ORIGINAL ARTICLE

Closure of Burst Abdomen After Major Gastrointestinal

OperationsComparison of Different Surgical Techniques
and Later Development of Incisional Hernia
Hjortur Gislason and Asgaut Viste
From the Department of Surgery, Haukeland University Hospital, Bergen, Norway

Eur J Surg 1999; 165: 958961

ABSTRACT
Objective: To find out the incidence of incisional hernia in patients who had resuture of a burst abdomen and to compare
different methods of wound closure and the development of incisional hernia.
Design: Retrospective study.
Setting: University hospital, Norway.
Subjects: 78 adults patients who had their burst abdomens resutured between January 1986 and December 1995.
Interventions: Five different methods were used to close the burst abdomen: interrupted or continuous sutures with or without
retention sutures, or retention sutures alone.
Main outcome measure: Incisional hernia after at least one year follow-up.
Results: Postoperative mortality was 14% (11/78), and 53 patients were followed up for at least a year. Incisional hernias
developed in 43% (23/53) of the patients. When interrupted sutures were used (with or without retention sutures) 34% (13/38)
of patients developed incisional hernias compared with 6/10 when the wound was closed with a continuous suture. Retention
sutures did not reduce the incidence of incisional hernia.
Conclusions: Incisional hernia is a common complication after resuture of a burst abdomen. We found no significant
differences in the incidence of incisional hernias when continuous and interrupted techniques were compared. Retention
sutures do not reduce the incidence of incisional hernias. There is still a need for refinements of the technique of closure of a
burst abdomen.
Key words: Abdominal wall closure, wound dehiscence, incisional hernia, retrospective study.

INTRODUCTION
Burst abdomen (wound dehiscence) is a serious
complication that carries high morbidity and a 10%
30% mortality. The rate of burst abdomen in most
clinical series remains between 1%3% (3
5, 10, 16, 21). With the incidence so low, few surgeons
have enough experience to make any serious claims
about the best treatment. Burst abdomen is often
associated with prolonged intestinal paralysis after
the operation and complete evisceration is possible, so
most surgeons recommend resuture, although packing
to encourage secondary healing could be preferable if
the patient is unfit for another operation.
Numerous studies have been published in recent
years examining different closure methods and suture
materials related to wound complications (wound
infection, burst abdomen, and incisional hernia).
However, we found only one report about the results
of re-suture, and that indicated that incisional hernia
develops in over half the cases (6).
Retention sutures inserted before closure and including all layers with or without the peritoneum, are
1999 Scandinavian University Press. ISSN 11024151

widely used to give additional security. However, the

only study that we know of that shows that these are
beneficial was published in 1954 (14). With modern
suture material their benefit seems to be largely
hypothetical.
The aim of the present study was to find out the
incidence of incisional hernia after operations for burst
abdomen, and to see if the development of an incisional
hernia could be related to the closure method used.

PATIENTS AND METHODS

The records of all patients who had major operations
for gastrointestinal conditions and then had a burst
abdomen resutured during the 10-year period 1986
1996 at the department of surgery, Haukeland University Hospital, were reviewed. These patients were
collected using a computer-generated search from a
system that records both diagnosis and specified
operation. Burst abdomen (wound dehiscence) was
diagnosed if either ascitic fluid or abdominal viscera
escaped from the wound. The underlying diseases, the
Eur J Surg 165

Burst abdomen and incisional hernia

Table I. Reasons for primary abdominal operation
Cause of operation

Number of patients (n = 78)

Gastrointestinal malignancy
Gastrointestinal perforation
Aortic aneurysm
Gastrointestinal obstruction
Gastrointestinal bleed
Gastrointestinal gangrene
Other

34
17
9
8
4
2
4

959

Table II. Mortality and complications after operation

for burst abdomen (n = 78)
No complications
Mortality
Serious complications
Wound abscess
Pulmonary embolism
Pneumonia
Deep vein thrombosis
Cardiac failure
Gastrointestinal bleed
Gastrointestinal obstruction
Gastrointestinal fistula
Re-dehiscence of wound

