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10 September, 2018 00:00 00 AM

Burst abdomen

Prof. Dr. Hafizuddin Ahmed
Burst abdomen

Burst abdomen is also called dehisence of abdominal wound. In this condition there occurs giving away of abdominal wound i.e. post operative separation of abdominal muscles and aponeurotic layers with extrusion of bowel or omentum.

Statistics:

Once it was very common in underdeveloped countries like Bangladesh and other poor countries of third world. Even now 1-3% of abdominal wounds give away on 6th – 8th post operative day when the strength of the wound following operation is at its weakest. Before discussing further the anatomy  of the anterolateral abdominal wall should be taken into our consideration.

Anatomy of the Anterolateral abdominal wall:

Skin of the anterior abdominal wall is capable of undergoing enormous  stretching as seen in pregnancy ,tumour, accumulation of fat (obesity),fluid (ascities)etc. Below umblicus (a scar formed by the remnants of the root of the umbilical cord) superficial fascia is divided into superficial faty layer (Fascia of camper) and deep membranous layer (fascia of scarpa ). There are 4 large muscles on either  side of midline. e.g. External oblique, Internal oblique.

Transversus  Abdominis and Rectus Abdominis. Besides there are two small muscles : Cremaster and Pyramidalis.

Between costal margin and arcuate line or Fold of Douglas (Semicircular end of posterior wall of Rectus), anterior wall of the Rectus sheath is formed by External oblique aponeurosis and anterior lamina of aponeurosis of Internal oblique.

Posterior wall is formed by posterior lamina of aponeurosis of Internal oblique and aponeurosis of Transversus Abdominis. However above the costal margin there is no posterior wall and anterior wall is formed by only External oblique aponeurosis. Below the  arcuate line all 3 flat muscles pass anteriorly and only Fascia Transversalis lies behind .

The sheath contains Rectus Abdominis, Pyramidalis, Superior and Inferior epigastric vessels, terminal parts of lower five inter costal subcostal nerves.

The superficial lymphatics above the level of umbilicus drain to Axillary Lymph Nodes and below that level to Superficial inguinal lymph Nodes. Besides the direction of fibres are also important to remember for the purpose of the strength of the abdominal wall eg.fibres of the Rectus Abdominis directed  vertically upwards, That of External Oblique runs downwards and forwards while in case of Internal Oblique they run  upwards and forwards though it’s lowers fibres run almost ventically downwards.

The fibres of Transversus Abdominis run horizontally . The aponeurosis of all 3 lflat muscles meet to make a fibrous raphe in midline which is called Linea Alba.

Etiology

The causes of Burst Abdomen may be considered under the following headlines:

A.General :

Old age with weak musculature.

Malnutrition

Anaemia

Granulocytopenia

Hypoproteinemia

Diabetes

Obesity

Tuberculosis

Renal failure with anaemia.

Malignancy.

Vitamin -A, C, D and Zinc deficiency .Zinc is a co-factor of DNA and RNA synthesis.

Drugs: Steroid bock inflammatory reperatory process with inhibition of fibrioplasia and collagen synthesis cytotoxic drugs.,Intensive antibiotic treatment also play a role in Burst Abdomen.

Immunocompromised patient

Sepsis.

B. Local :

Increased intra- abdominal pressure with forceful expiratory acts e.g.Vomitting ,Coughing ,shouting ,distension of abdomen etc.

Faulty or inadequate closure of the wound.

Poor local wound healing e.g. because of infection.

Faulty operation technique e.g. not giving drainage where required or putting drainage tube through main wound or not doing peritoneal toileting when situation demands.

Faulty or out dated suture materials. Suture should be chosed properly according to site and handled correctly with right knottings.

Ionizing Radiation.

Presence of Foreign Body,  necrotic tissue, unnecessary sutures.

Sign and symptoms:

Patient usually notices serosanuguinous discharge which may herald underlying abcess with impending wound dehisence.

Case History:

A case No 1:  Mafida Tayeb, 12 years old plump Libyan girl (who looked more developed than her age) was admitted in August 1978 in the Department of Surgery , Central Hospital, Ghadames, Libya with abdominal pain for 3 days having little rise of temperature and pulse rate.

O/ E: Her abdomen was firm, protruberant (girl being obese). There was tenderness over right iliac fossa, Psoas Test +ve , Cough Sign +ve , Obturator  Test -Ve, Rebound Tenderness +ve ,Rovsing’s  Sign +ve .Blood exam revealed leucocytosis .Heart rate: Tachycardia.

Under G.A. the abdomen was opened by lower right paramedian incision .There was diffuse peritonitis and appendix was found automatically amput

ated and lying in the peritoneal cavity.

Appendicular perforation   in the caecum was carefully repaired and abdomen was closed in layers keeping a drain .On the 8th post operative day alternate stitches and on the 9th post operative day rest of the stitches were removed. It seemed that the  operative wound has united perfectly but during the stitches removal the girl cried violently not due to pain but due to fear when the immature girl  saw scissors in my hand thinking that I am going to cut her. Due to language problem I could not console her nor could I explain what I was  going to do  with her.

