What is the management approach for a patient with burst abdomen, considering potential underlying conditions such as diabetes (DM) or hypertension (HTN)?

Management of Burst Abdomen

Immediate Surgical Intervention

Burst abdomen requires immediate surgical exploration and repair, with the choice of technique depending on hemodynamic stability, degree of contamination, and presence of infection. 1

Initial Assessment and Stabilization

• Assess hemodynamic status immediately - blood pressure, pulse rate, and signs of shock determine the entire surgical strategy 1, 2
• Evaluate for peritonitis - check for abdominal rigidity, rebound tenderness, and diffuse contamination 3, 1
• Check lactate levels to assess ongoing sepsis 4
• Initiate broad-spectrum antibiotics covering gram-negatives and anaerobes if infection is suspected 2
• Maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg during resuscitation 4

Surgical Management Algorithm

For Hemodynamically Stable Patients

Primary repair with interrupted sutures is the preferred technique, as interrupted sutures significantly reduce recurrence compared to continuous sutures (OR 0.143, p=0.025). 5

• Perform thorough debridement of necrotic tissue and infected material 1
• Use interrupted sutures for fascial closure rather than continuous technique 5
• Consider adding an absorbable intraperitoneal onlay mesh (IPOM) - while this does not reduce recurrence rates, it significantly reduces the need for additional revision surgeries 5
• Apply negative pressure wound therapy (NPWT) immediately to the wound, as this significantly reduces wound complications including re-dehiscence compared to standard gauze dressings 1
• Use a non-adherent interface layer between NPWT foam and any exposed bowel to prevent fistula formation 1

For Hemodynamically Unstable Patients

Proceed immediately to damage control surgery with abbreviated laparotomy focusing on source control. 3, 2

• Perform temporary abdominal closure (open abdomen technique) in patients with severe peritonitis, septic shock, or extensive visceral edema 3
• Defer definitive fascial closure until physiological derangement is corrected 3
• Plan for second-look laparotomy within 24-48 hours to reassess and perform definitive repair once stabilized 3

Grading System for Treatment Planning

• Grade 1-2 (partial dehiscence): Achieve fascial closure within 7-10 days using NPWT with non-adherent interface 1
• Grade 3 (complete dehiscence with entero-atmospheric fistula): Use NPWT to manage fistula output and prevent sepsis spread; spontaneous closure occurs in 8-55% of cases 1
• Grade 4 ("frozen abdomen" with extensive adhesions): Focus on wound granulation, contraction, and eventual skin grafting, as primary fascial closure is no longer possible 1

Risk Factor Management

Patient-Related Factors Requiring Heightened Vigilance

• Postoperative delirium is the strongest predictor of both burst abdomen occurrence (OR 5.058) and recurrence (OR 13.73) 5
• Liver cirrhosis significantly increases risk (OR 4.788) 5
• Intestinal resection dramatically increases risk (OR 172.510) 5
• Emergency surgery increases risk (OR 1.658) 5
• Diabetes mellitus, hypertension, malnutrition, and hypoproteinemia all contribute to wound failure 6, 7, 8

Surgical Site Infection

• Superficial surgical site infection is the most common cause of burst abdomen (40.7% of cases) 5
• Wound infection remains a major preventable risk factor 7, 8

Critical Pitfalls to Avoid

• Never delay NPWT application once dehiscence is recognized, as this leads to progression to higher grades and worse outcomes 1
• Never allow the 7-10 day window for fascial closure to pass without attempting closure in Grade 1-2 dehiscence, as fixity develops and eliminates the possibility of primary fascial closure 1
• Never apply NPWT foam directly to exposed bowel without a protective interface layer, as this causes bowel injury and fistula formation 1
• Never attempt complex definitive repairs in unstable patients - perform damage control first 2
• Never use continuous sutures when interrupted sutures are feasible, as continuous technique significantly increases recurrence risk 5
• Never operate for definitive repair when infection is uncontrolled, as this leads to recurrence 2

Postoperative Management

• Change NPWT dressings every 48-72 hours according to output volume and wound condition 1
• Monitor for signs of recurrence - reported recurrence rates are 12.9% even with optimal technique 5
• Provide adequate nutritional support to aid healing process 6
• Control postoperative delirium aggressively as it is the strongest modifiable predictor of recurrence 5

Expected Outcomes

• Mortality rates for burst abdomen range from 15.1% to 45% depending on underlying conditions and complications 3, 8
• Recurrence rates can be reduced to approximately 13% with interrupted sutures and mesh reinforcement 5
• Incisional hernia remains a long-term complication requiring ongoing surveillance 9