Cath Lab Digest

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Index: Ostomy Wound Manage. 2008;54(9):44-48.

Abstract

  Abdominal wound dehiscence is a major postoperative complication with a high mortality rate. Although the mainstay of management is immediate operative reclosure, critically ill patients are better served by conservative temporary measures and delayed operative closure. The evidence in the literature regarding the use of biosynthetic implants in abdominal wound dehiscence is limited. To expand knowledge of management options, a case of abdominal wound dehiscence post hysterectomy in a critically ill 69-year-old woman managed with placement of a porcine dermal collagen implant is described. The porcine dermal collagen implant was placed in an infected field for the repair of the fascial defect under local anesthesia. No additional surgery was required and, 9 months post surgery, the patient remained healthy without evidence of residual hernia. Biosynthetic implants may be an effective alternative for the acute management of fascial dehiscence in critically ill patients.

KEYWORDS: wound dehiscence, surgery, complications, infection, biosynthetic implant.

    Abdominal wound dehiscence is a major postoperative complication with high morbidity that may exceed 50% of patients and mortality rates ranging between 15% and 44%.^1-3 The mainstay of management is immediate reclosure of the abdominal wall with retention sutures, performed under general anesthesia. Critically ill patients for whom general anesthesia is risky and patients with wound or intra-abdominal sepsis in whom reclosure of the abdominal wall would be unsafe are better served by conservative temporary measures and delayed operative closure when their condition improves.^4,5 Several attempts to temporarily cover the open abdomen with synthetic meshes have been described in the literature; however, high complication rates are reported.^6-11 Although case studies describing the use of biosynthetic mesh implants for abdominal wall reconstruction suggest they can be used safely in contaminated wounds,^4,12-14 evidence in the existing literature for their use in the emergent management of abdominal wound dehiscence is scant. To expand knowledge of management options, the case of sepsis-associated abdominal wound dehiscence managed with placement of a porcine dermal collagen implant under local anesthesia is presented.

Case Report

    Ms. N, a 69-year old female patient, was referred with an acute abdomen, presenting with severe abdominal pain and tenderness, accompanied by absence of bowel sounds and mild generalized abdominal swelling 1 month after a hysterectomy had been performed. On admission, she was receiving oral corticosteroids for idiopathic thrombocytopenic purpura. Exploratory surgery revealed multiple abscesses, which were drained. Ms. N’s peritoneal cavity was lavaged with saline and antiseptic solution. Drains were placed within the abdominal cavity and the abdomen was closed with nylon sutures in a mass closure technique. Cultures of the abscesses showed Escherichia coli.

    Seven days postoperatively, Ms. N developed a wound infection and fascial dehiscence (see Figure 1). Because of her poor general condition (persistent sepsis, thrombocytopenia, and intravenous steroid use), physicians determined surgical reclosure of the abdomen under general anesthesia was not judicious. Instead, they decided to repair the abdominal wall defect under local anesthesia using a porcine dermal collagen implant.