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​​Overview

Wound healing is a critical outcome in surgery, and postoperative wound disruption or separation of the layers of a surgical wound with disruption of the fascia is a serious complication. Surgical incisions are acute wounds that activate the healing process. The healing process has four identified stages, namely: coagulation, inflammation, proliferative phase/granulation tissue formation and the remodelling phase, in reality it is a complex, continuous process (Demidova-Rice et al., 2012). Despite improvements in contemporary preoperative care and suture materials, the rate of surgical wound disruption has not decreased in recent years; estimated around six per cent after elective surgery and 16 per cent after emergency surgery (Sorensen et al., 2005). This may be attributable to the increasing incidence of risk factors within the patient population outweighing the benefits of technical achievements. Overall, surgical site infection (SSI) is the strongest predictor of wound disruption (Moghadamyeghaneh et al., 2015). Abdominal wound disruption typically occurs at 10 +/- 6.5 days (median eight days) after surgery (Kenig et al., 2014). A better understanding of which patients are at risk of such complications will help identify targets for preventative actions, patient satisfaction, and an equitable use of financial resources.

Post-partum perineal wound dehiscence remains a rare complication of vaginal delivery. Although infections rates in episiotomy wounds are surprisingly low, they are responsible for up to 80 per cent of wound dehiscence (Kamel & Khaled, 2014). The majority of perineal wound infections occur within the first three weeks postoperatively, after hospital discharge.

Risk Factors

Disruption of the vascular supply, thrombosis of blood vessels, and tissue hypoxia is common for all tissues subjected to surgery. When the blood supply is restored a number of factors may complicate healing with the most important being the proliferation of bacteria in the wound thus increasing the risk of infection (Sorensen et al., 2006).

Malnutrition is a common problem that adversely affects outcomes in surgical patients. Albumin is the most commonly used and reliable indicator of nutritional status, with preoperative hypoalbuminemia being an independent risk factor for the development of SSI (Hennessey et al., 2010).

Diabetic patients have a higher level of wound complications following general surgery and pregestational diabetes is associated with a 2.5 – fold increase in wound complications after Caesarean delivery (Takoudes et al., 2004). Obese patients have increased rates of diabetes mellitus as well as atherosclerosis vascular disease, both of which are associated with poor wound healing. In addition, thickness of subcutaneous fat is predictive of SSI. Finally, occult immune dysfunction is known to exist in the obese and one theory suggests that impairment of monocyte and macrophage function has the potential to be contributory (Winfield et al., 2016).

Smoking is also a risk factor for wound healing complications after different types of surgeries; plastic, abdominal, orthopedic, breast cancer and Caesarean delivery (Avila et al., 2012). Acute, high-dose systemic corticosteroid use likely has no clinically effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals (Wang et al., 2013).

Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery and these findings suggest that pre-operative interventions to reduce the patient's psychological stress level may improve wound repair and recovery (Broadbent et al., 2003). In children risk factors for wound disruption include patient age younger than one year, wound infection, median incision, and emergency surgery (van Ramshorst et al., 2009).

Operative vaginal delivery, third and fourth degree perineal laceration and meconium contamination, are the most significant factors leading to perineal wound infection (Williams, 2006).

Implications

Wound disruption still remains a major cause of morbidity in surgical patients (Hahler, 2006). Wound disruption can be divided into two types; those requiring immediate surgical intervention due to bowel protrusion and those that can be managed using a more conservative approach. Hospital stay is significantly longer for patients with wound disruption, with a median of 36 days, compared to 16 days in a control group (van Ramshorst et al., 2010). Wound complications are a burden for patients, their families, and the health care system. Accurately estimating the cost associated with wound complications is difficult due to the use of different care products and their varying costs, frequency of interventions and costs associated with staff time and resources, but it is believed that wound care has a significant impact on healthcare expenditure (Butcher & White, 2014). A post discharge wound complication costs, on average, an additional $3,000 (Marrs et al., 2014).

Perineal wound dehiscence, may lead to major physical, psychological and social problems if left untreated. It can be associated with persistent pain and discomfort at the perineal wound site, urinary retention, defecation problems, dyspareunia, psychosexual issues from embarrassment and altered body image (Williams & Chames, 2006).

Goal

Reduce the incidence of wound disruption in surgical and obstetrical patients by assessing risk, implementing risk factor modifications prior to surgery and instituting good wound care management.