On account of sudden rise of intra -abdominal pressure the newly united wound gave away and intestinal coils came out  of peritoneal cavity . Abdominal fat of the obese patient also acted as pile driver .She was taken to O.T. After surgical Toilet the wound was repaired in mass closure technique. Later as per decision of hospital director she was sent to Central Hospital, Tripoli by Libyan Arab Airlines for further treatment where I took her care.

B. Case 2 :

An adult male was admitted in the Surgical Unit I of Dhaka Medical College Hospital in 1973.Where I was  Assistant Registrar. The patient came with Acute Intestinal Obstruction .X-ray abdomen showed multiple fluid levels .It was admission day  and the professor in charge operated on him. A big ball of round worms found in the lumen of small intestine.Enterotomy was done under G.A and the worms were removed releasing the obstruction. Round worm obstruction was common in those days.

The abdomen was closed in layers .On the 8th post operative day the stitches were removed but the wound gave away. I developed interest in the matter and followed 3-4 cases of round worm obstruction with similar results.I asked my professor and he replied that the round worms secrete enterotoxin  which is the reason for bursting abdomen.Later when I was abroad I wrote to Medicine International Journal -London requesting to comment about it.

They contacted W.H.O -Geneva. The expert there replied that no enterotoxin is liberated by the round worms. It is due to infective process (while doing enterotomy) which leads to Burst Abdomen.

Wound Healing :

Carefully sutured wounds have approximately 70% of the strength of normal skin .When sutures removed usually at one week, wound strength is approximately 10%  of that of unwounded skin which rapidly increases over next 4 weeks .

Healing is characterized by formation of granulation tissue leading to fibrosis and scar formation.

Healing by first intension:

This type is seen in clear surgical uninfected incision approximated by suture.

Wound causes formation of clot which in addition to entrapped cells contain fibrin, fibronectin and complement proteins. Cytokinase and chemokinase released into area.

Released VEGF (Vascular Endothelial Growth Factor) Leads to permeability and oedema. Scab is formed by dehydration of surface clot. Within 24 hours neutrophils seen to migrate to clot, release proteolytic enzymes, clear debris .Within 24-48 hours epithelial cells from both edges of wound begin to migrate and proliferate yielding continuous epithelial layer that closes the wound.

By 3rd day neutrophils replaced by macrophages and granulation tissue invades. Collagens fibres are now evident. By the day 5 neurovascularization reaches peak as granulation tissue fills the incision area.  During 2nd week continued collagen accumulate and fibroblast proliferate.  By the end of 1st month scar is formed.

Healing by 2nd intension:

Secondary union or healing by 2nd intension occurs when there is extensive loss of tissue. Wound contraction occurs after lag of 2-3 days. Inter papillary process and hair follicles are not formed.

Procedure of Repair:

The disruption usually occurs in ward .The patient should be immediately isolated from other patients by a screen. Message should be sent to O.T. nurse to prepare be theater. Anaesthetist should be alarted. Before sending the patient to O.T . the extruded intestinal coils should be covered with sterile towel soaked with worm saline. Over that cotton wool and a firm binder is applied .The patient is advised not to cough or strain. In the theatre by interrupted monofilament nylon No.1 suture, parietal peritoneum, posterior rectus sheath, anterior rectus sheath all are approximated and single layer closure is done. The suture is mounted on a large half circle cutting needle.

Mattress sutures are most secure and tied over small swabs or rubber tubing so that they can’t cut through the skin. Each suture is placed 1.5 cm- 2 cm away from edge at a interval of 1cm from each other. Abdominal contents are protected and prevented from coming out by worm soaked towel or mop.

Sutures are tied by tripple layer and ends are cut flush with knots. Chromic catguts are avoided and unsuitable as they lose tensile strength fast and little left after 8-9 days.

Prevention:

Post operative nausea and vomiting should be promptly dealt with. Drains should be used to prevent accumulation of blood and serosanguinous or purulent fluid where necessary but should be removed as soon as possible when collection is less than 25ml /day as if itself can traumatise  tissue inviting infection.

Wound Care:

Within 48 hours after operative closure a layer of epithelial cells from wound edge bridges the gap and sterile dressings applied in the theater should not be disturbed before this time. Time to time wound should be inspected - if inflammed a wound swab should be sent for culture and sensitivity to the laboratory. Sutures should be removed not earlier than 6 days and not later than 10 days. Vitamin A and C may be given to the patient.

Adequate apposition avoiding too tight and too close suture, gentle handling of tissues and consideration to blood supply are important. Placement of incision should be in the line of minimum tension following Langer’s lines. Midline, Paramidian (upper and lower), Kocher’s, Grid   iron, Lanz etc so many incisions are there for various surgery.

Transverse incisions usually much less disrupts then vertical incision. Vertical incisions are more vulnerable .Support of abdominal viscera and wound can be done by abdominal binder dressing.

Conclusion:

Burst Abdomen is not so common now a days after invasion of laperoscopic surgery and advancement of board spectrum antibiotics. It is most distressing for the patient and disappointing for the surgeon. Before routine operation patient should be instructed to reduce his /her weight as fat acts as a pile driver.

Proper sterility and meticulous closure technique should be followed strictly during surgery with patience without making haste leaving the last part of surgical procedure to the apprentice doctor. Drainage tube always should be passed through a separate wound. Cross infection should be taken care of. Unnecessary movement of the staff should be avoided in the O.T. Visitors should be restricted in O.T and Post Operative and surgical wards.                 

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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