BURST

ABDOMEN

Dr. Toto Imam Soeparmono,

SpOG,K.Onk
Dep Obsgin RSPAD Gatot Soebroto
Jakarta

Halsteds principles
1 Closing dead space helps prevent
seroma formation and infection

2 Careful hemostasis helps improve

visualization and reduce infection
3 Aseptic technique helps prevent infection
William S. Halsted, M.D.

4 Sharp anatomic dissection minimizes

tissue trauma
5 Avoidance of tension ensures adequate
blood supply to healing tissues
6 Gentle handling of tissues minimizes
tissue trauma

The goal of tissue management

Help physicians develop a wound closure

strategy that will lead to optimal patient
outcomes
Achieving this in fascial closure can improve
healing and reduce wound complications

1.Seiler, et al. Ann Surg

2009;249:576-82
1.Bloemen, et al. Br J Surg 2011;98:633-9
2.Millbourn, et al. Arch Surg 2009; 144:1056-94

4 Complications in comparison of
different techniques of fascial closure:
Early complication:
Fascial dehiscence
Infection
Late complication:
Hernia formation
Suture sinus / Incision pain

Interruptions in healing can

lead to wound complications
Surgical site infection (SSI)

- Postoperative infection of skin and fascia

- Can extend to organs or anatomic
spaces1
Wound dehiscence

- Failure of tissue edges to close

- Complete disruption of fascia and
overlying tissues can result in burst
abdomen2

Incisional hernia

- Fascial closure fails, allowing underlying

organs to protrude through defect

- Most common with abdominal surgery

1. Mangram, et al. J Infect Control Hosp Epidemiol 1999;20:
247-278.
2. Romano, et al. HSR 2009;44:182-204.
3. Muysoms, et al. Hernia 2009;13:407-414.

SSI

Wound
Dehiscence

Incisional
Hernia

Wound complications
increase risk for more
complications
SSI
- 2x risk of incisional hernia1
- 6x risk of wound separation2
Wound dehiscence
- Associated with 47% incisional
hernias3
Incisional hernias
- Associated with SSIs2,3

Preventing one complication may prevent others

1.Israelsson, et al. Eur J Surg 1996;62:125-129.
2.van Ramhorst, et al. World J Surg 34:20-27.
3.vant Riet, et al. Am Surg 2004;70:281-6.

Meta-analysis of techniques for closure of

midline abdominal incisions
Reit M, et al. B. J. Surg 2002; 89: 1350-56
15 Studies, 6566 patients
To reduce the incidence of incisional hernia
without increasing wound pain or suture
sinus
frequency,SLOWLY
ABSORBABLE
CONTINUOUS sutures appear to be THE
OPTIMAL METHOD of fascial closure

Interrupted versus continuous suture

INTERRUPTED

CONTINUOUS

Advantages1,4
May be used to close irregular areas
May minimize spread of infection and
allow for removal of infected stitches
Reduced risk of wound closure failure
if there is a break in only one suture

Disadvantages1-3
Knots increase foreign body material
and risks of complications
Time consuming

Advantages1,4
Better tension distribution,
less tissue strangulation
Faster to create, shortening procedure time
Less expensive5,6,7
Less material reduces foreign body
introduction
Disadvantages2,3,4
Increased risk of wound closure failure
if there is a break2,3,4

1. Sissener T. Comp Anim 2006;11:14-19. 2. Boutros S, et al. J Trauma Injury Infect Crit Care
2000;48:495-497. 3. Seiler CM, et al. Ann Surg 2009;249:576-582. 4. Wong NL. J Dermatol Surg
Oncol 1993;19:923-931. 5. Kettle, et al. Cochrane Database Syst Rev 2012; 11:CD000947. 1
6.
Boutros, et al. J Trauma 2000;48:495-497. 7. Colombo, et al. Obstet Gynecol 1997;89:684-689.

Mass closure

Reduces risk of wound complications

Meta-analysis of 12,249 patients in 25 studies found that
mass closure was associated with significantly lower rates
of incisional hernia and wound dehiscence1
2010 RCT of patients undergoing gynecologic cancer
surgery found mass closure had lower incidences of wound
pain2

Mass Closure

1. Weiland DE, et al. Am J Surg 1998;176:666-670.

2. Berretta R, et al. Austrail N Zealand J Obstet Gynecol 2010;50:391-396.

Previous 5 meta-analysis
1.

Weiland et al.1988

2.

Hodgson et al. 2000

3.

Absorbable inferior to braided non-absorbable

Monofilament absorbalble similar to non-absorbable

Vant Riet et al. 2002

5.

Absorbable inferior to Non-absorbable

Rucinski et al. 2001

4.

Continuous = Interrupted
Absorbable inferior to Non-absorbable
Layer by layer closure inferior to One layer

Continous rapidly absorbable sig. inferior to Continous slowly

absorbable or non-absorbable

Gupta et al. 2008

Continuous = interrupted

All did not focus on the study population

but rather technique and material

A burst abdomen is
considered present when intestine,
omentum or other visceras were
seen in the abdominal wound
following surgery
A postoperative complication associated
with significant morbidity and mortality

Patofisiologi luka terbuka

Significant risk factors

Sepsis *
Cough
Anaemia
Malnutrition
Abdominal distension

* Most important risk factor

 Usually occurs during the first two

weeks after surgery
23 % to 84 % of wound, leakage of
serosanguineous fluid is observed
Ramshorst, et al. Surg Technol Int. 2010 Apr; 19: 111-9

Treatment
Conservative management options (wound
dehiscence) include use of saline-soaked gauze
dressings and negative pressure wound therapy
Operative management options:
- temporary closure options (open abdomen
treatment)
- primary closure with various suture techniques
- closure with applicationof relaxing incisions
- use of synthetic (non-absorbable or absorbable) and
biological meshes
- use of tissue flaps
Ramshorst, et al. Surg Technol Int. 2010 Apr; 19: 111-9

Luka dirawat setiap hari sampai

adanya granulasi

Tujuan tatalaksana awal ini:

1. Mencegah usus dari kekeringan dan cedera trauma
2. Kontrol infeksi lokal/sistemik
3. Debridement semua jaringan mati
4. Persiapan penutupan kulit.

