Overview and Implications
Wound healing is a critical outcome in surgery, and postoperative wound disruption 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 remodeling phase, in reality it is a complex, continuous process (Demidova-Rice et al., 2012). Surgical wound dehiscence (SWD) has been defined as the separation of the margins of a closed surgical incision that has been made in skin, with or without exposure or protrusion of underlying tissue, organs, or implants. Separation may occur at single or multiple regions, or involve the full length of the incision, and may affect some or all tissue layers. A dehisced incision may, or may not, display clinical signs and symptoms of infection (Ousey,2018).
Despite improvements in contemporary preoperative care and suture materials, the rate of surgical wound disruption has not decreased in recent years (Sorensen et al., 2005). CIHI's Hospital Harm Results reports the number of preventable, unintended harm due to wound disruption as ranged from 3,581 events in fiscal 2014, to 5,435 events in fiscal 2019 (CIHI, 2020). This may be attributable to the increasing incidence of risk factors within the patient population outweighing the benefits of technical achievements (Sorensen et al., 2005).
The causes of SWD can be categorized as: technical issues with the closure of the incision (e.g., unravelling of suture knots); mechanical stress (e.g., coughing can cause breakage of the sutures or rupture of the healing incision after suture or clip removal/reabsorption); and disrupted healing (e.g., due to comorbidities or treatments that hamper healing, or as a result of a surgical site infection [SSI]) (Ousey, 2018). However, overall 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). 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).
The prevention and management of surgical wound complications is a growing area of concern for patients, healthcare professionals, and administrators alike. In these times of rationalization of healthcare dollars, it is important to ensure that patients receive appropriate screening and care, beginning at the pre-operative assessment and continuing through to post-operative care and monitoring in the community. Best practice recommendations when combined with evidence-informed interventions should help clinicians develop the skills and tools needed to identify those at risk for complications and develop plans in collaboration with their patients to ensure a best practice approach (Harris, 2017).
Factors that could increase the risk of postoperative wound dehiscence (AHRQ-PDI 14, 2016, *Kamel & Khaled, 2014):
Adult Patient related:
- Male gender
- Increasing age
- Poor nutrition
- Chronic pulmonary disease
- Presence of prior scar or radiation at the incision site
- Non-compliance with postoperative instructions (such as early excessive exercise or lifting heavy objects)
- Increased pressure within the abdomen due to fluid accumulation (ascites); inflamed bowel; severe coughing, straining, or vomiting
- Long-term use of corticosteroid medications
- Emergency surgery
- Types of surgery (clean vs. contaminated)
- Surgical error
Factors that could increase the risk of postoperative wound dehiscence in the pediatric population (AHRQ PSI 11, 2016):
- Wound infections
- Age <1 year
- Emergency surgery
- Mechanical ventilation
- Median or vertical incisions
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.
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