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Factors affecting post-op erative laparotomy wound complications Original Research Article ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Factors affecting post-op erative laparotomy wound complications

Original Research Article

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

Factors affect ing post-operative lap arotomy wound complications

Khandra Hitesh P 1* , V yas Pratik H 1 , Patel Nilesh J 1 , Ma thew Jovin G 2

1 Assistant Professor, Departmen t of Surgery, Smt. NHL Municipal Medical Colleg e, Ahmedabad, India 2 PG Student, Department of Surgery, Smt. NHL Municipal Medical College, A hmedabad, India *Correspo nding author email: hitesh.khandra@gmail.com

How to cite this article: Khand ra Hitesh P, Vyas Pratik H, Patel Nilesh J, Mat hew Jovin G. Factors affecting post-operative laparot omy wound complications. IAIM, 2015; 2(1): 71- 75.

Availa ble online at www.iaimjournal.com

Received on: 31-12-2014

Acce pted on: 05-01-2015

Abstract

Despite the advances made in

asepsis, antimicrobial drugs, sterilization and

operative technique,

post-operative wound problem s continue to be a major threat. Clean sound h ealing of laparotomy wound after any intra-abdomi nal procedure is a cardinal index of good s urgical repair. Post- operative wound problems dela ys recovery and often increases stay and may pr oduce lasting sequel

and require extra resources

for investigations, management

and

nursing

care, therefore its

prevention is relevant to quality

patient care. Post-operative wound problems s eldom causes death,

yet it does prove to be an e conomic burden on patient and on health psychological trauma to the sur geon as it robs his hours of dedicated work on

system and induce operating table and

good carrier. Considering wou nd problems is quite common in developing co untries like India the

present study was taken up to f ind out the incidence of post-operative wound

problems and factors

that influence its occurrence.

Present study aimed to discover the sound, id eal method for the

abdominal wound closure with r egard to the problems associated with laparoto my wound.

Key words

Laparotomy, Wound infection, B urst abdomen, Incisional hernia.

Introduction

An abdominal

wound may

disruption in the anterior abdo

occur minal wall caused

due

to

by either trauma [1] or any surg ical intervention

in order to

gain

access

to

the underlying

pathology [2]. In the latte r scenario, incision

thus made passes through

various layers of the

anterior abdominal w all from skin, subcutaneous tissue, linea a lba and peritoneum. This incision when made in itiates a cascade of mechanisms at cellular le vel, which aims at achieving healing at incision site [3]. This healing

Factors affecting post-op erative laparotomy wound complications Original Research Article ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

International Archives of Integra ted Medicine, Vol. 2, Issue 1, January, 2015. Copy right © 2015, IAIM, All Rig hts Reserved.

Page 71

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) may occur by

Factors affecting post-op erative laparotomy wound complications

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

may occur by primary intentio n (wounds with opposed edges) or by seco ndary intention (wounds with separated edg es). Healing by secondary intention occurs wh enever there is extensive loss of cells and tiss ue as occurs in infarction, inflammatory ulce ration, abscess formation etc.

All patients were opera ted under general

anesthesia through midline

incision. Saline and

beta dine peritoneal wash w as given in all cases. Drainage was done thro ugh separate stab

incision as per selection by Mass or layered closure of

operating surgeon. abdomen was done

with absorbable or non a bsorbable material.

Factors affecting wound heali ng in abdominal

wall and those leading to co mplication have been discussed by various prev ious reports but

no clear consensus could be

made. General

patients profile like age, sex, n utritional status, pre-operative medical conditi on like anemia, diabetes, jaundice, renal fa ilure, bad ASA (American Society of Anesthesi ologists) scoring,

intra-operative knot breakage,

suture material

rupture or suture cut through , emergency or

elective surgery, type and dur ation of surgery and Post-operative wound infe ction or increase

in intra abdominal pressure factors leading to complication.

are the various post-laparotomy

Skin was opposed with stitches.

nylon intermittent

Post-operatively patient w as given antibiotic

according to need and

early ambulation

encouraged. Abdominal w ound was examined on 3 rd , 7 th and 10 th post -operative day and suture was removed. All pa tients were followed up for a period of 6 months.

