Abdominal wound dehiscence (AWD) is an important postoperative complication that poses significant challenges for healthcare providers and patients. It is characterized by the failure of a surgical wound to achieve adequate strength to resist mechanical stresses, resulting in partial or complete separation of the abdominal wall ^[1]. This condition is associated with high rates of morbidity and mortality, as well as increased healthcare costs for both patients and hospitals. Factors such as suture breakage, premature dissolution of absorbable sutures, and tissue tearing due to overly tight sutures contribute to the occurrence of AWD. Despite advancements in surgical techniques, no surgical unit has reported a 0% failure rate for this condition, highlighting its complexity and persistence as a clinical issue. It usually occurs in two forms partial and complete. Partial dehiscence involves the separation of one or more layers of the abdominal wall, with the underlying sheath and peritoneum remaining intact. In contrast, complete dehiscence is characterized by the disruption of all layers, often leading to visceral evisceration ^[2]. Studies show AWD occurs between 0.2% and 6% of cases while death rates range from 9% to 44% according to published research ^{[3, 4]}. The best surgical techniques won't prevent complications in patients battling severe medical problems. Technical problems during surgical procedures can lead to this harmful condition as well. AWD leads to long hospitalization, increases the frequency of incisional hernias, and needs for repeated operations while severely affecting patient health and hospital resources. AWD risk emerges from distinct elements that involve patient characteristics before surgery, surgical procedures, and recovery following medical intervention. Factors related to the patient such as age, sexual identity, diet, blood health, and health conditions affect wound recovery. Health emergencies, surgery methods, operation times, and infections after surgery play essential roles in whether a patient's wound breaks open again ^[5]. Scientists do many post-event studies to explore AWD risk factors yet their data shows mixed outcomes. Few studies used multivariate analysis to study multiple risk factors because they focused only on small patient samples at one location ^[6].

The treatment of abdominal wall dehiscence by reclosure of the abdominal wall layers. Patients undergoing abdominal wall repair experience delays if there is intestinal edema or if the abdominal area is rigid because they also face infections and intestinal fistulas. Medical teams treat AWD patients through four treatment routes: non-operative care, waiting for hernia formation, surgical repair with retention sutures, and mesh placement. Experts disagree on which treatment method provides the best results. Scientists conduct ongoing research to measure which medical approaches work best to reduce treatment risks and enhance patient recovery results ^{[7, 8]}. The high morbidity and mortality rates and health system strain of AWD demand researchers to determine how frequently it occurs and what the etiology and treatments can improve. The goal of the underlying study was to evaluate possible risk factors for abdominal wound dehiscence and its management.

This prospective interventional study was conducted in the Department of General Surgery, Bhaskar Medical College and Hospital. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study and possible outcomes in vernacular language.

Inclusion criteria

1. All patients who have undergone abdominal surgery at Bhaskar Hospital over 18 months and developed abdominal wound dehiscence in the Department of General Surgery or OBG were included in the study.
2. Partial or complete abdominal wound dehiscence
3. Males and Females
4. Aged 18 and above
5. Willing to participate in the study voluntarily

Exclusion criteria

1. Patients less than 18 years of age
2. History of previous laparotomy.
3. Referred from other Hospitals
4. Not available for follow-up

After selection of the patient based on the inclusion and exclusion criteria a detailed history and clinical examination was conducted, the data was noted on a proforma which included factors like age, gender, co-morbid factors, type of surgery, type of Intestinal pathology, type of incision, anemia, obesity, renal function test, serum electrolytes, hypoalbuminaemia. All the patients with wound dehiscence were given intravenous antibiotics according to culture and sensitivity and treated with various management strategies.

Treatment for abdominal wound dehiscence was determined by the type of complications and contamination of the wounds. Smaller dehiscences were managed with saline-moistened gauze and binders. Evisceration required immediate coverage of the exposed intestines with sterile, saline-moistened dressing followed by fluid resuscitation and emergency surgery. During the operative procedure, the abdomen was explored to find infections or anastomotic leaks. The infections must be taken care of before the closure. If the fascia was healthy then primary closure was performed. Inflamed or necrotic fascia required debridement. If the edges of the wounds were not being approximated without tension, then absorbable mesh was used. Skin grafts and flaps were used for epithelial and abdominal wall reconstruction.  The patients were kept in the hospital till their recovery and followed up every week for the first month and after two weeks for the next two months. The last follow-up was done after 6 months to determine the outcomes of the repairs.

Statistical analysis: All the available data was refined, organized, and uploaded to an MS Excel spreadsheet and analyzed by SPSS 22 version on Windows format. The continuous variables are represented as mean, standard deviation, and percentages. The categorical variables were calculated using Fischer's exact test to determine p values. The values of p (<0.05) were considered as significant.

The study conducted on 50 patients with abdominal wound dehiscence was analyzed and the following results were found. Our study population consisted of 50 patients between the ages ranging from 18 years to 80 years. The majority of the patients who had abdominal wound dehiscence belonged to the age group 51-60 years followed by31-40 years. Only one patient was above 70 years. The youngest patient was 18 years old and the oldest patient affected was 75 years old and the mean age of the patients affected was 43.08 years.

