Factors affecting post-operative laparotomy wound complications

Factors affecting post-operative laparotomy wound complications ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O)Factors affecting post-operative laparotomy wound complicationsKhandra Hitesh P1*, Vyas Pratik H1, Patel Nilesh J1, Mathew Jovin G21Assistant Professor, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India 2PG Student, Department of Surgery, Smt. NHL Municipal Medical College, Ahmedabad, India *Corresponding author email: [email protected] to cite this article: Khandra Hitesh P, Vyas Pratik H, Patel Nilesh J, Mathew Jovin G. Factorsaffecting post-operative laparotomy wound complications. IAIM, 2015; 2(1): 71-75. Available online at www.iaimjournal.comReceived on: 31-12-2014 Accepted on: 05-01-2015AbstractDespite the advances made in asepsis, antimicrobial drugs, sterilization and operative technique,post-operative wound problems continue to be a major threat. Clean sound healing of laparotomywound after any intra-abdominal procedure is a cardinal index of good surgical repair. Post-operative wound problems delays recovery and often increases stay and may produce lasting sequeland require extra resources for investigations, management and nursing care, therefore itsprevention is relevant to quality patient care. Post-operative wound problems seldom causes death,yet it does prove to be an economic burden on patient and on health system and inducepsychological trauma to the surgeon as it robs his hours of dedicated work on operating table andgood carrier. Considering wound problems is quite common in developing countries like India thepresent study was taken up to find out the incidence of post-operative wound problems and factorsthat influence its occurrence. Present study aimed to discover the sound, ideal method for theabdominal wound closure with regard to the problems associated with laparotomy wound.Key wordsLaparotomy, Wound infection, Burst abdomen, Incisional hernia.Introduction pathology [2]. In the latter scenario, incision thus made passes through various layers of theAn abdominal wound may occur due to anterior abdominal wall from skin,disruption in the anterior abdominal wall caused subcutaneous tissue, linea alba and peritoneum.by either trauma [1] or any surgical intervention This incision when made initiates a cascade ofin order to gain access to the underlying mechanisms at cellular level, which aims at achieving healing at incision site [3]. This healingInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 71Copy right © 2015, IAIM, All Rights Reserved.

Factors affecting post-operative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)may occur by primary intention (wounds with All patients were operated under generalopposed edges) or by secondary intention anesthesia through midline incision. Saline and(wounds with separated edges). Healing by beta dine peritoneal wash was given in all cases.secondary intention occurs whenever there is Drainage was done through separate stabextensive loss of cells and tissue as occurs in incision as per selection by operating surgeon.infarction, inflammatory ulceration, abscess Mass or layered closure of abdomen was doneformation etc. with absorbable or non absorbable material. Skin was opposed with nylon intermittentFactors affecting wound healing in abdominal stitches.wall and those leading to complication havebeen discussed by various previous reports but Post-operatively patient was given antibioticno clear consensus could be made. General according to need and early ambulationpatients profile like age, sex, nutritional status, encouraged. Abdominal wound was examinedpre-operative medical condition like anemia, on 3rd, 7th and 10th post-operative day anddiabetes, jaundice, renal failure, bad ASA suture was removed. All patients were followed(American Society of Anesthesiologists) scoring, up for a period of 6 months.intra-operative knot breakage, suture materialrupture or suture cut through, emergency or Resultselective surgery, type and duration of surgeryand Post-operative wound infection or increase Total 100 cases were taken for study. Out ofin intra abdominal pressure are the various which, 76 were emergency cases and 24 werefactors leading to post-laparotomy elective cases. Out of emergency surgery, 42complication. (55%) developed complication while 11 (45%)Material and methods among elective surgery. 40% patients in the age group 21-40 years developed wound complication, 23% in age ˂20 year whereas 37%The present study was a prospective study done in ˃40 year age group. 66 patients were male ofduring the period of July 2006 to September which 33 (50%), while 34 were female of which2008 at a tertiary care centre. A total number of 16 (47%) developed complication. The rate100 cases were studied and followed up for a shown in present study was higher in males thanperiod of 6 months. All patients with indication females explained by higher incidence offor laparotomy (emergency and elective) with smoking, alcoholism, malnutrition andcomplete 6 month follow up included, while associated medical illnesses. All 24 patients inpediatric patients were excluded. Ryle’s tube poor nutritional status developed complication,insertion for naso-gastric decompression and while 9 (20%) out of 44 with good nutrition hadurinary catheterization was done all cases. Pre- complications. 12 (92%) obese patients while 6operative antibiotics were given and anti- (32%) average patients had complications. Totaldiabetic and antihypertensive precautions were 19 (59%) patients with hospital stay of ˂10 days,taken as per medical advice. Preoperative 25 (54%) patients with hospital stay 10-15 daysshaving and local skin care with beta-scrub was and 9 (41%) patients with hospital stay ˃15 daysdone. In elective cases, when indicated bowel had complications. There was significant rise inpreparation was done either by stomach wash, the post-operative wound infection withtotal gut irrigation, or simple enema while in prolonged post-operative hospitalizationemergency cases no bowel preparation possible. because colonization of patients with hospitalInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 72Copy right © 2015, IAIM, All Rights Reserved.

