Abdominal wounds
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Plan the appropriate type of closure for specific patient and clinical situations. | Level of Evidence Not Assessed |
| 2 | Institute appropriate management of patient risk factors for dehiscence, such as malnutrition, anemia, sepsis and other factors, preoperatively if possible. | Level of Evidence Not Assessed |
| 3 | Determine and implement the most appropriate closure for large skin defects to prevent dehiscence and herniation, including use of tissue expansion, flaps and prosthetic mesh and staged reconstruction. | Level of Evidence Not Assessed |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 4 | Provide individualized education about post-operative care. | Level of Evidence 5 |
| Provide Local Wound Care | ||
|---|---|---|
| 5 | Use delayed primary closure on contaminated or dirty abdominal wounds. | Level of Evidence Not Assessed |
| 6 | Plan staged reconstruction when abdominal wall infection is present, with removal of prosthetic materials, such as mesh, which harbour infection. | Level of Evidence Not Assessed |
| 7 | Close small skin defects using primary closure and adequate skin mobilization. | Level of Evidence Not Assessed |
| 8 | Consider the use of vacuum-assisted closure to increase granulation, especially where drainage is delaying healing. | Level of Evidence Not Assessed |
| 9 | Apply the principles of wound care to management of abdominal wounds. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 10 | Establish and empower an interprofessional team to provide post-operative care. | Level of Evidence 5 |
Background
Abdominal wound dehiscence is associated with substantial morbidity and mortality, especially in elderly or malnourished patients. Burst abdomen is a complication of abdominal surgery whose incidence has not changed appreciably over the past century.Predisposing, contributing and causative factors have long been recognized. In the majority of cases, lack of compliance with suture protocols, with inadequate knot and suture technique, are causative.
Meta-analyses have revealed that the ideal suture is nonabsorbable and the ideal closure is continuous. However, many exceptions exist. Healthy thin patients undergoing elective laparotomy for benign conditions may safely have a continuous closure with absorbable sutures. Interrupted absorbable sutures provide better results with fewer complications for contaminated wounds and patients with serious or multiple comorbidities. Additional retention sutures may be required, and closure may be immediate or delayed. Delayed primary closure may reduce infection rates in dirty abdominal wounds compared with primary closure. An interrupted X closure may reduce the risk of dehiscence in patients with risk factors, such as anemia, sepsis, cough, malnutrition, or abdominal distention. It is also important to address patient risk factors for dehiscence preoperatively, if possible.
The incidence of abdominal herniation is approximately 4–10%. Transverse incisions have a lower rate of herniation than midline and paramedian incisions. Repair of incisional herniation can often be accomplished in a single stage unless complications develop.
Abdominal wall defects may result from malignancy or trauma. Traumatic abdominal injuries, such as gunshot wounds, are often grossly contaminated and require multiple-stage delayed reconstruction and closure. Abdominal wall infections may result from infections of mesh repairs of abdominal fascia. Mesh infections resist wound care techniques and antibiotic therapy and often present as draining abdominal sinuses. Resolution of the infection usually requires removal of infected mesh and staged abdominal reconstruction.
Standard wound care principles should also be applied to abdominal wounds, including care of the wound bed, appropriate local wound care and use of dressings, and management of systemic factors.
Small skin deficits can usually be repaired with primary closure by approximating the skin edges after undermining the skin extensively. Larger defects may require tissue expansion, myocutaneous or fasciocutaneous flaps, or prosthetic mesh and staged reconstruction. The major advantage of mesh is prevention of large intra-abdominal pressure increases that may sometimes be seen with hernia repairs and that may predispose to recurrence. The presence of prosthetic material and the likelihood of extensive adhesions are associated with a risk of infection. Temporary fascial approximation using absorbable mesh minimizes the fascial defect. After complete granulation, skin grafting and maturation of the graft, final reconstruction is performed.
Vacuum-assisted closure (VAC) promotes wound granulation and can be used to manage exposed fascia or grafts. VAC may accelerate healing of enteric-cutaneous fistulas by removing enteric fluids and promoting ingrowth of granulation tissue.