Results

Total 100 cases were take n for study. Out of

which, 76 were emergency

cases and 24 were

elective cases. Out of em ergency surgery, 42 (55%) developed complicat ion while 11 (45%)

among elective surgery. 40 % patients in the age

Material and methods

group 21-40 years

developed wound

The present study was a prospe ctive study done

complication, 23% in age ˂2 0 year whereas 37% in ˃40 year age group. 66 p atients were male of

during the period of July 200 6 to September

which 33 (50%), while 34 w ere female of which

2008 at a tertiary care centre. A

total number of

  • 16 (47%) developed com plication. The rate

100 cases were studied and fo llowed up for a period of 6 months. All patient s with indication

shown in present study was higher in males than females explained by h igher incidence of

for laparotomy (emergency an d elective) with

smoking, alcoholism,

malnutrition and

complete 6 month follow up

included, while

associated medical illnesse s. All 24 patients in

pediatric patients were exclud ed. Ryle’s tube

poor nutritional status dev eloped complication,

insertion for naso-gastric dec ompression and urinary catheterization was do ne all cases. Pre-

while 9 (20%) out of 44 wit h good nutrition had complications. 12 (92%) ob ese patients while 6

operative antibiotics were g iven and anti-

(32%) average patients had

complications. Total

diabetic and antihypertensive p recautions were

  • 19 (59%) patients with hosp ital stay of ˂10 days,

taken as per medical advic e. Preoperative

  • 25 (54%) patients with hos pital stay 10-15 days

shaving and local skin care wit h beta-scrub was

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

done. In elective cases, when

indicated bowel

had complications. There w as significant rise in

preparation was done either b y stomach wash,

the post-operative wou nd infection with

total gut irrigation, or simple

enema while in

prolonged post-operativ e hospitalization

emergency cases no bowel prep aration possible.

because colonization of pa tients with hospital

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) may occur by

International Archives of Integra ted Medicine, Vol. 2, Issue 1, January, 2015. Copy right © 2015, IAIM, All Rig hts Reserved.

Page 72

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) acquired microorganisms. Thes

Factors affecting post-op erative laparotomy wound complications

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

acquired microorganisms. Thes e organisms are

In a similar study conducted

by Cruse and Foord,

frequently antibiotic resista nce and gram

et al. [8] on 18090 patient s, it was found that

negative bacteria. For eme rgency surgery,

obese patients have 13.5 % wound infection

longer the duration of hospita l stay increased wound problems. It was assoc iated with more

rate. Obesity is associated w

ith other co morbid

conditions like diabet es, hypertension,

disturbances in internal milieu

of patients. Total

herniation etc., which can a ll, contribute to poor

8 (36%) patients with incision l ength of ˂10 cm,

wound strength and healin g. Keill, et al. [6] and

36 (50%) patients with incision

length 10-15 cm

Whipple, et al. [9] depicted

that anemic people

and 6 (100%) patients with inc ision length ˃15

have poor wound healing

and tend to have

cm had complications. Abdom inal drains were kept in 86 patients of which 54 %, whereas in 14

wound gaping. Hypoprotein emia contributes to

drain was not kept of which 2

(14%) developed

prolonged inflammatory fibroplasia, proliferation,

phase and impairs proteoglycan and

complication. 60% of laparoto mies with clean

collagen synthesis, neoangi ogenesis and wound

cases which showed only 25% rate while contaminated cases

wound problem showed 62% of

remodeling [10]. In a se ries of studies of collagen formation in diab etes, Goodson and

problem rate while in dirty case s it was 100%.

Hunt [11] have shown t hat obesity, insulin

Discussion

Abdominal wound compl ications after

laparotomy is a surgical emer gency with high

morbidity and mortality leading

to escalation in

hospital costs and prolonge d illness. The

reported incidence of major a bdominal wound

complication is 15-25% and is

associated with

mortality rate of 15-20% [4].

Although several

systemic factors, local mechan ical factors and post-operative events have b een blamed for

abdominal wound complication , yet there is no

clarity on the importance of factors.

each of these

In this study,

the

highest inci dence of wound

complication (40%) was recor ded

in

the

age

group of 21-40 years, proba bly because of

higher incidence of acute a bdomen in this decade. Our study showed no c orrelation of the increased incidence with the i ncreasing age as

was showed by Halasz, et al.

[5]. Our study

showed male predominance ( 66/100) as was

also

recorded by

studies of Ke ill, et al. [6] and

Penninckx, et

al.

[7].

Out

of

t he

total of

100

patients, 13 were found to be

obese (BMI>35).

resistance, hyperglycemia

and depressed

leukocyte function interf ere with collagen

synthesis and thus impair

wound healing. Pre-

existing systemic illness co ntributes to higher ASA score and higher wou nd dehiscence rates because of increase wound i nfection [12].

One of the significant findin g was that 76 of the

100 patients who had

developed wound

complication had undergo ne laparotomy on emergency basis, 5% p atient had wound dehiscence. Similar observa tion has been made

by Penninckx, et al. [ 7], where wound dehiscence rate was fo und to 6.7% in emergency laparotomy an d 1.5% in elective

cases. This fact may be

attributed to poor

patient preparation, compl icated inflammatory

disease, premorbid factors

and operating at odd

hours. Another characteri stic feature of our study was that these lapar otomy wounds were

either contaminated in 62%

or dirty in 100% of

patients. Similar results wer e found in a study by Haley, et al. [13], in w hich they showed

contaminated/ dirty wound s to be an important

predictor for wound infe ction. Haley, et al. demonstrated that the dura tion of surgery more than 2 hours was second g reatest independent

predictor of risk after a m

ultivariate analysis.