Factors affecting post-operative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)acquired microorganisms. These organisms are In a similar study conducted by Cruse and Foord,frequently antibiotic resistance and gram et al. [8] on 18090 patients, it was found thatnegative bacteria. For emergency surgery, obese patients have 13.5% wound infectionlonger the duration of hospital stay increased rate. Obesity is associated with other co morbidwound problems. It was associated with more conditions like diabetes, hypertension,disturbances in internal milieu of patients. Total herniation etc., which can all, contribute to poor8 (36%) patients with incision length of ˂10 cm, wound strength and healing. Keill, et al. [6] and36 (50%) patients with incision length 10-15 cm Whipple, et al. [9] depicted that anemic peopleand 6 (100%) patients with incision length ˃15 have poor wound healing and tend to havecm had complications. Abdominal drains were wound gaping. Hypoproteinemia contributes tokept in 86 patients of which 54%, whereas in 14 prolonged inflammatory phase and impairsdrain was not kept of which 2 (14%) developed fibroplasia, proliferation, proteoglycan andcomplication. 60% of laparotomies with clean collagen synthesis, neoangiogenesis and woundcases which showed only 25% wound problem remodeling [10]. In a series of studies ofrate while contaminated cases showed 62% of collagen formation in diabetes, Goodson andproblem rate while in dirty cases it was 100%. Hunt [11] have shown that obesity, insulin resistance, hyperglycemia and depressedDiscussion leukocyte function interfere with collagen synthesis and thus impair wound healing. Pre-Abdominal wound complications after existing systemic illness contributes to higherlaparotomy is a surgical emergency with high ASA score and higher wound dehiscence ratesmorbidity and mortality leading to escalation in because of increase wound infection [12].hospital costs and prolonged illness. The One of the significant finding was that 76 of thereported incidence of major abdominal wound 100 patients who had developed woundcomplication is 15-25% and is associated with complication had undergone laparotomy onmortality rate of 15-20% [4]. Although several emergency basis, 5% patient had woundsystemic factors, local mechanical factors and dehiscence. Similar observation has been madepost-operative events have been blamed for by Penninckx, et al. [7], where woundabdominal wound complication, yet there is no dehiscence rate was found to 6.7% inclarity on the importance of each of these emergency laparotomy and 1.5% in electivefactors. cases. This fact may be attributed to poorIn this study, the highest incidence of wound patient preparation, complicated inflammatorycomplication (40%) was recorded in the age disease, premorbid factors and operating at oddgroup of 21-40 years, probably because of hours. Another characteristic feature of ourhigher incidence of acute abdomen in this study was that these laparotomy wounds weredecade. Our study showed no correlation of the either contaminated in 62% or dirty in 100% ofincreased incidence with the increasing age as patients. Similar results were found in a study bywas showed by Halasz, et al. [5]. Our study Haley, et al. [13], in which they showedshowed male predominance (66/100) as was contaminated/ dirty wounds to be an importantalso recorded by studies of Keill, et al. [6] and predictor for wound infection. Haley, et al.Penninckx, et al. [7]. Out of the total of 100 demonstrated that the duration of surgery morepatients, 13 were found to be obese (BMI>35). than 2 hours was second greatest independent predictor of risk after a multivariate analysis.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 73Copy right © 2015, IAIM, All Rights Reserved.

