Holly M. Hovan MSN, RN-BC, APRN, CWOCN-AP
An abdominoperineal resection (APR) is an operation in which a surgeon removes the anus, rectum, and sigmoid colon, usually to treat low rectal cancers.
By the WoundSource Editors
Dehiscence occurs when a surgical incision that was closed opens, either partially or completely. Dehiscence is most likely to take place within the first two weeks after surgery, but it can occur as late as one month after surgery.1
There are many dehiscence risk factors. In some cases, people can take steps to reduce or eliminate dehiscence risk factors before surgery; other risk factors cannot be eliminated. People with multiple risk factors are especially prone to developing dehiscence.
Learn more about dehiscence by attending "Common Post-Operative Complications, and How to Avoid Them," presented by Nancy Collins, PhD, RD, LDN, NWCC, FAND and Alex K. Wong, MD, FACS, available only at WoundCon Summer on July 17th
If dehiscence does occur, both clinicians and patients can take steps to promote closing of the wound.
A variety of underlying health conditions can increase a patient's risk for developing dehiscence after surgery. Such conditions include the patient being overweight or obese, hypertension, anemia, and hypoproteinemia.1 If possible and feasible, effort should be made to treat the patient's health condition or conditions before surgery. For example, people who are overweight may benefit from beginning a weight-loss and exercise program in advance of surgery.2
Some risk factors can be reduced or eliminated altogether, whereas others cannot. For example, because the skin of patients over the age of 65 is more fragile than the skin of their younger counterparts, they are more likely to develop dehiscence.1 Along with age, sex plays a role: men experience dehiscence at higher rates than women. Patients with a medical history of stroke or who have chronic obstructive pulmonary disease (COPD), diabetes, or cancer also have higher rates of dehiscence.
Some patient behaviors can also increase the risk of dehiscence. Smoking, for example, is a risk factor. For that reason, quitting smoking before surgery is recommended. Abusing alcohol and eating poorly are also risk factors.
Surgery itself can contribute to dehiscence. Research has shown that surgery length plays a role; if an operation is longer than two and a half hours, there is an increased chance of dehiscence.1 In addition, people who need emergency surgery are more likely to have wounds that dehisce than are patients who have scheduled surgery.1 Other surgical factors that contribute to dehiscence are the experience and skill of the surgeon, the type of surgical incision, the type of suture materials used to close the incision, and the location of the incision, among other factors.
After surgery, activities that involve repetitive strain on the wound area, such as coughing, vomiting, or laughing, can exert stress on the wound site and cause the wound to open. Patients can work to avoid some of these activities. Other activities require treatment of the underlying problem. For example, a person with constipation who is exerting pressure during bowel movements may be advised to take stool-softening medication.
Research has found that one of the most predictive risk factors for dehiscence is surgical site infection. Surgical incisions have a higher chance of opening if the wound becomes infected. Therefore, appropriate wound care is of paramount importance, and clinicians should watch the wound for signs of infection, such as reddening of skin in the wound area, increasing amounts of exudate, and the presence of necrotic tissue.3
How Can Dehiscence Be Treated?
The objective of managing dehiscence is to create a healing environment in which the wound will close. The dehiscence management protocol will be different for each patient and depends on the severity of dehiscence, the location of the surgical incision, and the patient's medical history.
For an uninfected wound with minor dehiscence, the only management that may be necessary is standard wound care, such as advanced wound care dressings to provide an optimal moist environment. Dehisced wounds with moderate to heavy exudate require absorbent dressings to manage moisture.4 If the clinician suspects that the wound will take longer than usual to heal, negative pressure wound therapy (NPWT) may be indicated as well.4,5 Necrotic tissue must be removed by using one or more methods of debridement (biological, enzymatic, autolytic, mechanical, surgical) to promote healing.
Severely dehisced wounds without infection require more intervention to be successfully managed. Each dehiscence case is unique, but common treatments for severe dehiscence include surgical debridement and re-operation to close the wound.4 Although minor and moderately dehisced wounds may be effectively treated in an outpatient setting, patients with severely dehisced wounds generally require hospital admittance.
Many of the same protocols mentioned here apply to a dehisced wound that is infected. If the wound is infected, the local infection should be managed with antimicrobial dressings. If NPWT is used, an antimicrobial wound interface may be called for.4 Antibiotic medication may be prescribed if the infection becomes systemic.3
1. Chun JC, Yoon SM, Song WJ, Jeong HG, Choi CY, Wee SY. Causes of surgical wound dehiscence: a multicenter study. J Wound Manag Res. 2018;14(2):74-79. http://jwmr.org/upload/pdf/jwmr-2018-00374.pdf. Accessed May 10, 2020.
2. Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC Surg. 2017;17:19. https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-017-0207-0#citeas. Accessed May 10, 2020.
3. Sandy-Hodgett K, Ousey K, Howse E. Ten top tips: management of surgical wound dehiscence. Wounds Asia 2018. 2018;1(1):16-19. https://www.woundsinternational.com/uploads/resources/89dbb6edff8d11ca74.... Accessed May 10, 2020.
4. Surgical wound dehiscence: improving prevention and outcomes. Wounds International. 2018. https://www.woundsinternational.com/resources/details/consensus-document.... Accessed May 10, 2020.
5. Hunter S, Thompson P, Langemo D, Hanson D, Anderson J. Understanding wound dehiscence. Nursing2007. 2007; 37(9):28-29. https://journals.lww.com/nursing/fulltext/2007/09000/understanding_wound.... Accessed May 10, 2020.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.