Factors affecting post-operative laparotomy wound complications

Factors affecting post-operative laparotomy wound complications

International Archives of Integrated Medicine, Vol.

Copy right © 2015, IAIM, All Rights Reserved.

Original Research Article

Factors affecting post

wound complications

Khandra Hitesh P1*

, Vyas Pratik H1Assistant Professor, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad,

2PG Student, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India

*Corresponding author email:

How to cite this article: Khandra Hitesh P

affecting post-operative laparotomy wound complications

Available online at

Received on: 31-12-2014

Abstract

Despite the advances made in asepsis, antimicrobial drugs, sterilization and operati

post-operative wound problems continue to be a major threat. Clean sound healing of laparotomy

wound after any intra-abdominal procedure is a cardinal index of good surgical repair. Post

operative wound problems delays recovery and often incr

and require extra resources for investigations, management and nursing care, therefore its

prevention is relevant to quality patient care. Post

yet it does prove to be an economic burden on patient and on health system and induce

psychological trauma to the surgeon as it robs his hours of dedicated work on operating table and

good carrier. Considering wound problems is quite common in developing countries like India th

present study was taken up to find out the incidence of post

that influence its occurrence. Present study aimed

abdominal wound closure with regard to the problems associat

Key words

Laparotomy, Wound infection, Burst abdomen, I

Introduction

An abdominal wound may occur due to

disruption in the anterior abdominal wall caused

by either trauma [1] or any surgical intervention

in order to gain access to the underlying

operative laparotomy wound complications

International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015.

, IAIM, All Rights Reserved.

Factors affecting post-operative laparotomy

wound complications

, Vyas Pratik H1, Patel Nilesh J

1, Mathew Jovin G

Assistant Professor, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad,

PG Student, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India

*Corresponding author email: [email protected]

Khandra Hitesh P, Vyas Pratik H, Patel Nilesh J, Mathew Jovin G

operative laparotomy wound complications. IAIM, 2015; 2(1): 71-75.

Available online at www.iaimjournal.com

2014 Accepted on:

Despite the advances made in asepsis, antimicrobial drugs, sterilization and operati

operative wound problems continue to be a major threat. Clean sound healing of laparotomy

abdominal procedure is a cardinal index of good surgical repair. Post

operative wound problems delays recovery and often increases stay and may produce lasting sequel


prevention is relevant to quality patient care. Post-operative wound problems seldom causes death,

an economic burden on patient and on health system and induce


Considering wound problems is quite common in developing countries like India th

present study was taken up to find out the incidence of post-operative wound problems and factors

ccurrence. Present study aimed to discover the sound, ideal method for t

regard to the problems associated with laparotomy wound.

Laparotomy, Wound infection, Burst abdomen, Incisional hernia.

An abdominal wound may occur due to

disruption in the anterior abdominal wall caused

] or any surgical intervention

in order to gain access to the underlying

pathology [2]. In the latter sc

thus made passes through various layers of the

anterior abdominal wall from skin,

subcutaneous tissue, linea alba and peritoneum.

This incision when made initiates a cascade of

mechanisms at cellular level, which aims at

achieving healing at incision site [

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Page 71

operative laparotomy

, Mathew Jovin G2

Assistant Professor, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India

PG Student, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India

Mathew Jovin G. Factors

75.

Accepted on: 05-01-2015

Despite the advances made in asepsis, antimicrobial drugs, sterilization and operative technique,

operative wound problems continue to be a major threat. Clean sound healing of laparotomy

abdominal procedure is a cardinal index of good surgical repair. Post-

eases stay and may produce lasting sequel


operative wound problems seldom causes death,

an economic burden on patient and on health system and induce


Considering wound problems is quite common in developing countries like India the

operative wound problems and factors

to discover the sound, ideal method for the

ed with laparotomy wound.

]. In the latter scenario, incision

thus made passes through various layers of the

anterior abdominal wall from skin,

subcutaneous tissue, linea alba and peritoneum.

This incision when made initiates a cascade of

mechanisms at cellular level, which aims at

at incision site [3]. This healing




may occur by primary intention (wounds with

opposed edges) or by secondary intention

(wounds with separated edges). Healing by

secondary intention occurs whenever there is

extensive loss of cells and tissue as occurs in

infarction, inflammatory ulceration, abscess

formation etc.