References
| Essential Publications |
|---|
| 1 | Disinfecting agent – Povidone-iodine |
Quality Indicator
|
Type: RCT |
| Chang FY, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Can povidone-iodine solution be used safely in a spinal surgery? European Spine Journal 2006;15(6):1005-1014. | |||
| The purpose of this study was to evaluate the effectiveness and safety of the use of povidone-iodine solution in spinal surgeries. There was no significant difference in wound healing, fusion rate, pain and function score, and ambulatory capacity between those treated with povidone-iodine and those treated only with normal saline solution. This indicates that povidone-iodine can be used safely in spinal surgery. | |||
| 2 | Disinfecting agent – Povidone-iodine |
Quality Indicator
|
Type: RCT |
| Harihara Y, Konishi T, Kobayashi H, Furushima K, Ito K, Noie T, Nara S, Tanimura K. Effects of applying povidone-iodine just before skin closure. Dermatology 2006;212(Suppl 1):53-57. | |||
| In this study, povidone-iodine was examined to see if it reduces the incidence of surgical site infection. The difference in infection rates with and without povidone-iodine was not significant. | |||
| 3 | Enteral nutrition |
Quality Indicator
|
Type: Systematic review |
| Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004080. DOI: 10.1002/14651858.CD004080.pub2. | |||
| In this paper, the effect of early enteral feeding of gastrointestinal surgery patients is discussed. There was not a significant difference between enteral feeding and the traditional method of keeping patients “nil by mouth” in reducing complications. | |||
| 4 | Prophylactic antibiotics - Appendectomy |
Quality Indicator
|
Type: Systematic review |
| Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD001439. DOI: 10.1002/14651858.CD001439.pub2. | |||
| The effect of prophylactic antibiotics on the prevention of complications in appendectomy patients is examined in this study. 45 studies containing 9576 patients were reviewed, and the general consensus was that the use of antibiotics at any point before, during, or after surgery is effective in preventing complications. | |||
| 5 | Prophylactic antibiotics – Fourth-degree perineal tear |
Quality Indicator
|
Type: Systematic review |
| Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005125. DOI: 10.1002/14651858.CD005125.pub2. | |||
| The researchers hoped to examine the effectiveness of antibiotic prophylaxis in reducing complications in fourth-degree perineal tear from vaginal birth, but no randomised controlled trials could be found. Research is needed on this topic. | |||
| 6 | Prophylactic antibiotics – Hernia |
Quality Indicator
|
Type: Systematic review |
| Aufenacker TJ, Koelemay MJW, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. British Journal of Surgery 2006;93(1):5-10. | |||
| The purpose of this study was to determine whether systematic antibiotic prophylaxis prevented infection after surgery for an abdominal wall hernia repaired with mesh. There is no indication for routine prophylactic antibiotics, especially in low-risk patients. Further studies are needed to verify this finding. | |||
| 7 | Prophylactic antibiotics - Hernia |
Quality Indicator
|
Type: Systematic review |
| Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003769. DOI: 10.1002/14651858.CD003769.pub3. | |||
| Elective hernia repair has a higher than average infection rate for clean surgeries. In this review, the effectiveness of prophylactic antibiotics for preventing infection in this type of surgery is examined. The results were non-significant, with prophylaxis reducing infection rate only marginally, therefore prophylactic antibiotics cannot be universally recommended. | |||
| 8 | Prophylactic antibiotics – Laparoscopic cholecystectomy |
Quality Indicator
|
Type: RCT |
| Chang WT, Lee KT, Chuang SC, Wang SN, Kuo KK, Chen JS, Sheen PC. The impact of prophylactic antibiotics on postoperative infection complication in elective laparoscopic cholecystectomy: a prospective randomized study. Am J Surg 2006;191(6):721-725. | |||
| The purpose of this paper was to investigate the effects of prophylactic antibiotics on postoperative infection complications in elective laparoscopic cholecystectomy. The difference in infection rate was not significant between the antibiotic group and the control group administered isotonic sodium chloride solution. The authors do not recommend the use of prophylactic antibiotics because they do not significantly lower the already low infection rate. The credibility of these findings was compromised by the study’s weak methodology. The allocation was determined by the operative schedule and dropouts were not described, though the study was single-blinded. | |||
| 9 | Prophylactic antibiotics – Postcesarean infection |
Quality Indicator
|
Type: RCT |
| Rudge MV, Atallah AN, Peracoli JC, Tristao Ada R, Mendonca Neto M. Randomized controlled trial on prevention of postcesarean infection using penicillin and cephalothin in Brazil. Acta Obstet Gynecol Scand 2006;85(8):945-948. | |||
| In this study, different antibiotic regimens were evaluated based on their effectiveness at preventing infectious complications in low-income women undergoing cesarean delivery. Cost-effectiveness was also analysed. A postcesarean prophylactic antibiotic regimen such as penicillin or intravenous cephalothin decreases the risk of infection and is cost-effective. | |||
| 10 | Surgical tools – High-frequency electric surgical knives |
Quality Indicator
|
Type: RCT |
| Ji GW, Wu YZ, Wang X, Pan HX, Li P, Du WY, Qi Z, Huang A, Zhang LW, Zhang L, Chen W, Liu GH, Xu H, Li Q, Yuan AH, He XP, Mei GH. Experimental and clinical study of influence of high-frequency electric surgical knives on healing of abdominal incision. World J Gastroenterol 2006;12(25):4082-4085. | |||
| In this study, the use of electric surgical knives was associated with a significantly higher infection rate and delayed wound healing compared to a common lancet. Details on the animal testing that led to the clinical testing in this paper were provided. The authors suggest using a common lancet rather than an electric knife. | |||