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Journal of Wound Management and Research > Volume 14(2); 2018 > Article
Chun, Yoon, Song, Jeong, Choi, and Wee: Causes of Surgical Wound Dehiscence: A Multicenter Study

Abstract

Surgical wound dehiscence is a postoperative complication involving breakdown of surgical incision site. Despite the increased knowledge of wound healing mechanism before and after surgery, wound dehiscence may increase the length of hospital stay, increase patient inconvenience and rates of re-operation. The purpose of this study was to analyze the causes of wound dehiscence in patients undergoing reoperation at 4 hospitals of Soonchunhyang Medical Center. The number of patients in each hospital and those operated previously were compared. In addition, other characteristics of patients were compared in patients who underwent reoperation. In 22 out of 1,026 patients consulted at the Seoul hospital, 32 cases out of 1,295 at Bucheon hospital, 14 cases out of 1,687 at Cheonan hospital and 15 cases out of 374 at Gumi hospital, wound revision was performed for wound dehiscence. Patients at the Department of Obstetrics and Gynecology were the most common and included 33 patients (39.8%). The most common intervention before wound revision was Cesarean section in 14 patients (19.3%). In this study, we retrospectively reviewed patients who underwent wound revision due to wound dehiscence and analyzed the underlying causes of the postoperative complication.

Introduction

Surgical wound dehiscence is a postoperative complication involving breakdown of surgical incision site. Despite the increased knowledge of wound healing process before and after surgery and the development of preoperative care and suture materials, wound dehiscence may increase the length of hospital stay, increase patient inconvenience and rates of re-operation. In addition, wound dehiscence after abdominal surgery is associated with mortality rates of 10−44% [1,2].
Several studies investigated risk factors causing wound dehiscence. Patients older than 65 years are more likely to develop wound dehiscence because of deterioration in tissue repair mechanism compared with younger patients [3]. Other well-known risk factors include hypoproteinemia, local wound infection, anemia, hypertension, and emergency surgery [1]. Risk factors that increase intra-abdominal pressure such as abdominal distension, excessive coughing, vomiting, and constipation increase the possibility of wound dehiscence after surgery [4]. In addition, surgical experience, operative time exceeding 2.5 hours, type of incision, suture material, drain, medical history such as obesity with body mass index (BMI) greater than 30 [5], stroke, chronic obstructive pulmonary disease (COPD), pneumonia, and malignancy also affect wound dehiscence [6]. In particular, studies show increased wound dehiscence rates in patients with more than 5 risk factors [1].
Despite many studies investigating the risk factors causing wound dehiscence and efforts to control them, patients continue to suffer from wound dehiscence. The purpose of this study is to analyze the causes of wound dehiscence in patients undergoing reoperation at 4 hospitals of Soonchunhyang Medical Center, South Korea.

Methods

From January 2013 to November 2017, patients underwent surgery at other departments and reoperation following a diagnosis of wound dehiscence and referral to the Department of Plastic and Reconstructive Surgery at 4 hospitals of Soonchunhyang Medical Center. The patients were divided into two groups: conservative treatment and surgical treatment. The number of patients in each hospital and previous operation were compared. In addition, age, time from previous surgery to postoperative reoperation, and other medical histories were compared in patients who underwent reoperation.

Results

Twenty-two out of 1,026 patients consulted at Seoul hospital, 32 cases out of 1,295 at Bucheon hospital, 14 cases out of 1,687 at Cheonan hospital and 15 cases out of 374 in Gumi hospital, underwent wound revision for wound dehiscence (Table 1). The patients were classified according to age, previous diagnosis or operation, duration of revision after first operation, and past medical history (Table 2). The patients included 27 males (32.5%) and 56 females (67.5%) with an average age of 48.35 years (0–89 years). Obstetrics and Gynecology (OBGY) was the most common department with 33 patients (39.8%) followed by 15 patients from Neurosurgery (NS), 11 patients from Orthopedic Surgery (OS), 10 patients from General surgery (GS), 8 patients from Emergency Medicine (EM), 2 patients from Thoracic Surgery (TS), 2 patients from Internal medicine (IM), 1 patient from Urology (UR), and 1 patient from Otolaryngology (ENT) departments. The most common surgical history was primary repair by various departments (16 patients, 19.3%). The second common surgical history was Cesarean section (C/Sec) in 14 patients (16.9%), which accounted for 42.4% of all patients who underwent wound revision after operation at OBGY. The mean BMI of the patients was 24.4 (Range of 15.97−45.26). The mean BMI of the patients of OBGY was 25.98 (Range of 18.59−45.26), and patients who underwent C/Sec was 24.73 (Range of 19.75−29.2). Nineteen patients (22.9%) had a history of hypertension (HTN) and 10 patients (12.0%) had diabetes (DM). The current or ex-smokers included 15 patients (18.1%) and the average pack-year (PY) was 15.3 PYs (Table 3). The mean time from the first operation to wound revision was 30.8 days. It was 24.29 days for patients from OBGY and 25.98 days for patients undergoing C/Sec was.