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) acquired microorganisms. Thes

International Archives of Integra ted Medicine, Vol. 2, Issue 1, January, 2015. Copy right © 2015, IAIM, All Rig hts Reserved.

Page 73

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) The increase in

Factors affecting post-op erative laparotomy wound complications

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

The increase in intra abdo minal pressure because of nausea, vomiting or cough results in

breakage of suture, undoing of

knots or pulling

  • 3. Cotran Ramzi S,

K umar Vinay, Collins

Tucker. Robin’s Pa thologic Basis of

Disease. 6 th edition.

USA: W.B. Saunders

through the tissue. Jenkin, et a l. [14] proved in his study that facial layers ten d to lengthen as the wound distends where a s suture length

remains the same leading to br eakage of suture, undoing of knot or pulling thro ugh tissue. Post- operative wound infection w as found to be single most common factor ob served in 90% of our patients as a cause of ab dominal wound complication. It has been sh own by various

other studies [15] that tens ile strength of staphylococcus aureus contami nated wounds in rat on 6 th post-operative d ay was much decreased. These infected wou nds slowly break down and then heal by granu lation tissue. All

our patients had multiple

risk factors

contributing wound complica tion. The least

number of risk factors record ed were 3 and

maximum number was 11, the interpreted by Riou, et al. [16].

same was also

Co; 2001, p. 89.

  • 4. Poole GV. Mech anical factors in abdominal woun d closure. The prevention

of

fascial

dehiscence. Surg., 1 985; 97: 631–9.

  • 5. Halasz NA. Dehisc ence of laparotomy wounds. Amer J Su rg., 1968; 116: 210–
    4.

  • 6. Keill RH, Keitzer

WF, Nichols WK.

Abdominal woun d dehiscence. Arch Surg., 1973; 106: 57 3–7.

  • 7. Penninckx FM, Poel mans SV, Kerremans RP. Abdominal wo und dehiscence in

    • gastro- enterolo gical

surgery. Ann

Surg., 1979; 189: 34 5–52.

  • 8. Cruse PJE, Foord R. The epidemiology of wound infection: A

10 year prospective

study of 62939 wo unds. SurgClin North

Am., 1980; 60: 27.

Conclusion

It is necessary to mention that

wound healing is

a multi factorial problem, influe nced by a variety

of factors not included in the

present study,

even though the surgical ar t of monolayer

closure technique proved its su periority in terms of wound healing, strength and security.

References

  • 1. Thomas CL. Taber’s Cy clopedic Medical Dictionary. 17 th editio n. Philadelphia: F.A. Davis Company; 19 93, p. 2165.

  • 2. Coleman DJ. In. Russel

RCG, Williams NS

and Bulstrode CJK (e ds), Bailey and

Love’s: Short Practice

of Surgery. 23 rd

edition. Vol. 29. L ondon: Arnold

Publisher London; 2000.

  • 9. Whipple AO. The

critical latent

or

lag

period in the heal ing of wounds. Ann

Surg., 1940; 112: 48 1.

  • 10. Pollack SV. Wound Nutritional factors

healing: A review III.

affecting

wound

healing. J Der matology Surg

Oncol., 1979; 5: 615 .

  • 11. Goodson WH III,

Hunt

TK.

Wound

healing and dia betic patient. Surg Gynecol Obstet., 19 79; 149: 600–8.

  • 12. Sawyer GS, Pr uett LP. Wound

infection. Surgical

clinics

of

North

America, 1984; 74(3 ): 523.

 
  • 13. Haley Rw, Culver

DH,

Morgan

WM.

Identifying patient s at high risk of

surgical wound

infection. Am

J

Epidemiol., 1985; 12 1: 206.

 
  • 14. Jenkins TPN. The

burst

abdominal

wound: A mechan ical approach. Br J Surg., 1976; 63: 873 –6.

  • 15. Smith M, Enquist IF. A quantitative study of the impaired he aling resulting from

Factors affecting post-op erative laparotomy wound complications ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) The increase in

International Archives of Integra ted Medicine, Vol. 2, Issue 1, January, 2015. Copy right © 2015, IAIM, All Rig hts Reserved.

Page 74

Factors affecting post-op erative laparotomy wound complications infection. Surggynecol 125: 965–73. Obstet., 1967; 16. Riou JP,
Factors affecting post-op erative laparotomy wound complications
infection. Surggynecol
125: 965–73.
Obstet., 1967;
16. Riou
JP,
Cohen JR, Joh nson H. Factors

influencing wound d ehiscence. Am J Surg., 1992; 163: 324–3 0.

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

Source of support: Nil

Conflict of inter est: None declared.

Factors affecting post-op erative laparotomy wound complications infection. Surggynecol 125: 965–73. Obstet., 1967; 16. Riou JP,

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