43
11
24
12
5
4
3
2
2
2
1
1

Some patients had more than one complication

Table III. Surgical technique used to close burst abdomen and later development of incisional hernia
Number of patients
Sutures

Hernia (n = 23)

No hernia (n = 30)

Interrupted retention sutures

Continuous retention sutures
Interrupted
Continuous
Retention sutures alone

11
5
2
1
4

18
3
7
1
1

All interrupted compared with all continuous sutures, p = 0.16.

All retention sutures compared with non, p = 0.31.

orginal procedure, and the type of incision were

recorded. The surgical technique used, continuous or
interrupted, the type of suture material and the use and
number of retention sutures was at the individual
surgeons discretion. Major postoperative complications and mortality were also recorded. A wound
infection was diagnosed if there was clear evidence of
pus. An incisional hernia was defined as a bulge, visible
and palpable when the patient was standing, and often
requiring support or repair.
Statistical analysis
The significance of differences was assessed using
Fishers exact test, and possibilities of less than 0.05
were accepted as significant.
RESULTS
78 patients, 55 men and 22 women, were operated on
for burst abdomen during the period 198696. Median
age at operation was 70.5 years (range 4191). All
patients had operations for major gastrointestinal or
vascular conditions (Table I), and 53% (41/78) were
emergency operations. Wound disruption occurred a
median of 10 days postoperatively (range 130), and of

these 15 patients were reoperated on before the sixth

day. We found that 34 of the patients (44%) had wound
infections. In all cases it was a midline incision that
burst. The postoperative morbidity and mortality are is
shown in Table II.
Twenty five patients (32%) were excluded from the
follow-up analysis: 17 patients died during the first
year (including the 11 who died postoperatively) and in
8 cases the records were insufficient or patients did not
attend for follow-up at the outpatient clinic.
In 53 patients followed up postoperatively for the
presence of incisional hernia, (median 23 months,
range 18 years), we found that 43% (23 patients) had
an incisional hernia. The suture techniques used for
these patients are shown in Table III. One surgeon used
retention sutures only and four of his five patients
developed incisional hernias.
Retention sutures (external) were used in 42 of 53
cases, and a median of 4.3 sutures was used (range 2
10).
The suture material used to repair burst abdomen is
shown in Table IV. Absorbable sutures were used
almost exclusively.
Table V shows the timing of the resuture related to
the development of incisional hernia.
Eur J Surg 165

960

H. Gislason and A. Viste

Table IV. Suture materials used to close burst abdomens and later development of incisional hernia
Number of patients
Suture materials

Hernia (n = 23)

No hernia (n = 30)

Polyglactin (Vicryl)
Polyglycolic acid (Dexon)
Polyglyconate (Maxon loop)
Polydioxanone (PDS)
Polyamide (Ethilon)
Unknown material

6
6
6
2
0
3

12
11
4
0
2
1

Table V. Time of resuture of burst abdomen and later development of incisional hernia
Number of patients
Day of resuture

Hernia (n = 23)

No hernia (n = 30)

Day eight or earlier

After day eight

7
16

15
15

p = 0.17

DISCUSSION
In a recent prospective randomised study we examined
the incidence of wound complications after 599 major
gastrointestinal operations done in our hospital (5). In
this series we found a burst abdomen rate of 2%, a
wound infection rate of 14%, and wound hernias in 7%
one year after the operation. We noticed that half the
patients operated on for burst abdomen developed
incisional hernias, which was to us a surprisingly high
rate.
The present retrospective study shows that wound
dehiscence is associated with a high mortality (14%)
and a morbidity of 36% in patients who survived the
operation (Table II).
Grace and Cox (6) found that the incidence of
incisional hernias after operation for burst abdomen
was over half, and probably higher in patients who had
paramedian rather than midline incisions. The present
study confirms these results as we found that our
incidence of incisional hernias after operation for burst
abdomen was 43%. However, all the incisions that
broke down were midline, because most of the major
gastrointestinal operations are done through midline
incisions at our hospital. No other studies have been
published on this issue.
Published studies have shown no apparent differences in the rate of wound complications when the
primary incision is closed with continuous or interrupted sutures (4, 5, 13, 14, 15, 16, 19, 21). The continuous method has some theoretical advantage, as
tension is evenly distributed along the suture lines
(7, 8). It is also faster and cheaper and preferred by
Eur J Surg 165