Figure 1: Age-wise distribution of cases included in the study

In this study, the incidence of abdominal wound dehiscence is higher in males 28 cases (56%) compared to females 22 cases (44%). Most of the cases in this study had no other co-morbidities or systemic illnesses i.e. 18 cases (36% cases), 8 patients (16%) had chronic obstructive pulmonary disease, and 7 patients (14%) had type 2 diabetes mellitus. Two patients had chronic renal failure with hypertension. One patient had all three chronic obstructive pulmonary disease, diabetes & hypertension. Out of 50 cases in this study, 37 patient's BMI is in normal range. 3 patients were underweight and 3 patients were obese.7 patients were overweight.

Table 1 shows the BMI range in patients with abdominal wound dehiscence

Patients included in the study had been operated on for diverse surgical conditions. Out of 50 patients who had abdominal wound dehiscence, the majority i.e. 17 cases were hollow viscous perforation, out of which the highest number of cases was duodenal perforation (8 cases) followed by ileal perforation (6 cases), appendicular perforation (5 cases), and only 1 case was diagnosed perforated Meckel's diverticulum. The next common diagnosis was intestinal obstruction (9 cases) out of which the majority are obstructed incisional hernia (5 cases). Malignancy was found in only 5 cases (Figure 2).

Figure 2: Distribution of patients with abdominal wound dehiscence according to underlying intra-abdominal pathology

Among all patients in the present study, 31 (62%) were operated as emergency surgeries and 19 (38%) as elective surgery. Out of 50 cases of abdominal wound dehiscence, perforation, the most common surgery that preceded the onset of wound dehiscence was found to be laparotomy with Graham's omental patch closure for perforated duodenal ulcer in 9 cases. The second most commonly performed surgery was resection and anastomosis in 8 cases. The other common surgeries undergone were laparotomy with primary closure of ileal perforation in 5 cases and open appendicectomy in 5 cases.

Table 2: Various abdominal procedures leading to abdominal wound dehiscence

In this study, 40% of cases were clean contaminated followed by 38% clean cases, and the remaining 22% were contaminated. Among all cases operated, 30 cases (60%) cases were operated for more than 150 mins, and the remaining were operated for less than 150 mins. Out of 50 cases operated, 39 cases (78%) operated with midline incision and only one case operated with Kocher’s incision developed wound dehiscence (Figure 3).

Figure 3: Frequency of abdominal wound dehiscence in relation to type of incision

Out of n=50 cases studied, 31 cases (62%) were anaemic out of which 14 cases were found to be with <8mg/dl, with 2 cases 6mg/dl. The remaining 19 cases were normal. Out of all anemic patients, 17 patients were female and 14 were males. The mean Hb value in this study was 9.6mg/dl. The estimation of albumin levels revealed that 23 cases had normal albumin levels. 27 cases (54%) had hypoalbuminemia. Out of which,16 patients were males The mean value was 3.65mg/dl. Out of 50 cases studied, 18 cases (36%) had normal blood sugar levels and 7 cases (14%) had blood sugar levels >150mg/dl. The mean value was 112.2mg/dl. The renal parameters show 5 cases (10%) had hypokalemia and the remaining were normal. N=12 cases had elevated renal parameters i.e., both Serum Creatinine and blood urea. The majority of cases 22 cases (44%) had wound discharge, followed by cough in 17 cases (34%). Abdominal distension and vomiting were present in 4 cases each, and cough and wound discharge in three cases.  Abdominal wound dehiscence occurred between 5-13 days postoperatively. Most cases were found to present with burst abdomen on the 7th and 9th postoperative days (18 cases, 32% and 16% respectively), with the highest incidence on the 7th postoperative day.

Clinical presentation: Among subjects, 26 cases (52%) presented with pus discharge, 18 cases (36%) with serous discharge, and 6 cases (12%) presented with wound gaping. TYPE OF Suture Material Used: Among observations, 26 cases (52%) developed wound dehiscence when the closure was done by polyglactin. The least number of wound dehiscence was noted when closure was done by PDS i.e., in 5 cases (10%). Using polypropylene, 8 cases (16%) developed wound dehiscence.

Figure 4: Type of suture material related in the cases of dehiscence

Out of 50 cases, n=31 cases (62%) abdominal closure technique used was layer to layer and in the remaining 19 cases (38%) mass closure was done.  The most common organism isolated from wound samples in this study was Escherichia coli in 28 cases followed by Klebsiella in 13 cases, Staphylococcus aureus i from 2 samples, and Pseudomonas aeruginosa in 7 cases. The range of hospital stay for all abdominal wound dehiscence cases was 13-46 days. The average hospital stay was 23.5 days. 50% of the patients stayed for < 20 days and only 6% for > 40 days. Hospital stays for more than 20 days were noted in 25 cases and were mainly due development of complications and co-morbid factors associated with the disease.