Factors affecting wound healing in abdominal

wall and those leading to complication have

been discussed by various previous reports but

no clear consensus could be made. General

patients profile like age, sex, nutritional status,

pre-operative medical condition like anemia,

diabetes, jaundice, renal failure, bad ASA

(American Society of Anesthesiologists) scoring,

intra-operative knot breakage, suture material

rupture or suture cut through, emergency or

elective surgery, type and duration of surgery

and Post-operative wound infection or increase

in intra abdominal pressure are the various

factors leading to post

complication.

Material and methods

The present study was a prospective study done

during the period of July 2006 to September

2008 at a tertiary care centre. A total number of

100 cases were studied and followed up for a

period of 6 months. All patients with indication

for laparotomy (emergency and elective) with

complete 6 month follow up included

pediatric patients were excluded.

insertion for naso-gastric decompression and

urinary catheterization was done all cases. Pre

operative antibiotics were given and anti

diabetic and antihypertensive precaution

taken as per medical advice. Preoperative

shaving and local skin care with beta

done. In elective cases, when indicated

preparation was done either by stomach

total gut irrigation, or simple enema while in

emergency cases no bowel preparation




may occur by primary intention (wounds with

opposed edges) or by secondary intention

(wounds with separated edges). Healing by

occurs whenever there is

extensive loss of cells and tissue as occurs in

infarction, inflammatory ulceration, abscess

Factors affecting wound healing in abdominal

wall and those leading to complication have

previous reports but

no clear consensus could be made. General

patients profile like age, sex, nutritional status,

operative medical condition like anemia,

diabetes, jaundice, renal failure, bad ASA

(American Society of Anesthesiologists) scoring,

operative knot breakage, suture material

rupture or suture cut through, emergency or

elective surgery, type and duration of surgery

operative wound infection or increase

in intra abdominal pressure are the various

factors leading to post-laparotomy

s a prospective study done

during the period of July 2006 to September

2008 at a tertiary care centre. A total number of

100 cases were studied and followed up for a

ents with indication

(emergency and elective) with

up included, while

excluded. Ryle’s tube

gastric decompression and

was done all cases. Pre-

given and anti-

diabetic and antihypertensive precautions were

as per medical advice. Preoperative

shaving and local skin care with beta-scrub was

In elective cases, when indicated bowel

done either by stomach wash,

total gut irrigation, or simple enema while in

ency cases no bowel preparation possible.

All patients were operated under general

anesthesia through midline incision. Saline and

beta dine peritoneal wash was

Drainage was done through separate stab

incision as per selection by operating surgeon.

Mass or layered closure of abdomen

with absorbable or non absorbable material.

Skin was opposed with nylon intermittent

stitches.

Post-operatively patient was

according to need and early ambulation

encouraged. Abdominal wound

on 3rd

, 7th

and 10th

post

suture was removed. All patients were followed

up for a period of 6 months.

Results

Total 100 cases were taken for study

which, 76 were emergency cases and 24

elective cases. Out of emergency surgery

(55%) developed complication while 11

among elective surgery. 40% patients in the age

group 21-40 years developed wound

complication, 23% in age ˂20 y

in ˃40 year age group. 66 patients were male of

which 33 (50%), while 34 were female of which

16 (47%) developed complication. The rate

shown in present study was higher in males than

females explained by higher incidence of

smoking, alcoholism,

associated medical illnesses. All 24 patients in

poor nutritional status developed complication,

while 9 (20%) out of 44 with good nutrition had

complications. 12 (92%) obese patients while 6

(32%) average patients had

19 (59%) patients with hospital stay of

25 (54%) patients with hospital stay

and 9 (41%) patients with hospital stay

had complications. There was significant rise

the post-operative wound infection with

prolonged post-operative hospitalization

because colonization of patients with hospital

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Page 72

were operated under general

through midline incision. Saline and

was given in all cases.

done through separate stab

incision as per selection by operating surgeon.

