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Conference Highlight

The Patient With Surgical Wound Dehiscence

According to a consensus document from the World Union of Wound Healing Societies (WUWHS), “Surgical wound dehiscence (SWD) is 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.”1

Lawrence Colen, MD, FACS, lectured on the topic of SWD at the 2019 Diabetic Limb Salvage meeting, held in Washington, DC, from April 4-6. Surgical wound dehiscence is an under-reported, major issue affecting a large number of patients that impacts a patient’s length of hospital stay, hospital readmission, number of surgeries needed, and amputation, said Dr. Colen. In his presentation, Dr. Colen used the WUWHS definition of SWD as he covered the grades of SWD, issues and impacts faced, causes, preventative measures, management, among other important considerations for the clinician. An abbreviated version of Dr. Colen’s presentation is reported herein.

Causes of SWD
Technical issues. Important factors to keep in mind when dealing with SWD or potential SWD from a technical standpoint include suture breakage, poor incisional or flap design, and closure under tension. Suture breakage, Dr. Colen stated, consists of suture failure, suture knots coming undone, sutures placed too close to the incisional edge, and sutures placed too far apart. When closing a patient’s wound, the clinician should remember these technical issues that, if minded, will aid in preventing SWD.

Mechanical stress. In terms of mechanical stress, Dr. Colen implored attendees to consider premature weight bearing following plantar foot surgery and inadequate immobilization postoperatively adjacent to joints. These two factors can pose challenges for clinicians due to patient compliance with the treatment and management regimen.

Incidence
Post abdominal and cardiothoracic surgeries have a plethora of data reporting SWD on those patients, said Dr. Colen. However, little data are available on SWD alone in patients who underwent foot and ankle surgery; reported data involve surgical site infections, which does not provide a fully accurate picture of SWD in this patient population. Further, data on morbidity, mortality, and health care costs are not specific to lower extremity SWD. Though, Dr. Colen believes we can extrapolate that SWD in the under-reported patient population equates to increased hospital costs, hospital length of stay, readmission rates, and higher risk of amputation.

Prevention
As with all wounds, the best course of treatment is prevention. Clinicians can manage the risk factors, said Dr. Colen. These risk factors include patient compliance, smoking cessation, a vascular evaluation for patient with peripheral vascular disease, and considering the use of nutritional supplements. Other factors that should be considered in a patient’s assessment are medications (eg, modifying immunosuppressants, if applicable; appropriate perioperative antibiotics; pentoxifylline use; Vitamin A administration in patients on steroids), debriding non-vitalized tissue in traumatic wounds, and hemoglobin levels <8% in patients with diabetes. In terms of the surgical procedure, clinicians can remember to avoid adding tension in the wound closure and considering the angiosomes of the foot and ankle when planning the incisions.

Management
A crucial point in managing SWD is addressing the patient’s comorbidities, as Dr. Colen also mentioned in the prevention portion of his lecture. Controlling infection, both surgically and medically, as well as edema of the lower extremity also were stressed. With SWD management, Dr. Colen said debriding nonviable tissues by scalpel, ultrasonic, and hydrosurgical should be considered.

The local wound care must be designed to keep a moist wound healing environment. According to Dr. Colen, this can be accomplished with antibiotics ointments/creams, topical enzymes with moist dressings, silver-impregnated hydrofiber dressing for exudative wounds, and negative pressure wound therapy (NPWT). If using NPWT, it should be done in conjunction with appropriate debridement, but it may be a definitive treatment for superficial or small foot and ankle wounds. In contaminated wounds, NPWT with instillation may be beneficial. Overall, NPWT can simplify surgical closure of the wound.

Surgical approaches for wound management, due to exposed tendon, bone, or hardware, are also necessary for the clinician to contemplate. Dr. Colen shared his experience of using suture repair, delayed primary closure, skin grafts, local flap, and free tissue repair as viable options for the surgical approach.

Conclusions
At the end of the day, Dr. Colen said clinicians should consider the best option for their specific patient. Not all treatments and approaches fit each patient. In wound care especially, there is no one-size-fits-all treatment or therapy. In regard to this, clinicians must consider their patient’s comorbidities and socioeconomic ability to be compliant with the selected course of wound management; however, prevention should always be at the forefront of clinicians’ minds so as to avoid needing the aforementioned information on SWD management that Dr. Colen expertly provided to the audience.

Reference
1. World Union of Wound Healing Societies (WUWHS) Consensus Document. Surgical wound dehiscence: improving prevention and outcomes. Wounds Int. 2018;1-46. Available at: https://www.woundsinternational.com/resources/details/consensus-document-surgical-wound-dehiscence-improving-prevention-and-outcomes.

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