Type of wound dehiscence showed that 32 patients constituting 64% had partial dehiscence in which 22 cases (44%) were superficial and 10 cases (20%) involved fascial dehiscence. The majority of cases (16 cases) were within the age group 40-70yr. Out of which 15 cases were males and 17 were females. N=18 patients (36%) had complete wound dehiscence. The majority of patients with complete wound dehiscence were males 13 patients (72%) and only 5 patients were female (27%). All the patients with complete wound dehiscence fell in the age group 35-75 years. 8 cases Only one patient was 18yrs. Partial superficial wound dehiscence was managed by regular dressing and secondary suturing in 20 cases, 6 were managed by vacuum-assisted closure, and 1 case by Smead Jones technique (Table 4). Partial fascial dehiscence was managed by mesh closure in 3 cases and tension suturing in 1 case. Complete wound dehiscence was managed by mesh closure in 7 cases, tension closure in 9 cases, and by Bogota bag in 3 cases.

Table 4: Management of abdominal wound dehiscence

Abdominal wound dehiscence (AWD) is an important postoperative complication, with significant morbidity and mortality. It occurs despite advancements in preoperative and surgical care. It poses substantial challenges for patient recovery, often leading to prolonged hospital stays, incisional hernias, and reoperations. The results of our study showed that out of 50 cases of abdominal wound dehiscence, 56% of cases were male and 44% female, resulting in a male-to-female ratio of 1.2:1. In other similar studies have reported a higher incidence in males as compared to females by Spiliotis et al. ^[9] (60% males) and Ramshorts et al. ^[4] found 75% males in their respective studies. The higher male prevalence may be linked to factors such as increased abdominal wall tension and smoking, which affects tissue repair. Most cases (40%) were clustered in the 51–60 age group, with a mean age of 43.08 years, similar to studies by Waqar et al. ^[10] (39.67 years) and Spiliotis et al. ^[9] (69.5 years). Advanced age correlates with reduced tissue repair mechanisms and compromised immune responses, as noted in earlier reviews where over 77% of cases involved patients above 50 years ^[11-14]. This study observed that 36% of patients had no comorbidities, while 16% were associated with COPD, which increases intra-abdominal pressure. Diabetes was noted in 24% of patients, in concordance with studies by Zochampuia et al. ^[15] (30%) and Debananda et al. ^[16] (34.9%). Poor wound healing due to diabetes is attributed to impaired angiogenesis, reduced inflammation, and compromised collagen synthesis. In our study we found hypoalbuminemia was present in 45% of cases, with a mean albumin level of 3.65 g/dL, indicating poor nutritional status. Anemia, observed in 62% of cases (mean Hb 9.6 g/dL), was a major contributor, as it reduces tissue oxygenation and impacts the immune system, consistent with findings from Zochampuia et al. ^[15] (52.5%).

In the current study, most cases (62%) occurred following emergency laparotomies, similar to Waqar et al. ^[10] (72%) and Spiliotis et al. ^[9] (60%) (3, 5). Emergency surgeries often involve poor preoperative preparation, worse nutritional status, and increased contamination. Hollow viscus perforation (34%) was the common intra-abdominal pathology, with duodenal perforations being the primary cause (16%). Prolonged surgeries (>150 minutes) were observed in 60% of cases, increasing infection risks, also reported by Zochampuia et al. ^[15] (72.5%) and Ramneesh et al. ^[17]. Vertical midline incisions were used in 72% of cases of wound dehiscence, aligning with findings from Parmar et al. ^[18] which showed higher dehiscence rates with midline incisions compared to transverse incisions (26). The use of polyglactin sutures resulted in higher dehiscence (52%) than PDS sutures (16%), consistent with van't RM et al. ^[19] meta-analysis showing poorer outcomes with rapidly absorbable sutures. Mass closure techniques resulted in fewer complications compared to layered closures (28). Escherichia coli was the most common pathogen (56%), followed by Klebsiella (26%), consistent with studies by Nichols et al. ^[20] and Wassef et al. ^[21]. Postoperative wound infections were the most common complication (50%), with 52% presenting with pus discharge. We managed the partial dehiscence (40%) with secondary suturing or VAC therapy. Complete dehiscence required tension sutures (18%) or mesh repair (14%). The Bogota bag technique was employed in cases with bowel edema.

Abdominal wound dehiscence (AWD) is influenced by patient factors (age, anemia, hypoalbuminemia), patient’s co-morbid conditions like chronic obstructive pulmonary disease, diabetes, hypertension, obesity should be identified prior and should be managed appropriately to reduce the incidence of wound dehiscence. Surgical techniques and emergency settings are also important determinants. Proper preoperative optimization, use of appropriate suture materials, and timely management are essential to reducing complications. Mass closure technique by slowly absorbable suture material is preferred to reduce the incidence of wound dehiscence. Reducing the operative time and taking appropriate aseptic precautions can reduce the incidence of wound dehiscence.

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