What is the appropriate management for a surgical wound that has dehisced while the sutures are still in place?

Management of Wound Dehiscence with Sutures Still in Place

For a surgical wound that has dehisced while sutures remain in place, immediately assess for infection and then perform re-closure with fresh sutures using a continuous subcuticular technique with slowly absorbable monofilament material (4-0 poliglecaprone or polyglactin), removing any compromised original sutures first. 1, 2

Immediate Assessment Protocol

When discovering dehiscence with sutures still present, perform a focused examination looking for:

• Infection signs: erythema, warmth, purulent drainage, increasing pain (especially if disproportionate to injury), or foul odor 1, 2
• Systemic indicators: fever, chills, leukocytosis, tachycardia, or red streaks extending from the wound 1, 2
• Wound characteristics: depth of separation, ability to approximate edges without tension, and presence of tissue necrosis 2

The presence of sutures does not prevent dehiscence and may actually harbor bacteria if the wound is infected. 2

Management Algorithm Based on Infection Status

For Clean, Non-Infected Dehiscence:

Remove the original sutures completely before proceeding with re-closure, as retained suture material significantly increases infection risk. 2

Re-close definitively with sutures rather than relying on adhesive strips or tissue adhesives, which provide insufficient mechanical support and carry a 3.35-fold higher risk of wound breakdown (95% CI 1.53-7.33; NNT=43). 1, 3

Use continuous subcuticular technique with slowly absorbable monofilament sutures (4-0 poliglecaprone or 4-0 polyglactin), which reduces superficial wound dehiscence by 92% (RR 0.08; 95% CI 0.02-0.35) compared to interrupted sutures. 1, 2, 3

Achieve tension-free closure by making periosteal incisions when necessary to allow proper approximation without strangulation of wound edges. 2

For Infected or Contaminated Dehiscence:

Remove all retained suture material immediately, as this dramatically increases infection risk and provides a nidus for bacterial colonization. 2

Obtain Gram stain and culture of any purulent drainage before initiating antibiotics. 2

Initiate antibiotic therapy active against Staphylococcus aureus, including MRSA coverage if risk factors are present (healthcare exposure, prior MRSA, injection drug use). 2

Consider delayed primary closure after infection control is achieved, or use negative pressure wound therapy (VAC) for complex cases with fascial dehiscence or compromised healing. 4

Use triclosan-coated sutures when re-closing contaminated wounds, as they reduce surgical site infection risk (OR 0.72; 95% CI 0.59-0.88). 2, 3

Optimal Re-Suturing Technique

When performing re-closure of a dehisced wound:

• Use slowly absorbable monofilament sutures (4-0 poliglecaprone or polyglactin) that retain 50-75% of original tensile strength after 1 week, providing extended wound support during the critical healing period. 1, 2, 3

• Apply continuous subcuticular technique rather than interrupted transcutaneous sutures, as this eliminates the need for future suture removal (which likely contributed to the original dehiscence) and provides superior wound support. 1, 2, 3

• Maintain a suture-to-wound length ratio of at least 4:1 to minimize recurrent dehiscence and ensure adequate mechanical support. 2, 3

• Consider layered closure if the dehiscence extends beyond superficial tissue, starting with deeper layers before closing the skin. 2

Post-Repair Management

After re-suturing a dehisced wound:

• Keep the wound completely dry for the first 24-48 hours to allow proper adhesion and initial healing; brief showers are acceptable after 24 hours only if the area can be kept dry. 1

• Avoid applying ointments, creams, or lotions over or near the closure site, as these compromise healing. 1

• Maintain closure for 10-14 days for trunk, arms, or legs (5-7 days for facial wounds), with high-tension areas requiring the full 14 days before any manipulation. 1

• Inspect daily for signs of infection (increasing pain, redness, swelling, drainage), increasing separation, or wound edge gapping. 1, 2

Critical Pitfalls to Avoid

Never re-apply adhesive strips (Steri-Strips) as the sole management for dehisced wounds, as they provide insufficient mechanical support and will fail. 1

Do not leave any original suture material in place when infection is present or suspected, as this dramatically increases infection risk and prevents proper healing. 2

Avoid using tissue adhesives for re-closure of dehisced wounds, as they have an unacceptable 3.35-fold higher risk of wound breakdown compared to sutures. 1, 3

Do not delay seeking definitive closure if the wound is clean and can be approximated without tension, as early intervention prevents progression to complete dehiscence and reduces infection risk. 1, 2

Never use rapidly absorbable sutures for re-closure, as they lose tensile strength too quickly and increase the risk of recurrent dehiscence. 2, 3

Special Considerations for High-Risk Wounds

For patients with compromised healing (malnutrition, hypoalbuminemia, anemia, chronic lung disease, emergency procedures, or multiple risk factors):

• Consider negative pressure wound therapy (VAC) for complex abdominal wound dehiscence with fascial involvement or frank bowel exposure, maintaining continuous negative pressure at -75 to -125 mm Hg with dressing changes every 2 days until definitive closure can be achieved. 4

• Use triclosan-coated antimicrobial sutures for re-closure in contaminated fields or high-risk patients, as these significantly reduce surgical site infection prevalence. 2, 3

• Evaluate for systemic factors that contributed to the original dehiscence (hypoalbuminemia, anemia, malnutrition, chronic lung disease) and address these before or concurrent with re-closure. 5