Surgical wound dehiscence

Surgical wound dehiscence

Barbara Hahler

Surgical incisions are acute wounds that activate the healing process. Although it has four identified stages, wound healing in reality is a complex, continuous process. The four stages are hemostasis, inflammation, proliferation, and maturation (Chin, Diegelmann, & Schultz, 2005). After a wound is created, hemorrhage is the initial response. During hemostasis, platelets aggregate and degranulate, activating blood clotting. Once the clot forms, it begins to break down. As the clot is degrading, the capillaries dilate and become more permeable. Fluids flow to the wound site, activating the complement cascade. The complement system induces lysis, the destruction of select cells. This system helps neutrophils bind to bacteria, facilitating phagocytosis and bacterial destruction. Macrophages also are present at the wound site and help destroy bacteria. They are a source of cytokines and growth factors that are essential for normal wound healing (Chin et al., 2005).

The proliferation phase of wound healing usually begins 3 days after injury and lasts for several weeks. During this phase, granulation tissue forms in the wound space. Fibroblasts, which move to the wound and proliferate, are responsible for the synthesis of collagen and other connective tissue development; they are critical for wound repair. The fibroblasts are stimulated by growth factors and converted by cytokines into wound fibroblasts, which have increased collagen synthesis behavior. In sutured incisions, collagen synthesis peaks at day 5. Although granulation tissue is not present, by day 5 it is possible to palpate a healing ridge just under the intact suture line (Waldrop & Doughty, 2000). Epithelialization occurs when granulation is complete. This involves the migration of epithelial cells across the skin edges, a process that begins almost immediately after surgery and may be complete in 2-3 days (West & Gimbel, 2000).

At approximately 7 days after surgery, the maturation phase begins. This phase lasts for 1 year or more. Continued collagen deposition and remodeling contribute to the increased tensile strength of wounds. Approximately 20% of normal tensile strength is present at 3 weeks after surgery. A maximum of 70%-80% tensile strength is achieved after 1 year (Jones, Bale, & Harding, 2004).

Factors Contributing to Surgical Wound Dehiscence

Very simply, dehiscence is a mechanical failure of wound healing. Conditions associated with increased risk of wound dehiscence are anemia, hypoproteinemia, malnutrition, obesity, malignancy, jaundice, use of steroids, and diabetes (Sorensen et al., 2005). Male gender and advanced age also are associated with wound disruption. Specific surgical procedures lead to a higher incidence of wound dehiscence, including procedures for colon diseases, peptic ulcer disease, and emergency laparotomy (Waqar et al., 2005).

Obesity is associated with an increased infection rate and technical difficulties in closing an incision (Meeks & Trenhaile, 2005). Steroids given in moderate doses over a long period of time seem to decrease the tensile strength of a healing wound. Diabetics encounter more healing problems than non-diabetics, and have a greater risk of developing wound infections. Patients with diabetes experience less collagen synthesis and deposition, decreased wound breaking strength, and impaired leukocyte function (Waldrop & Doughty, 2000). These differences in wound repair may occur partially due to altered insulin levels and decreased levels of growth factors, such as insulin-like growth growth factor-1 and transforming growth factor-beta. Insulin therapy and exogenous growth factors can increase collagen deposition and increase tensile strength of wounds (Waldrop & Doughty, 2000). The jaundiced patient may experience prolonged healing and risk for wound dehiscence, which is related to a pro-inflammatory state resulting from portal and systemic endotoxemia. Endotoxemia is a result of an altered bowel barrier function due to the absence of bile in the bowel (Koivukangas, Oikarinen, Risteli, & Haukipuro, 2005).

Malnutrition or radiation therapy associated with malignancies may lead to wound separation. Radiation may cause obliterating endarteritis, resulting in decreased blood supply to the tissues. Patients with malignancies also are more likely to have a contaminated wound or abscess cavity (Meeks & Trenhaile, 2005). Male patients outnumber women by at least 2 to 1 for wound dehiscence (Hanif et al., 2000).

