What is the management of abdominal wound dehiscence?

Management of Abdominal Wound Dehiscence

Immediate Management

Apply negative pressure wound therapy (NPWT) immediately to the dehisced wound, as this significantly reduces wound complications including re-dehiscence compared to standard gauze dressings. 1

Initial Assessment and Stabilization

• Determine the grade of dehiscence to guide treatment strategy:

  • Grade 1-2: Partial dehiscence with or without exposed viscera but no fistula formation 1
  • Grade 3: Complete dehiscence complicated by entero-atmospheric fistula 1
  • Grade 4: "Frozen abdomen" with extensive adhesions and fixity (develops after prolonged open abdomen) 1

• Identify high-risk patients who are most likely to experience dehiscence: males over 64 years old, patients with complicated neoplastic or inflammatory diseases, emergency interventions, obesity, pulmonary/cardiovascular problems, hypoproteinemia, and wound infection 2, 3

Treatment Algorithm by Grade

For Grade 1-2 Dehiscence (No Fistula)

Primary goal: Achieve fascial closure within 7-10 days before fixity develops and the wound progresses to Grade 4. 1

• Apply NPWT with a non-adherent interface layer directly over exposed organs to prevent progression to Grade 3 or 4 1

• Attempt early fascial closure (within 7 days) whenever possible, as this is the optimal window before adhesions form 1

• If early closure is not feasible, NPWT can extend the window for primary fascial closure up to 21-49 days, though success rates decline after 10 days 1

• For partial closure scenarios where only segments of the abdominal wall can be closed, use NPWT as wound filler in the dehiscent areas 1

For Closed Incisions at High Risk of Dehiscence

Apply incisional NPWT prophylactically on the closed incision in high-risk patients to prevent dehiscence. 1

• This approach significantly reduces wound complications including dehiscence compared to standard dressings 1
• The "splinting effect" of NPWT aids patient mobility and supports the wound during movement 1

For Grade 3 Dehiscence (With Entero-Atmospheric Fistula)

Use NPWT to manage fistula output and prevent spread of intra-abdominal sepsis, though no existing method is ideal for this complication. 1

• For visible fistulae: Create a "floating stoma" by isolating the fistula with an ostomy bag, using NPWT to achieve secure bag adhesion while managing the adjacent wound 1

• For remote fistulae: Either convert to an entero-cutaneous fistula through separate incision and drainage, or treat the entire wound with NPWT allowing granulation and contraction (though this results in Grade 4 wound) 1

• Provide a conduit from the fistula source through the dressing to prevent pooling beneath the foam, using either an ostomy bag or drain 1

• Surgical repair by suturing is rarely successful; segmental resection can be attempted with caution regarding anastomosis site, or consider controlled stoma creation 1

• Spontaneous fistula closure has been observed in 8-55% of cases managed with NPWT 1

For Grade 4 Dehiscence (Frozen Abdomen)

Once fixity develops with extensive granulation tissue and adhesions, primary fascial closure is no longer possible. 1

• Management focuses on wound granulation, contraction, and eventual skin grafting rather than fascial closure 1
• This represents a failure to achieve timely closure and should be avoided through aggressive early management 1

Specific Technical Considerations for NPWT Application

• Always use a non-adherent interface layer between NPWT foam and exposed bowel to prevent direct contact, bowel injury, and fistula formation 1

• Anchor drainage tubes using the "splinting" effect of NPWT to keep drains close to fistula mouths while preventing bowel damage from dislodgement 1

• Change NPWT dressings according to output volume and wound condition, typically every 48-72 hours 1

Alternative Closure Techniques for Complex Cases

• For patients with tissue friability (such as Ehlers-Danlos syndrome type IV), consider barbed suture techniques that distribute wound forces over larger surface areas rather than concentrating tension at wound edges 4

• For wounds with bowel exposure and infection, use intrawound continuous negative pressure with irrigation and artificial dermis application to promote dermis-like tissue proliferation on bowel surfaces 5

Prevention Strategies

Take extra preventive measures at the time of initial wound closure when two or more risk factors are present. 2

• Ensure adequate pulmonary toilet to prevent coughing 3
• Promptly treat ileus with abdominal decompression to prevent vomiting and increased intra-abdominal pressure 3
• Maintain strict attention to electrolyte and protein balance pre- and post-operatively 3
• Consider prophylactic mesh reinforcement (such as Ventrofil plates) in very high-risk patients 2

Critical Pitfalls to Avoid

• Do not delay NPWT application once dehiscence is recognized, as early intervention prevents progression to higher grades 1

• Do not allow the 7-10 day window for fascial closure to pass without attempting closure, as fixity develops rapidly thereafter and eliminates the possibility of primary fascial closure 1

• Do not apply NPWT foam directly to exposed bowel without a protective interface layer, as this causes bowel injury and fistula formation 1

• Do not use standard gauze dressings when NPWT is available, as outcomes are significantly worse 1