Discussion

Various causes of wound dehiscence include surgical experience, surgical incision, suture material, and patient factors such as age, nutritional status, and other accompanying diseases [1,46]. Preoperative risk factors include poor laboratory findings, infection, hypertension, and emergency surgery [1]. In particular, wound infection is the most relevant factor [6], and it increases the possibility of wound dehiscence by decreasing tensile strength and fibroblast concentration. Decreased fibroblast concentration triggers tissue destruction during wound healing [1]. Hypoproteinemia also reduces tensile strength [6]. It is required to reduce the incidence of wound dehiscence through preoperative control of these areas. Postoperative risk factors include abdominal distension, excessive coughing, vomiting, and constipation [5], and resolving these symptoms with appropriate medication may reduce the likelihood of wound dehiscence
In this study, we retrospectively reviewed patients who underwent wound revision due to wound dehiscence with reference to various causes. We reviewed the operative and other medical history prior to wound revision and analyzed the causes of wound dehiscence.
First of all, proportion of female patients were higher than male patients, but this result may be less meaningful in that proportion of patients with wound dehiscence was higher in OBGY patients. The most common surgical history was primary repair, but this also has less significance in that this data includes primary repair in the emergency room by residents. Unlike previous literature, age, BMI, medical or social history did not show any special significance in this study. However, The results suggest that the proportion of patients with wound dehiscence requiring wound revision was higher in patients who underwent operation by OBGY department, especially after C/Sec. This high rate of wound dehiscence after C/Sec or other OBGY surgery at multiple center of this study suggest that there may be some relation between wound dehiscence and OBGY surgery, especially C/Sec.
C/Sec is still one of the most commonly used surgical techniques in obstetrics and gynecology. Currently, 36% of deliveries in Korea are performed by C/Sec [7]. In the United States, about one-third of all mothers undergo C/Sec, and 15% of all deliveries worldwide are performed by C/Sec [8]. Despite the generalization of C/sec, marital morbidity and mortality risk are still higher than vaginal delivery [5,8]. Wound dehiscence and infection after C/Sec are important causes of postoperative morbidity and account for 10% of pregnancy-related mortality [10]. The rate of postoperative wound dehiscence after C/Sec has been reported to be 2.5−16% [11]. In this study, 16.9% of patients who underwent wound revision were C/Sec patients despite the usual method, which shows that our results are similar to those of previous literature. On the other hand, the rate of wound dehiscence after other abdominal surgery has been reported to be 0.4−3.5% [2,3,6], However, there are few studies comparing C/Sec or OBGY surgery with other abdominal surgery.
In addition, previous studies have shown that wound dehiscence usually occurs 4 to 14 days after surgery and occurs most commonly between 6 and 8 days. Wound dehiscence may occur even after 30 days post-surgery [2,4]. In this study, wound revision was performed at an average of 30.8 days after the first operation. However, one limitation of our data is that the actual onset time of wound dehiscence was not verified; there probably will be some difference between the onset of dehiscence and the time of re-operation.
The limitations of this study are as follows: First, the number of patients is limited, and the effect of other factors may not be considered as a retrospective study. Second, when selecting the patient group, the patient’s diagnosis was retrospectively confirmed. Therefore, it is possible that these patients may have been excluded in the absence of a diagnosis of wound dehiscence although wound revision was performed. Third, because of the selection of patients who underwent wound revision among patients with wound dehiscence, the boundary between surgery and conservative treatment was based on subjective aspects. Fourth, other aspects of the patient group were not considered. For example, severe abdominal distention results in a higher incidence of wound dehiscence [1]. However, the factors for evaluation of maternal abdominal distension were not reflected in the patients who underwent C/Sec.
This study showed a difference in wound dehiscence based on the type of surgery. A randomized controlled study with large number of patients undergoing different surgeries and collaborative research among multiple departments is needed. Such a study will facilitate identification of modifiable risk factors for surgery with a high probability of wound dehiscence and focus attention on the control of risk factors contributing to wound dehiscence.

Conclusion

This study analyzed the incidence of surgical wound dehiscence by investigating the causative factors and the differences among patient groups across several medical centers. Therefore, it is essential to consider the risk factors causing wound dehiscence in advance for preventive interventions. In addition, further studies with a well-controlled and cooperative design are required to address the study limitations.