Local factors also are very important to consider. For example, infection predisposes a wound to disruption in the early postoperative period (Sorensen et al., 2005). Increased abdominal pressure also is associated with wound disruption. This may be caused by abdominal complications, such as nausea and vomiting, ileus, or a bowel obstruction, or by pulmonary complications, such as atelectasis or bronchitis (Doughty, 2005). Infection and poor wound healing frequently are seen in ischemic wounds (see Table 1). Low blood oxygen content can predispose devitalized tissue to bacterial colonization (McGuckin, Goldman, Bolton, & Salcido, 2003). The persistent presence of micro-organisms leads to an increased number of phagocytes that release proteolytic enzymes, free radicals, and inflammatory mediators. The effect of these substances is additional tissue injury and wound deterioration (Gardner & Frantz, 2004). The inflammatory mediators produce local thrombosis, resulting in hypoxia. The hypoxia contributes to further bacteria growth, establishing a prolonged inflammatory cycle (Gardner & Frantz, 2004). Chronic tissue hypoxia also leads to collagen with inadequate tensile strength which contributes to wound dehiscence (Waldrop & Doughty, 2000).

Interventions to Reduce the Incidence of Dehiscence

Patients should be instructed to reduce or eliminate the use of tobacco products for at least 30 days prior to surgery (Centers for Disease Control and Prevention [CDC], 1999). Medications with an anticoagulant effect, such as aspirin or nonsteroidal anti-inflammatory drugs, also should be eliminated prior to surgery. A physician should be contacted to determine when each medication should be stopped (Doughty, 2005). These measures will help promote hemostasis, and improve oxygenation and perfusion to the tissues. Patients also should be encouraged to optimize their nutrition prior to scheduled surgery, especially their protein intake, to facilitate wound healing (Doughty, 2005). Protein is responsible for repair and synthesis of enzymes involved in wound healing, cell replication, and collagen synthesis. The recommended daily protein intake for adults is 0.8g/kg per day (Posthauer & Thomas, 2004). Patients should be encouraged to increase their intake of protein-rich foods, such as meat, fish, legumes, milk, and cheese. Supplemental drinks also may provide additional protein. The Institute for Healthcare Improvement (IHI) also recommends several measures to reduce surgical site infections. These include maintaining high levels of inspired oxygen, avoiding shave prep of the operative site, controlling serum glucose levels, preventing hypothermia, and using prophylactic antibiotics (IHI, 2006).

During the surgical procedure, measures to reduce the risk of infection are implemented. Immediately after surgery, the nurse should maintain patients’ warmth and manage pain because both measures help to reduce vasoconstriction (Doughty, 2005; West & Gimbel, 2000). Hypovolemia is a potent vasocontrictor (West & Gimbel, 2000). Adequate blood volume will help maintain tissue oxygen levels. Tissues that are adequately perfused usually are able to heal (Waldrop & Doughty, 2000). Patients who are well perfused rarely get wound infections, a contributing factor for wound dehiscence (West & Gimbel, 2000). Blood volume also should be maintained by adequate fluid replacement. Supplemental oxygen should be used to maintain normal oxygen levels as needed. Good blood glucose control also is important for healing (Doughty, 2005). Wound repair in patients with diabetes mellitus is characterized by decreased collagen synthesis and deposition and decreased breaking strength. Many of the effects of diabetes mellitus are related to glycemic control. The management of patients with diabetes and wounds should include strict glycemic control, and measures to reduce trauma and maximize tissue perfusion (Doughty, 2005; Waldrop & Doughty, 2000).

Retention sutures may be placed to reinforce other closures. Retention sutures will reduce the incidence of wound dehiscence, but not eliminate it (Meeks & Trenhaile, 2005). The CDC recommends that incisions be covered by sterile dressings for at least 24-48 hours postoperatively (CDC, 1999). Some surgeons will continue dressings until epithelialization is complete. The skin’s bacterial barrier is established once the incision is epithelialized. The edges of the incision will be approximated and no drainage is present. At this time, dressings are optional.

Wounds heal by primary, secondary, or tertiary intention. Surgical wounds that are approximated heal by primary intention, mainly by deposition of connective tissue. Wounds that dehisce frequently are left to heal by secondary intention. These wounds heal more slowly due to the amount of connective tissue that is necessary to fill the wound. Some surgical wounds initially are left open; then later the superficial edges are closed, and the center heals by granulation tissue. These wounds heal by tertiary intention (Waldrop & Doughty, 2000).

Incisional supports should be considered for patients at risk for wound dehiscence, including those patients who are obese or malnourished, or have a chronic cough or chronic steroid use (Doughty, 2005). Supports include binders for abdominal incisions and surgical bras for patients with sternal wounds or large breasts (Doughty, 2005).

