of the Abdominal
Wall With a One-Knot
Control Following Laceration
of Inferior Upper
Abdominal Wound Dehiscence
The seepage of serosanguineous fluid through a closed
abdominal wound is an early sign of abdominal wound dehiscence with
possible evisceration. When this occurs, the surgeon should remove
one or two sutures in the skin and explore the wound manually, using
a sterile glove. If there is separation of the rectus fascia, the patient
should be taken to the operating room for primary closure. Wound dehiscence
may or may not be associated with intestinal evisceration. When the
latter complication is present, the mortality rate is dramatically
increased and may reach 30%.
The basic principles of management of abdominal
wall dehiscence and evisceration are early diagnosis and surgical closure.
The latter is accompanied by mass closure with wide sutures of heavy
delayed synthetic absorbable suture.
The purpose of the operation is
to close the abdominal wall.
Physiologic Changes. Dehiscence may stem from wound
hematomas or from excessive intra-abdominal pressure secondary to abdominal
coughing or vomiting that has disrupted the sutures. It is most commonly
seen in patients with properties of poor wound healing, such as patients
with diabetes, oncology patients, and patients taking steroid medications.
Points of Caution. All attempts should
be made to diagnose and manage this problem promptly to minimize the
risk of intestinal evisceration.
All sutures should be placed prior
to tying any one suture.
The patient showing abdominal wall dehiscence
with evisceration of the small intestine is placed in the supine
position under general anesthesia.
The contaminated edges of the wound including
a combination of the peritoneum and rectus fascia are excised.
At the xiphoid end of the incision,
the needle is placed through point a to point a' through
all layers of rectus fascia muscle and peritoneum. When the needle
is brought out of point a', it is passed through the
loop end of the suture.
The needle is brought through point
b to point b', 2 1/2 cm from point a and point a',
The sutures are not pulled taut
for the remainder of the suture c through n, m, etc.
By leaving the sutures loose, the surgeon has the best opportunity
to place the sutures precisely. When the sutures have been completely
placed, they can be cinched up taut. Here one sees the technique
of placing the final sutures from m' to n.
One strand of the double suture is cut, while the uncut strand
is passed through the wound opening beneath the abdominal wall
and out of point n from inside to out.
The sutures are cinched up
snugly but are not tight. The two single-suture strands are tied
after all the loops have been tightened. Multiple throughs, more
than five, are placed in this knot.
The suture has been tied. To date, there
has been no item of data to show that this closure has any less
or any greater strength than the more time-consuming Smead-Jones
closure with running far-to-near-near-far suture.