most surgeons. However, when the abdomen bursts, the

wound is often infected, and the strength of tissue is
reduced so that sutures easily cut through. In that case it
might be reasonable to use interrupted sutures.
Although the difference is not significant, our results
indicate that the interrupted method might be better
than the continuous.
Retention sutures did not prevent the appearance of
incisional hernia. In 48% of cases where retention
suture were used hernia developed, compared with
27% (3/11) when they were not used (p = 0.31). These
results are similar to those of Grace and Cox (6). In
addition, retention sutures are cosmetically unacceptable, and probably cause more postoperative pain. We
know of no studies that have shown them to be of
benefit and we think that they should not be used.
The timing of re-suture is probably important. In the
present study, 15 patients (15/78) were operated on, on
or before the fifth day after the primary operation. In
these cases the cause was probably faulty operative
technique. Grace and Cox (6) showed that early resuture favours a sound wound, and that reoperation
after the eighth day is related to an increased rate of
complications. Our results support these findings as we
found 32% (7/22) incisional hernias in patients
operated on for burst abdomen on the 8th day or earlier
after the primary operation, compared with 52% (16/
31) in patients operated on after the eighth day.
How to prevent wound complications after the
primary operation has been a matter of debate for
decades. The suture materials used nowadays are of
good quality and studies that have compared different
materials show little or no differences (17, 18, 20).

Burst abdomen and incisional hernia

Theoretically, monofilament sutures that retain their
tensile strength for a long time are to be preferred
(9, 11, 18). However, the most important cause of
wound rupture is the thread cutting through the tissue
(6, 11, 16).
Absorbable sutures were used almost exclusively in
our study (Table IV). Vicryl (polyglactin) and Dexon
(polyglycolic acid) are absorbable multifilament sutures which lose their tensile strength relatively quickly
(it has essentially gone within 30 days) (17, 18). On the
other hand, Maxon (polyglyconate) and PDS (polydioxanone) are monofilament materials that are absorbed more slowly and still have about half their
initial tensile strength on the 28th postoperative day
(17, 18). If the development of a hernia after operation
for burst abdomen were to be related to the qualities of
the suture material, one would expect to find more
hernias in incisions closed with Vicryl or Dexon.
However, this was not the case.
Repair of incisional hernias is associated with
recurrence rates of 4050% (12) and it might be
important to adapt the experience achieved here to get
better results when resuturing a burst abdomen. Many
reports have been published recently of good results
using prosthetic material for repair of large incisional
hernia. The low recurrence rate is presumably because
the repair is tension-free. Reports show that prosthetic
materials can also be used in the presence of wound
infection (1, 2). To achieve better results after repair of
a burst abdomen the repair should be undertaken as
early as possible, and perhaps a mesh should be
applied.
In conclusion, incisional hernia is a common
complication after repair of a burst abdomen. The
choice of suture material, use of continuous or
interrupted sutures and the use of retention sutures
were of no consequence in preventing incisional hernia
in this small series, but we are aware of the danger of a
Type II error.
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Submitted February 12, 1998; submitted after revision May

13, 1998; accepted November 25, 1998
Address for correspondence:
Hjortur Gislason, M.D.
Department of Surgery
Haukeland Hospital
NO-5021 Bergen
Norway

Eur J Surg 165