1/3 atas ditutup dengan flap kulit lokal

dengan anestesi lokal

24 jam kemudian, 1/3 tengah ditutup

dengan cara serupa

24 jam kemudian, 1/3 bawah ditutup.

Teknik Penjahitan Pada Burst

Abdomen
Mass closure with / without
Mesh
Retention closure

Penjahitan ulang
1. Debridement tepi luka
2. Pembuangan materi jahitan sebelumnya
3. Benang nonabsorbable 1/0 tebal
interrupted atau slow absobable material
4. Mengambil jaringan luas dari tepi luka (>
3cm) dan termasuk semua lapisan.
5. Bisa memakai mesh dan jahitan retensi

Burst abdomen dijahit ulang menggunakan jahitan retensi

Wong SY, Kingsnorth AN. Abdominal wound dehiscence and incisional hernia. Basic Surgical Techniques. Surgery. 2002.

Gambar skematis jahitan figure of eight bilateral terbalik,

seperti lasso (jangkar menyusup ke kedua tepi fasia (1
dan 1)
Polipropilen
e 0.
Jahitan
meninggalka
n 1 cm
antara
masuknya
jahitan dan
titik
keluarnya.

Sekuens jahitan (1-4 dan 5-8) dan aspek final (a) setelah implantasi mesh
polipropilen. Rectal sheath anterior harus dijahit dengan pola posterior untuk
melengkapi rekonstruksi

Prosedur
dilengkapi
dengan
implantasi
mesh
polipropilene
besar di antara
rectus sheath
posterior dan
muskulurs
rektus.

Smead-Jones closure

Rock JA, Jones HW. Te Lindes. Operative Gynecology. 10th ed. Lippincott Williams and Wilkins. 2008

Perbandingan teknik penjahitan interrupted

dengan continous pada repair luka operasi terbuka

Tidak adanya konsensus dari metode teknik

penjahitan pada repair luka terbuka
Dilakukan kajian meta-analisis untuk
mengukur odds rasio (OR)
Kajian 23 studi teknik penjahitan interrupted
berhubungan dengan penurunan dehisens
secara signifikan dibandingkan dengan
metode penjahitan continous (OR, 0,576;
p=0,014; RR 39,8%).

Perbandingan teknik penjahitan interrupted

dengan continous pada repair luka operasi
terbuka
Teknik penjahitan interrupted juga lebih baik
pada penggunaan dengan benang
nonabsorbable, insisi vertikal dan mass closure.
Tidak ada perbedaan risiko terjadinya hernia
insisional pada kedua metode ini
Kesimpulan: teknik penjahitan interruped dapat
menurunkan odds rasio dari terjadinya dehisens
setengahnya dibandingkan dengan teknik
penjahitan continous

Common types of synthetic absorbable

sutures and their in-vivo half-lives

Polyglactin 910 (Vicryl) two weeks

Polyglycolic acid (Dexon) two weeks
Poliglecaprone (Monocryl) two weeks
Polydioxanone (PDS) three weeks
Polyglyconate (Maxon) six weeks

Synthetic nonabsorbable sutures

have longer wound security (300 days or
more).
Some examples of this type of suture include
polyamide (Nylon)
polypropylene (Prolene)
polybutester (Novafil)
polyester (Mersilene).

 Many trials and new techniques

were developed to prevent or at
least reduce the risk of wound
dehiscence, but burst abdomen
remain a formidable morbidity
Lofty W. Burst abdomen: is it preventable complication ?
Egyptian J Surg 2009; 28, 3: 128-132

 Despite
improved
surgical
techniques and the use of prosthetic
mesh, incisional herniation remains
a major problem for the general
surgeon
Adotey JM. Incisional hernia : A review. Nigerian J Med 2006, Vol 15, 1: 34-43

Summary: factors and treatment

concerning surgical wound healing
Factor

Treatment

Systemic
Hypoalbuminemia, anemia, vi C
deficiency, steroid therapy, active
infection, old age
Local
Poor hemostasis & bllod supply,
ragged wound edge,
contamination of raw wound
edges, inadequate drainage of
underrcut wounds , poor
technique making & closing
incision ,anaesthesia
Posoperative
Violent coughing & emesis, ileus,
strain at urination & passing flatus

Correct imbalances when possible

before surgery. When correction is
not possible, use retention sutures in
addition to standard closure
Good surgical technique and good
anaesthesia. Consider antibiotics
(systemic and local) if infection is
present or contamination un
avoidable. Type of anesthesiais not a
factor
Preroperativepreparation and
postoperative anticipation with
institution of appropriate measures
immediately

Eisenstat MS. Causes and management ofsurgical wound dehiscence.

Cleveland Clinic Quarterly. 2013, vol 39;1: 33-42

KESIMPULAN
Belum adanya konsensus dari metode teknik
penjahitan pada repair luka terbuka.
Lebih baik mencegah terjadinya luka operasi
dengan manajemen pre, intra, dan post-op
yang optimal.

Ucapan terima kasih

dr. Sulaeman Daud dan
dr. Riyan Hari Kurniawan
Ethicon

08/21/08