Acknowledgements

This work was supported in part by the Soonchunhyang University Research Fund. No potential conflict of interest relevant to this article was reported.

Table 1
Comparison of patients referred to Department of Plastic and Reconstructive Surgery and patients who underwent wound revision for wound dehiscence at four hospitals of Soonchunhyang Medical Center
Hospital Wound dehiscence
Gumi 15/374 4.01%
Cheonan 14/1687 0.8%
Bucheon 32/1295 2.47%
Seoul 22/1026 2.14%
Table 2
Characteristics of patients who underwent wound revision at Department of Plastic and Reconstructive Surgery at four hospitals of Soonchunhyang Medical Center
Patient Sex Age Department Cause BMI DM Hx. HTN Hx. Smoking status Period to reoperation
1 Female 20 OBGY C/Sec 27.60 no no no 18 days
2 Female 53 OBGY Uterine myomectomy 26.01 no yes no 25 days
3 Female 24 OBGY C/Sec 23.05 no no no 38 days
4 Male 77 UR Circumcision 23.44 no no no 17 days
5 Female 61 EM Primary repair 23.75 no no 20 PYs 20 days
6 Male 38 NS Decompressive craniectomy 23.41 no no no 21 days
7 Male 72 OS Laminectomy 19.53 no no 25 PYs 16 days
8 Female 33 OBGY C/Sec 28.55 no no no 13 days
9 Male 26 TS Pneumothorax 21.38 no no 4 PYs 12 days
10 Female 27 OBGY Ectopic pregnancy 20.68 no no no 9 days
11 Female 31 OBGY C/Sec 19.92 no no no 28 days
12 Female 77 EM Primary repair 24.17 no no no 12 days
13 Female 35 OBGY C/Sec 19.75 no no no 6 days
14 Female 34 OBGY C/Sec 26.25 no no no 16 days
15 Female 39 OBGY C/Sec 29.20 no no no 9 days
16 Female 49 OBGY Total hysterectomy 25.39 no no no 20 days
17 Female 59 OBGY Salpingo-oophrectomy 35.52 yes yes no 30 days
18 Female 44 OBGY Total hysterectomy 20.23 no no no 21 days
19 Female 35 OBGY Laparoscopic salpingo-oophrectomy 24.24 no no no 15 days
20 Female 40 OBGY C/Sec 21.18 no no no 25 days
21 Female 40 OBGY Total hysterectomy 34.04 no no no 35 days
22 Male 44 NS Primary repair 22.99 no no 20 PYs 17 days
23 Male 23 EM Primary repair 17.90 no no 3 PYs 11 days
24 Female 54 GS Panperitonitis 28.89 no no no 29 days
25 Female 81 NS Laminoplasty 29.00 no yes no 13 days
26 Female 75 OBGY Salpingo-oophrectomy 18.65 no no no 48 days
27 Female 36 OBGY C/Sec 27.84 no yes no 19 days
28 Female 83 OBGY Vulvectomy 20.69 no yes no 7 days
29 Female 17 OS Primary repair 23.34 no no no 21 days
30 Female 40 OBGY C/Sec 23.71 no no no 15 days
31 Male 31 OS Mass excision 24.22 no no 5 PYs 20 days
32 Female 49 OBGY Total hysterectomy 45.26 yes yes no 21 days
33 Female 37 OBGY C/Sec 26.35 no no no 34 days
34 Male 16 OS Primary repair 23.62 no no no 29 days
35 Female 58 OBGY Total hysterectomy 23.26 no no no 22 days
36 Female 70 IM ICD insertion 20.70 no yes no 48 days
37 Female 32 OBGY C/Sec 20.80 no no no 20 days
38 Female 38 OBGY Uterine myomectomy 18.59 no no no 143 days
39 Female 59 OBGY Total hysterectomy 36.30 yes no no 29 days
40 Female 74 EM Primary repair 27.47 yes yes no 19 days
41 Male 74 IM ICD insertion 28.51 no no no 13 days
42 Male 31 NS Primary repair 32.51 no no no 6 days
43 Male 23 EM Primary repair 21.61 no no no 6 days
44 Female 69 OBGY Total hysterectomy 26.05 no yes no 57 days
45 Female 19 OBGY Salpingo-oophrectomy 24.13 no no no 53 days
46 Male 26 NS Lumbosacral fusion 19.88 no no no 36 days
47 Male 42 NS Craniotomy 23.57 yes no 20 PYs 28 days
48 Female 73 GS Panperitonitis 37.06 no yes no 75 days
49 Female 41 GS Mastectomy 19.13 no no no 38 days
50 Female 52 OBGY Primary repair 25.75 no no no 15 days
51 Female 44 NS Decompressive craniectomy 22.24 no no no 13 days
52 Female 75 OS Achilles tendon repair 25.07 no yes no 45 days
53 Female 31 OBGY C/Sec 28.00 no no no 52 days
54 Male 57 OS Mass excision 26.30 no no no 133 days
55 Female 51 GS Low anterior resection 30.86 no yes 10 PYs 35 days
56 Female 47 GS Loop ileostomy 18.23 no no 5 PYs 54 days
57 Female 0 NS Skull fracture - no no no 9 days
58 Male 6 OS Polysyndactyly 15.97 no no no 22 days
59 Female 51 OBGY Total hysterectomy 28.20 yes yes no 36 days
60 Male 55 GS Abdominal perineal resection 22.43 no no 35 PYs 85 days
61 Female 57 OS Primary repair 19.72 yes yes no 28 days
62 Female 53 OBGY Total hysterectomy 27.53 no no no 17 days
63 Female 73 NS Cranioplasty 18.67 no yes no 26 days
64 Male 38 OS Mass excision 24.63 yes no no 27 days
65 Male 48 EM Primary repair 25.86 no no no 7 days
66 Female 61 NS Laminectomy 22.09 no yes no 179 days
67 Female 34 OBGY C/Sec 24.03 no no no 47 days
68 Male 32 ENT Primary repair 23.67 no no no 5 days
69 Female 66 TS Mitral valve replacement 22.60 no no no 45 days
70 Male 54 NS Decompressive craniectomy 27.33 no no 9 PYs 32 days
71 Female 49 NS Decompressive craniectomy 20.89 no no no 23 days
72 Female 74 OBGY Total hysterectomy 30.75 yes no no 31 days
73 Male 34 EM Primary repair 18.84 no no no 6 days
74 Male 89 GS Panperitonitis 20.48 no no no 25 days
75 Female 47 EM Primary repair 21.34 no no no 14 days
76 Male 73 GS Loop colostomy 23.97 yes no 20 PYs 30 days
77 Female 67 OS Primary repair 23.61 no no no 19 days
78 Male 49 NS Craniotomy 24.50 no no 14 PYs 21 days
79 Male 63 GS Pancreaticoduodenectomy 22.89 no yes no 19 days
80 Male 49 OS Trimalleolar fracture 20.31 no no 10 PYs 143 days
81 Male 82 GS Permcath insertion 19.75 no yes 30 PYs 14 days
82 Female 78 NS Craniotomy 25.97 no yes no 8 days
83 Female 45 NS Meningioma 21.31 no no no 10 days