The nurse should inspect incisions each shift for evidence of separation, and assess for any signs of infection such as redness, warmth, and edema around the incision (Gardner & Frantz, 2004). The incision should be palpated for evidence of a healing ridge (commonly present by day 5). This will feel like an area of induration beneath the skin extending to about 1 cm on each side of the incision (West & Gimbel, 2000). If the healing ridge remains absent by day 5 to 9, the nurse will suspect delayed healing and risk for dehiscence. Systemic factors, such as malnutrition and elevated glucose level, that hinder wound healing also should be evaluated (Gardner & Frantz, 2004).

Signs of Wound Dehiscence

Wound dehiscence frequently occurs without warning. The diagnosis may be obvious if evisceration is present. Frequently patients report a pulling or ripping sensation, or note that “something has given way.” In 23%-83% of cases, serosanguinous drainage is present from the wound prior to the dehiscence (Waqar et al., 2005). Most dehiscences occur 4-14 days after surgery, with a mean of 8 days (Meeks & Trenhaile, 2005; van’t, De Vos Van Steenwijk, Bonjer, Steyerberg, & Jeekel, 2004). Diagnosis can be made based on clinical presentation and wound inspection in the majority of cases. Imaging studies, such as ultrasound, computerized tomography scan, or MRI, can be used if the diagnosis is unclear (Meeks & Trenhaile, 2005).

Immediate Nursing Interventions

If wound dehiscence is detected, the nurse will return the patient to bed and lower the head of the bed to no higher than 20 degrees (Moz, 2004). Evisceration also may have occurred and measures to reduce abdominal pressure should be implemented. The patient should bend the knees and avoid coughing to reduce abdominal pressure. Sterile gauze or towels soaked in sterile saline should be placed over the wound or any exposed bowel. The nurse should not try to push any viscera back into abdomen. The color of the tissue and any exposed bowel should be assessed, and the supervisor and surgeon notified of the change in the patient’s condition. The nurse should assess the patient’s vital signs and oxygen saturation every 15 minutes. The patient should be reassured regarding his or her condition. Pain should be assessed and managed appropriately. An intravenous line should be present in case the patient needs immediate surgery. The patient should have nothing by mouth. It is important for the nurse to stay with the patient to monitor vital signs and monitor for shock until the patient is seen by a physician (McConnell, 1998; Moz, 2004). After a surgeon has examined the wound, an abdominal binder may be ordered to support the abdomen if surgery is not indicated (Meeks & Trenhaile, 2005)

Wound Management

The dehisced wound is managed the same as any other open wound if immediate surgical closure is not done. Topical therapy should include measures to maintain a moist environment, reduce infection, manage pain, and eliminate all necrotic material (Doughty, 2005). Hydrogel or gel dressings are water-based or glycerin-based products available as amorphous gels, gauze impregnated with gel, or sheet gels. Hydrogels help maintain a moist wound environment for dry wounds, and they promote granulation and epithelialization. After application, they are covered with a dry dressing, or a dry dressing and transparent film (Hess, 2002). Alginate dressings can be effective for wounds with a moderate-to-large amount of drainage. Alginates, which are derived from brown seaweed, consist of woven fibers formed into sheets or ropes. When used to fill a wound, alginates absorb drainage and form a soft gel. Some formulations can absorb up to 20 times their weight in fluid. They can be covered with secondary gauze dressing or a transparent film dressing (Hess, 2002).

Silver is a broad-based antimicrobial agent that controls bacteria, mold, and yeast. Some silver agents control methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) when at appropriate concentrations. Silver inhibits cellular respiration, denatures nucleic acids, and alters cell membrane permeability (Warriner & Burrell, 2005). Silver dressings come in several formulations, including sheets, combined with alginates and foams, as well as wound fillers. Some silver-impregnated dressings are meant to be worn for up to several days. These dressings are usually covered with a dry gauze secondary dressing. Because several types of silver dressings are available, it is imperative to read the product insert carefully prior to use of these dressings.

Collagen dressings encourage the deposition and organization of collagen in the wound bed (Hess & Kirsner, 2003). These dressings are available in sheets, pads, gels, and particles. Collagen dressings may be used as the primary dressing for dehisced wounds with minimal-to-heavy exudates. A secondary dressing will be required (Hess, 2002).

Negative pressure wound therapy may be used for full-thickness dehisced wounds with moderate-to-heavy drainage. Negative pressure is applied to a special dressing that is placed in the wound bed. Interstitial fluid is removed from the wound, circulation increased, and more rapid formation of granulation tissue occurs (Hess, 2002) (see Table 2).


