any retained suture material as this significantly increases infection risk, obtain Gram stain and wound culture, and initiate antibiotics covering Staphylococcus aureus including MRSA if risk factors exist 1.

Management Algorithm Based on Dehiscence Type

Small Superficial Dehiscence (≤6mm)

Allow spontaneous healing by secondary intention without attempting immediate surgical closure, as this approach has proven effective for dehiscences of this size 1, 2. This conservative approach includes:

• Proper wound bed preparation using the T.I.M.E. framework (Tissue debridement, Infection/inflammation control, Moisture control, Edge preparation) 3, 2
• Complete pressure relief from any prosthetics or appliances 2
• Systemic antibiotics if bone substitute materials or significant contamination risk exists 2
• Expected healing within 2-4 weeks 2

Large Fascial Dehiscence with Bowel Exposure

Apply negative pressure wound therapy (NPWT) as the primary management strategy for fascial dehiscences that cannot be immediately closed 3, 4. NPWT provides:

• Continuous negative pressure of -75 to -125 mm Hg 4
• Dressing changes every 2 days 4
• Enhanced drainage of fluid from the deep abdominal cavity 3
• Successful definitive fascial closure achieved in 69% of patients (9 of 13) with fascial dehiscence 4
• Ability to transition to outpatient therapy once stable 4

For entero-atmospheric fistulae (Grade 3 open abdomen), NPWT manages output and diverts effluent away from the open wound, with provision of a conduit through the dressing to prevent pooling 3.

Delayed Primary Closure Criteria

Only attempt delayed primary closure if ALL criteria are met 1, 2:

• Timing window within 7-10 days of original wound creation
• Complete absence of infection
• Clean and healthy granulation tissue present
• Adequate blood supply to wound edges
• Tension-free closure achievable

Use layered closure starting with deeper layers if dehiscence extends beyond superficial tissue 1. For re-closure, employ:

• Absorbable subcuticular continuous sutures (4-0 poliglecaprone or 4-0 polyglactin), which reduce superficial wound dehiscence by 92% compared to non-absorbable interrupted sutures 3, 1
• These sutures retain 50-75% of original tensile strength after 1 week, providing continued wound support 3, 1
• Monofilament non-absorbable sutures (5-0 or 6-0) for facial wounds 1

Prevention of Recurrent Dehiscence

Apply incisional NPWT on the closed incision to facilitate healing and prevent complications, as this significantly reduces wound complications including wound dehiscence compared to standard gauze dressings 3.

Consider triclosan-coated sutures as they significantly reduce surgical site infection prevalence compared to non-coated sutures 1.

Critical Pitfalls to Avoid

• Never attempt closure of an infected wound, as this will result in abscess formation and treatment failure 1, 2
• Never close under tension, as dehiscence rates increase dramatically with tension 2
• Do not delay beyond 10 days if considering delayed primary closure, as wound contracture makes later closure increasingly difficult 2
• Avoid rushing to surgical re-closure if the wound is healing spontaneously by secondary intention 2
• Do not use adhesive steri-strips routinely after resuturing, as evidence shows no improvement in cosmetic outcomes or scar width when added to buried dermal sutures 3, 1
• Remove sutures prematurely can lead to inadequate wound tensile strength and increase dehiscence risk (facial wounds: 5-7 days; other locations: 7-9 days) 1

Post-Management Monitoring

• Keep wounds clean and dry for the first 24-48 hours 1
• Monitor closely for infection signs: increasing pain, redness, swelling, or purulent discharge 1
• For intraoral wounds, restrict patient to soft food with no biting/chewing in treated area 2
• Continue antibiotics for full prescribed course 2
• If re-intervention is needed after complete healing failure, wait 6-9 months before attempting surgical augmentation procedures 2, 5