PY, Pack-year.

Table 3
Analysis of patients who underwent wound revision at Department of Plastic and Reconstructive Surgery at four hospitals of Soonchunhyang Medical Center
Number Rate (%) Mean
Sex Female 56 67.5 -
Male 27 32.5 -

Age (year-old) - - 48.35

BMI (kg/m2) - - 24.43

Department OBGY 33 39.8 -
GS 10 12.0 -
OS 11 13.3 -
UR 1 1.2 -
EM 8 9.6 -
TS 2 2.4 -
NS 15 18.1 -
IM 2 2.4 -
ENT 1 1.2 -

History DM 10 12.0 -
HTN 19 22.9 -
Smoking (Current or ex-smoker) 15 18.1 15.3 PYs

Cause - Primary repair 16 19.3 -
OBGY C/Sec 14 14.5 -
Total hysterectomy 10 12.0 -
Salpingo-oophrectomy 3 3.6 -
Uterine myomectomy 2 2.4 -
Vulvectomy 1 1.2 -
Laparoscopic salpingo-oophrectomy 1 1.2 -
Ectopic pregnancy 1 1.2 -
UR Circumcision 1 1.2 -
OS Achilles tendon repair 1 1.2 -
Mass excision 3 3.6 -
Trimalleolar fracture 1 1.2 -
Polysyntactyly 1 1.2 -
NS Skull fracture 1 1.2 -
Meningioma 1 1.2 -
Lumbosacral fusion 1 1.2 -
Laminoplasty 1 1.2 -
Laminectomy 2 2.4 -
Decompressive craniectomy 4 4.8 -
Craniotomy 3 3.6 -
Cranioplasty 1 1.2 -
TS Mitral valve replacement 1 1.2 -
Pneumothorax 1 1.2 -
IM ICD insertion 2 2.4 -
GS Permcath insertion 1 1.2 -
Panperitonitis 3 3.6 -
Pancreaticoduodenectomy 1 1.2 -
Abdominal perineal resection 1 1.2 -
Low anterior resection 1 1.2 -
Loop ileostomy 1 1.2 -
Loop colostomy 1 1.2 -
Mastectomy 1 1.2 -

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