Despite advances in preoperative care, the rate of surgical wound dehiscence has not decreased in recent years; 1%-3% of patients experience wound dehiscence. A nursing goal for the postoperative patient is always prevention of wound dehiscence. Recognition of risk factors is essential. For example, older males with ascites are at very high risk. Prevention of wound infection and mechanical stress on the incision are important.

Management of dehisced wounds may include immediate surgery if bowel is protruding from the wound. If surgery is not needed, management is essentially the same as that of any other wound through maintenance of a moist wound environment, reduction of bioburden and pain, and promotion of granulation tissue. Mortality rates associated with dehiscence have been reported between 14% and 50% (Hanif et al., 2000; Waqar et al., 2005). One of the complications (morbidity) of dehisced wounds is an incisional hernia, which develops in an estimated 43% of patients (van’t et al., 2004). Researchers followed 126 patients who had wound dehiscence repair for a mean of 37 months and found that 31% of the hernias were diagnosed more than 2 years postoperatively. Nurses need to ensure adequate nutrition and reduced tension on the abdomen, and implement measures to prevent incisional infections.


Centers for Disease Control and Prevention (CDC). (1999). Guideline for prevention of surgical site infection, 1999. Retrieved June 27, 2006, from pdf/guidelines/SSI.pdf

Chin, G., Diegelmann, R., & Schultz, G. (2005). Cellular and molecular regulation of wound healing. In A. Falabella & R. Kirsner (Eds.), Wound healing (pp. 17-37). Boca Raton, FL: Taylor & Francis Group.

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Khan, M., Naqvi, A., Irshad, K., & Chaudhary, A. (2004). Frequency and risk factor of abdominal wound dehiscence. Journal of the College of Physicians & Surgeons Pakistan, 14(6), 355-357.

Kiovukangas, V., Oikarinen, A., Risteli, J., & Haukipuro, K. (2005). Effect of jaundice and its resolution on wound epithelization, skin collagen synthesis, and serum collagen propeptide levels in patients with neoplastic pancreaticobiliary obstruction. Journal of Surgical Research, 124(2), 237-243.

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McGuckin, M., Goldman, R., Bolton, L., & Salcido, R. (2003). The clinical relevance of microbiology in acute and chronic wounds. Advances in Skin and Wound Care, 16(1), 12-25.

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Posthauer, M., & Thomas, D. (2004). Nutrition and wound care. In S. Baranoski & E. Ayello (Eds.), Wound care essentials (pp. 157-186). Philadelphia: Lippincott, Williams and Wilkins.

Sorensen, L., Hemmingsen, U., Kallehave, F., Wille-Jorgensen, P., Kjoergaard, J., Moller, L., et al. (2005). Risk factors for tissue and wound complications in gastrointestinal surgery. Annals of Surgery, 241(4), 654-658.

van’t, R.M., De Vos Van Steenwijk, P., Bonjer, H., Steyerberg, E., & Jeekel, J. (2004). Incisional hernia after repair of wound dehiscence: Incidence and risk factors. The American Surgeon, 70, 281-286.

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Waqar, S., Malik, Z., Razzaq, A., Abdullah, M., Shaima, A., & Zahid, M. (2005). Frequency and risk factors for wound dehiscence/burst abdomen in midline laparotomies. Journal Ayub Medical College Abottabad, 17(4), 70-73.

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Barbara Hahler, MSN, RN, APRN, BC, CWOCN, is a Clinical Nurse Specialist, Wound, Ostomy, and Continence Nursing, St. Vincent Mercy Medical Center, Toledo, OH.

Note: The author reported no actual or potential conflict of interest in relation to this continuing nursing education article.

Table 1.

Factors Contributing to Wound Dehiscence

* Anemia

* Malnutrition

* Obesity

* Malignancy

* Jaundice

* Use of steroids

* Diabetes

* Male gender

* Advanced age

* Wound infection

* Increased abdominal pressure (coughing, vomiting, distention,


Source: CDC, 1999

Table 2.

Wound Care Products

Dressing Drainage Absorbed Function

Hydrogel Minimal Hydrate wound

Alginate Moderate to large Absorb drainage; promote

moist wound healing

Silver dressings Minimal to large Reduce bacterial load of

wound; some absorption of


Collagen dressings Minimal to large Provide collagen to wound


Negative pressure Minimal to large Stimulate granulation

wound therapy tissue; absorb drainage

Source: Hess, 2002

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