Surgical wound dehiscence (SWD) not only affects comprehensive hospitals but also impacts community healthcare systems. Recent studies have shown that SWD significantly increases the costs of community care.SWD is one of the common complications after surgery, and its treatment poses significant challenges to clinical practice. With the aging population and the global increase in chronic diseases such as diabetes and obesity, patient-related comorbidities may increase the risk of SWD occurrence. Therefore, specific management measures should be provided for high-risk individuals before and after surgery. Early identification of risk levels, followed by accurate assessment and timely treatment, can prevent small issues from evolving into major disasters. Proper assessment, diagnosis, treatment, and documentation must not be overlooked. Furthermore, a multidisciplinary approach is required for the treatment of SWD patients to ensure consistency in treatment.
Currently, the global annual number of surgeries is quite substantial, with major surgeries reaching up to 234 million (WEISER 2008). In China, nearly 60 million various surgical procedures are performed each year. Primary healing of surgical wounds is achieved through sutures, staples, biological glue, tape, dressings, or NPWT, and the healing process often begins within hours after closure (ROERO 2010). There are many reasons for postoperative wounds failing to heal, including patient-related factors such as age, cardiovascular diseases (WEBSTER 2003; VAN RAMSHORST 2010), mechanical reasons leading to suture breakage or knot loosening (BARONSKI 2012), infection or dehiscence (RIOU1992; RIDDERSTOLPE 2001), and radiotherapy or chemotherapy (SPILIOTIS 2009).
In the UK, surgical site infections (SSI) account for 20% of healthcare-associated infections, and at least 5% of hospitalized patients will develop SSI (LEAPER2004). In North America, the financial costs associated with SSI are estimated to reach 10 billion USD per year (URBAN 2006), while Europe spends between 1.47-19.1 billion euros annually on SSI, and Australia spends approximately 268 million AUD per year (MCLAWS2003).
Effective management to improve postoperative wound healing and prevent wound infections and complications is crucial.
1.Identification of Risk Factors
a)Advanced age: >65 years
b)Signs of systemic and local wound infection
c)Obesity
d)Previous surgery on the same anatomical site
e)Intraoperative risk factors,
i.Emergency surgery (Watanabe 2008)
ii.Type of surgery
iii.Duration of surgery
iv.Intraoperative warming (Wong 2007)
f)Postoperative risk factors, such as increased intra-abdominal pressure (coughing, repeated vomiting, and constipation)
2.Identification of Signs and Symptoms of Wound Dehiscence
a)Separation of any part of the incision edges;
b)Suture breakage (unhealed areas);
c)Redness at the incision site;
d)Pain at the incision site;
e)Local swelling, edema, seroma;
f)Bleeding;
g)Exudate.
3.Accurate Assessment and Classification of Dehisced Wounds
This includes continuous assessment of the patient: A complete and accurate wound assessment (anatomical location, size, tissue type and characteristics, type/amount of exudate, odor, pain) is crucial; assessment results and treatment plans should be documented in detail after each evaluation. The type and classification of wound dehiscence can provide key information to clinicians for developing appropriate treatment plans. There are two types of wound dehiscence: a)Partial dehiscence;
b)Full-thickness dehiscence.
4.Assessment of Clinical Infection Indicators
a)Insufficient vitality of wound tissue
b)Necrosis
c)Failure of wound size to decrease
d)Excessive granulation tissue formation
e)Increased exudate f)Erythema
g)Increased or unexplained pain
h)Foul odor
i)Confirmation of infection presence (microbiology)
j)Increased temperature of surrounding tissue
5.Determining Treatment Goals
Treatment goals may differ from primary healing, thus clear and achievable goals should be documented; they should also be communicated and discussed with the patient, explaining all planned measures.
The treatment goal is to prepare the wound bed for subsequent closure. Interventions include assessing the wound bed to confirm the presence of necrotic tissue and infection. If infection is suspected, antibiotics should be used judiciously, and drains, sutures, or staples should be removed, along with surgical debridement. After necrotic tissue is removed, superficial dehiscence can be closed by secondary intention. For large and deep dehisced wounds, NPWT or reoperation may be considered for closure (Avila 2012). All cases of wound dehiscence should involve consultation with a wound care specialist nurse.
6.Proper Wound Bed Preparation
Effective wound bed preparation is essential for the wound healing process. Techniques for assessing inflammation, such as the TIME framework, assist in wound assessment.The TIME framework provides a systematic approach to wound healing assessment, including the removal of devitalized tissue, infection control, maintenance of moisture balance, and promotion of epithelialization (Fletcher 2005).
7.Managing Patient Expectations
Managing patient expectations begins with understanding their expectations. Frequent and honest communication regarding healing and pain management is key to the overall patient experience. Maintaining openness and honesty in communication helps build trust and makes patients feel comfortable. Managing patient expectations regarding wound healing during the treatment process is crucial, focusing on timely communication of potential outcomes, such as further surgical interventions, increased frequency of care, and pain management. The impact on the patient’s overall health is also important.
8.Multidisciplinary Management Approach
The treatment of dehisced wounds requires multidisciplinary involvement, including surgeons, infection specialists, home care or community care, nutritionists, and other specialists.
9.Patient and Caregiver Education
The first indicators of wound dehiscence may include: sudden pain at the wound site, tachycardia, abnormal and/or excessive serous or serosanguinous exudate, changes in wound contour, and exposure of internal organs. It is important for patients to understand these manifestations and know how to notify healthcare personnel upon discovery. Patient education can be conducted through verbal communication/demonstration or in the form of brochures/flyers. In community care settings, informational flyers describing wound complications and emergency contact numbers can be left in the patient’s home.
10.Post-Discharge Monitoring
Continuous follow-up of patients’ wounds, medications, health, and accurate documentation is critical for optimizing patient outcomes. Regular reassessment of wounds can determine treatment needs, reflecting the demands of the wound healing stages. Detailed documentation in the wound management plan aids communication among multidisciplinary team members and ensures continuity of care. Accurate records enable researchers, epidemiologists, and health economists to better study and understand related issues, thereby formulating reasonable policies. There is no need for further evidence regarding the health costs and clinical impacts of wound dehiscence. Additionally, policy formulation requires more evidence support.