Mass or layered closure of abdomen was done

absorbable material.

opposed with nylon intermittent

was given antibiotic

according to need and early ambulation

encouraged. Abdominal wound was examined

post-operative day and

removed. All patients were followed

taken for study. Out of

emergency cases and 24 were

f emergency surgery, 42

(55%) developed complication while 11 (45%)

elective surgery. 40% patients in the age

developed wound

˂20 year whereas 37%

year age group. 66 patients were male of

which 33 (50%), while 34 were female of which

(47%) developed complication. The rate

s higher in males than

females explained by higher incidence of

malnutrition and

associated medical illnesses. All 24 patients in

poor nutritional status developed complication,

(20%) out of 44 with good nutrition had

(92%) obese patients while 6

complications. Total

atients with hospital stay of ˂10 days,

) patients with hospital stay 10-15 days

and 9 (41%) patients with hospital stay ˃15 days

had complications. There was significant rise in

operative wound infection with

rative hospitalization

colonization of patients with hospital




acquired microorganisms. These organisms are

frequently antibiotic resistance and gram

negative bacteria. For emergency surgery

longer the duration of hospital stay increased

wound problems. It was associated with more

disturbances in internal milieu of patients. Total

8 (36%) patients with incision length of

36 (50%) patients with incision length

and 6 (100%) patients with incision length

cm had complications. Abdominal drains

kept in 86 patients of which 54%, whereas in 14

drain was not kept of which 2 (14%) developed

complication. 60% of laparotom

cases which showed only 25% wound problem

rate while contaminated cases show

problem rate while in dirty cases it wa

Discussion

Abdominal wound complications after

laparotomy is a surgical emergency with high

morbidity and mortality leading to escalation in

hospital costs and prolonged illness. The

reported incidence of major abdomina

complication is 15-25% and is associated with

mortality rate of 15-20% [4]. Although several

systemic factors, local mechanical factors and

post-operative events have been

abdominal wound complication, yet there is no

clarity on the importance of each of these

factors.

In this study, the highest incidence of wound

complication (40%) was recorded in the age

group of 21-40 years, probably because of

higher incidence of acute abdomen in this

decade. Our study showed no correlation of the

increased incidence with the increasing age as

was showed by Halasz, et al.

showed male predominance (66/100) as was

also recorded by studies of Keill

Penninckx, et al. [7]. Out of t

patients, 13 were found to be obese (BMI>35).




acquired microorganisms. These organisms are

frequently antibiotic resistance and gram

negative bacteria. For emergency surgery,

longer the duration of hospital stay increased

lems. It was associated with more

rnal milieu of patients. Total

atients with incision length of ˂10 cm,

36 (50%) patients with incision length 10-15 cm

and 6 (100%) patients with incision length ˃15

inal drains were

kept in 86 patients of which 54%, whereas in 14

(14%) developed

complication. 60% of laparotomies with clean

only 25% wound problem

rate while contaminated cases showed 62% of

while in dirty cases it was 100%.

Abdominal wound complications after

laparotomy is a surgical emergency with high

morbidity and mortality leading to escalation in

hospital costs and prolonged illness. The

reported incidence of major abdominal wound

25% and is associated with

]. Although several

systemic factors, local mechanical factors and

operative events have been blamed for

abdominal wound complication, yet there is no

clarity on the importance of each of these

In this study, the highest incidence of wound

complication (40%) was recorded in the age

40 years, probably because of

e of acute abdomen in this

decade. Our study showed no correlation of the

increased incidence with the increasing age as

, et al. [5]. Our study

ominance (66/100) as was

also recorded by studies of Keill, et al. [6] and

f the total of 100

patients, 13 were found to be obese (BMI>35).

In a similar study conducted by Cruse and Foord

et al. [8] on 18090 patients

obese patients have 13.5% wound infection

rate. Obesity is associated with other co morbid

conditions like diabetes, hypertension,

herniation etc., which can all, contribute to poor

wound strength and healing. Keill

Whipple, et al. [9] depicted that anemic people

have poor wound healing and tend to have

wound gaping. Hypoproteinemia contributes to

prolonged inflammatory phase and impairs

fibroplasia, proliferation, proteoglycan and

collagen synthesis, neoangiogenesis and wound

remodeling [10]. In a series of studies of

collagen formation in diabetes, Goodson and

Hunt [11] have shown that obesity, insulin

resistance, hyperglycemia and depressed

leukocyte function interfere with collagen

synthesis and thus impair wound healing. Pre

existing systemic illness contributes to higher

ASA score and higher wound dehiscence rates

because of increase wound infection [12].