Factors affecting post-operative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)The increase in intra abdominal pressure 3. Cotran Ramzi S, Kumar Vinay, Collinsbecause of nausea, vomiting or cough results in Tucker. Robin’s Pathologic Basis ofbreakage of suture, undoing of knots or pulling Disease. 6th edition. USA: W.B. Saundersthrough the tissue. Jenkin, et al. [14] proved in Co; 2001, p. 89.his study that facial layers tend to lengthen as 4. Poole GV. Mechanical factors inthe wound distends where as suture length abdominal wound closure. Theremains the same leading to breakage of suture, prevention of fascialundoing of knot or pulling through tissue. Post- dehiscence. Surg., 1985; 97: 631–9.operative wound infection was found to be 5. Halasz NA. Dehiscence of laparotomysingle most common factor observed in 90% of wounds. Amer J Surg., 1968; 116: 210–our patients as a cause of abdominal wound 4.complication. It has been shown by various 6. Keill RH, Keitzer WF, Nichols WK.other studies [15] that tensile strength of Abdominal wound dehiscence. Archstaphylococcus aureus contaminated wounds in Surg., 1973; 106: 573–7.rat on 6th post-operative day was much 7. Penninckx FM, Poelmans SV, Kerremansdecreased. These infected wounds slowly break RP. Abdominal wound dehiscence indown and then heal by granulation tissue. All gastro- enterological surgery. Annour patients had multiple risk factors Surg., 1979; 189: 345–52.contributing wound complication. The least 8. Cruse PJE, Foord R. The epidemiology ofnumber of risk factors recorded were 3 and wound infection: A 10 year prospectivemaximum number was 11, the same was also study of 62939 wounds. SurgClin Northinterpreted by Riou, et al. [16]. Am., 1980; 60: 27. 9. Whipple AO. The critical latent or lagConclusion period in the healing of wounds. Ann Surg., 1940; 112: 481.It is necessary to mention that wound healing is 10. Pollack SV. Wound healing: A review III.a multi factorial problem, influenced by a varietyof factors not included in the present study, Nutritional factors affecting woundeven though the surgical art of monolayerclosure technique proved its superiority in terms healing. J Dermatology Surgof wound healing, strength and security. Oncol., 1979; 5: 615. 11. Goodson WH III, Hunt TK. Wound healing and diabetic patient. Surg Gynecol Obstet., 1979; 149: 600–8.References 12. Sawyer GS, Pruett LP. Wound infection. Surgical clinics of North1. Thomas CL. Taber’s Cyclopedic Medical America, 1984; 74(3): 523. Dictionary. 17th edition. Philadelphia: 13. Haley Rw, Culver DH, Morgan WM. F.A. Davis Company; 1993, p. 2165. Identifying patients at high risk of2. Coleman DJ. In. Russel RCG, Williams NS surgical wound infection. Am J and Bulstrode CJK (eds), Bailey and Epidemiol., 1985; 121: 206. Love’s: Short Practice of Surgery. 23rd 14. Jenkins TPN. The burst abdominal edition. Vol. 29. London: Arnold wound: A mechanical approach. Br J Publisher London; 2000. Surg., 1976; 63: 873–6. 15. Smith M, Enquist IF. A quantitative study of the impaired healing resulting fromInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 74Copy right © 2015, IAIM, All Rights Reserved.

Factors affecting post-operative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) infection. Surggynecol Obstet., 1967; 125: 965–73.16. Riou JP, Cohen JR, Johnson H. Factors influencing wound dehiscence. Am J Surg., 1992; 163: 324–30.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 75Copy right © 2015, IAIM, All Rights Reserved.