What is the recommended management of a burst abdomen (post‑operative abdominal wound dehiscence)?

Management of Burst Abdomen (Postoperative Abdominal Wound Dehiscence)

Immediate surgical exploration is mandatory for burst abdomen, with the specific approach determined entirely by hemodynamic stability: stable patients should undergo primary fascial re-closure with interrupted sutures, while unstable patients require damage control surgery with open abdomen management. 1

Immediate Assessment and Resuscitation

Hemodynamic status determines everything – assess for cold/clammy extremities, persistent tachycardia, and hypotension as these indicate impending septic shock and mandate damage control approach. 1

• Establish large-bore IV access and initiate aggressive crystalloid resuscitation immediately 1
• Start broad-spectrum antibiotics covering gram-negatives and anaerobes as soon as burst abdomen is identified 1, 2
• Obtain arterial blood gas to evaluate lactate and metabolic acidosis – these guide severity of physiologic derangement 1
• Initiate vasopressor support if hypotension persists despite fluid therapy 1

Critical timing principle: Surgical delay beyond admission reduces survival by approximately 2.4% per hour in unstable patients with peritonitis. 1

Surgical Strategy Based on Hemodynamic Status

For Hemodynamically STABLE Patients (Normotensive, Warm Extremities, No Vasopressors)

Primary fascial re-closure with interrupted sutures is the definitive approach – this technique significantly reduces recurrence compared to continuous sutures (OR 0.143 for recurrence). 3

• Perform thorough abdominal irrigation with warm saline to reduce bacterial load 1
• Debride all necrotic fascia and infected tissue 4
• Re-approximate fascial edges with interrupted, non-absorbable sutures (not continuous) 3
• Consider placement of intraperitoneal absorbable mesh (IPOM) – while this doesn't prevent recurrence, it significantly reduces need for additional revision surgeries 3
• Obtain tissue biopsies from wound edges to exclude malignancy (present in 10-16% of perforations) 1, 2, 5

For Hemodynamically UNSTABLE Patients (Hypotension, Vasopressor-Dependent, Septic Shock)

Damage control surgery with open abdomen is mandatory – attempting definitive closure in unstable patients markedly increases mortality. 1, 6

• Perform abbreviated laparotomy focused solely on source control 1, 2
• Copious irrigation with warm saline 1
• Leave abdomen open with temporary abdominal closure (TAC) technique 1, 6
• Do NOT attempt definitive fascial closure, complex resections, or mesh placement during initial operation 1, 2

Mandatory indications for open abdomen approach: 1

• Inability to close fascia without tension
• Persistent intra-abdominal infection after initial control
• Extensive visceral edema with concern for abdominal compartment syndrome
• Ongoing severe septic shock with progressive organ dysfunction

Staged Management for Open Abdomen Cases

• Schedule planned re-explorations every 36-48 hours until peritonitis resolves and hemodynamic stability achieved 1, 5
• Continue ICU-level resuscitation targeting normalization of lactate and base deficit 1
• Maintain broad-spectrum antimicrobials throughout postoperative period 1
• Perform definitive fascial closure only after: hemodynamic stability confirmed, source control achieved, and no ongoing peritonitis 1

Special Considerations for Post-Bariatric Surgery Patients

If burst abdomen occurs after bariatric surgery, systematic exploration is required: 5

• Assess all anastomoses (gastro-jejunal, jejuno-jejunal) 5
• Evaluate excluded stomach (gastric remnant) 5
• Evaluate excluded duodenum 5
• Search for gastro-gastric fistula (present in significant proportion of marginal ulcer cases) 5

Critical Pitfalls to Avoid

• Never delay surgery for extensive imaging in unstable patients – CT is reserved only for hemodynamically stable cases 1, 5
• Never perform definitive resections or complex anastomoses in hypotensive/vasopressor-dependent patients – these carry extremely high risk of leak and death 1, 2
• Never use continuous sutures for fascial re-closure – interrupted sutures reduce recurrence by 86% 3
• Never forget tissue biopsies – malignancy is present in 10-16% of cases even in emergency settings 1, 2, 5

Key Risk Factors Predicting Recurrence

Patient factors associated with recurrent dehiscence: 3

• Postoperative delirium (OR 13.73 for recurrence) – requires aggressive prevention and management
• Liver cirrhosis (OR 4.788 for initial burst)
• Emergency surgery (OR 1.658)
• Intestinal resection (OR 172.5)

Conservative Management Options (Non-Operative)

Conservative management is NOT recommended as primary approach given high mortality (up to 45%) associated with burst abdomen. 7, 4 However, if surgery is absolutely contraindicated due to terminal illness or patient refusal, options include negative pressure wound therapy or saline-soaked gauze dressings. 4