One of the significant finding was that 76 of

100 patients who had developed wound

complication had undergone laparotomy on

emergency basis, 5% patient had wound

dehiscence. Similar observation has been made

by Penninckx, et al. [

dehiscence rate was found to 6.7% in

emergency laparotomy and 1.5% in elective

cases. This fact may be attributed to poor

patient preparation, complicated inflammatory

disease, premorbid factors and operating at odd

hours. Another characteristic feature of our

study was that these laparotomy wounds were

either contaminated in 62% or dirty in 100% of

patients. Similar results were found in a study by

Haley, et al. [13], in which they showed

contaminated/ dirty wounds to be an important

predictor for wound infection. Haley

demonstrated that the duration of surgery more

than 2 hours was second greatest independent

predictor of risk after a multivariate analysis.

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Page 73

In a similar study conducted by Cruse and Foord,

] on 18090 patients, it was found that

.5% wound infection

rate. Obesity is associated with other co morbid

conditions like diabetes, hypertension,

herniation etc., which can all, contribute to poor

wound strength and healing. Keill, et al. [6] and

] depicted that anemic people

have poor wound healing and tend to have

wound gaping. Hypoproteinemia contributes to

tory phase and impairs

fibroplasia, proliferation, proteoglycan and

collagen synthesis, neoangiogenesis and wound

In a series of studies of

iabetes, Goodson and

Hunt [11] have shown that obesity, insulin

resistance, hyperglycemia and depressed

leukocyte function interfere with collagen

synthesis and thus impair wound healing. Pre-

existing systemic illness contributes to higher

gher wound dehiscence rates

because of increase wound infection [12].

cant finding was that 76 of the

100 patients who had developed wound

complication had undergone laparotomy on

emergency basis, 5% patient had wound

dehiscence. Similar observation has been made

7], where wound

dehiscence rate was found to 6.7% in

emergency laparotomy and 1.5% in elective

cases. This fact may be attributed to poor

patient preparation, complicated inflammatory

disease, premorbid factors and operating at odd

aracteristic feature of our

study was that these laparotomy wounds were

either contaminated in 62% or dirty in 100% of

patients. Similar results were found in a study by

et al. [13], in which they showed

contaminated/ dirty wounds to be an important

predictor for wound infection. Haley, et al.

demonstrated that the duration of surgery more

than 2 hours was second greatest independent

predictor of risk after a multivariate analysis.




The increase in intra abdominal pressure

because of nausea, vomiting or cough results in

breakage of suture, undoing of knots or pulling

through the tissue. Jenkin, et al.

his study that facial layers tend to lengthen as

the wound distends where as suture length

remains the same leading to breakage of suture,

undoing of knot or pulling through tissue. Post

operative wound infection was found to be

single most common factor observed in 90% of

our patients as a cause of abdominal wound

complication. It has been shown by various

other studies [15] that tensile st

staphylococcus aureus contaminated wounds in

rat on 6th

post-operative day was much

decreased. These infected wounds slowly break

down and then heal by granulation tissue. All

our patients had multiple risk factors

contributing wound complicat

number of risk factors recorded were 3 and

maximum number was 11, the same was also

interpreted by Riou, et al. [16].

Conclusion

It is necessary to mention that wound healing is

a multi factorial problem, influenced by a variety

of factors not included in the present study,

even though the surgical art of monolayer

closure technique proved its superiority in terms

of wound healing, strength and security.

References

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Publisher London; 2000.




The increase in intra abdominal pressure

or cough results in

breakage of suture, undoing of knots or pulling

et al. [14] proved in

his study that facial layers tend to lengthen as

the wound distends where as suture length

remains the same leading to breakage of suture,

undoing of knot or pulling through tissue. Post-

operative wound infection was found to be

single most common factor observed in 90% of

our patients as a cause of abdominal wound

complication. It has been shown by various

other studies [15] that tensile strength of

staphylococcus aureus contaminated wounds in

operative day was much

decreased. These infected wounds slowly break

down and then heal by granulation tissue. All

our patients had multiple risk factors

contributing wound complication. The least

number of risk factors recorded were 3 and

maximum number was 11, the same was also

It is necessary to mention that wound healing is

factorial problem, influenced by a variety

t included in the present study,

even though the surgical art of monolayer

closure technique proved its superiority in terms

of wound healing, strength and security.

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Nil Conflict of interest:

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Page 75

Conflict of interest: None declared.

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Factors affecting post-operative laparotomy wound complications