Secondary Suturing for Burst Abdomen (Wound Dehiscence)

Definition and Overview

• Bailey & Love's Short Practice of Surgery, 28th ed., p. 5799

When Does It Occur?

• Most commonly on day 5-8 post-operatively, when wound tensile strength is at its lowest
• Often heralded by a serosanguinous ("pink fluid") discharge from the wound - a classic warning sign
• The patient may report a "popping" sensation after straining or coughing

Risk Factors

• Malnutrition, obesity, diabetes mellitus
• Renal failure, jaundice
• Sepsis, malignancy
• Steroid therapy
• Emergency surgery

• Inadequate or poorly tensioned wound closure
• Infection, haematoma, or seroma at the wound
• Raised intra-abdominal pressure (bowel obstruction, COPD with excessive coughing)

Pre-operative Management (Before Return to Theatre)

• Cover eviscerated bowel immediately with warm, moist saline-soaked packs
• Keep the patient NBM; establish IV access
• Correct fluid and electrolyte imbalances
• Administer systemic antibiotics
• If evisceration is NOT present: an abdominal binder may be used as a temporising measure; however, if the full extent of dehiscence is uncertain, operative exploration is mandatory
• Plan for general anaesthesia - this operation cannot be adequately performed under local or spinal anaesthesia

Surgical Technique: Secondary Suturing

1. Anaesthesia and Preparation

• Performed in the operating theatre under general anaesthesia
• Full muscle relaxation is needed to allow re-approximation of the fascia without undue tension

2. Wound Exploration

• Open the entire skin incision
• Carefully inspect and trace the fascial closure suture back to intact, non-dehisced fascia
• Debride all non-viable and infected tissue at fascial edges - anatomy must be clear before closure

3. Abdominal Exploration and Lavage

• Gently explore the peritoneal cavity, especially if there is purulent, feculent, or bilious discharge - the source must be identified and managed
• If the wound is clean (no purulent discharge), limit exploration to avoid iatrogenic bowel injury
• Lavage the peritoneal cavity with warm normal saline

4. Placement of Retention Sutures (before tying)

• Using heavy non-absorbable monofilament or braided suture (e.g., No. 2 nylon, Prolene, or stainless steel)
• Placed 3-4 cm from the fascial edge, passing through: skin → subcutaneous fat → anterior rectus sheath → rectus muscle → posterior rectus sheath → peritoneum (full thickness)
• These are placed without tying at this stage
• Sutures should ideally lie in the extraperitoneal/preperitoneal space to minimise visceral contact and avoid the "cheese wire" effect on bowel loops
• Protect bowel with a malleable retractor during each needle pass; needle must be visualised at all times

5. Fascial Closure

• Close the fascia using large bites of non-absorbable suture (e.g., Prolene or PDS), using the mass-closure technique
• Begin with sutures at each end of the wound and meet in the middle
• Final sutures are placed without excessive tension to allow adequate visualisation and needle passage
• Important note: the peritoneum does not need to be closed separately - it does not contribute significantly to wound strength

6. Skin Closure and Tying of Retention Sutures

• Close the skin very loosely (this is a contaminated/potentially infected field)
• Thread each retention suture through a short segment of sterile IV tubing (or red rubber catheter bolster) to distribute pressure across the skin and prevent suture cut-through
• Tie down the retention sutures - no excessive tension required

7. Post-operative wound management

• In patients with suspected infection, poor tissue quality, or excessive tension - it may be preferable to leave the wound open and manage with regular dressings or vacuum-assisted closure (VAC) pumps

Retention Sutures: Key Points

• Current Surgical Therapy, 14th ed., p. 1422; Pye's Surgical Handicraft, 22nd ed., p. 7262
• VUMC Global Surgical Atlas - Closure of Laparotomy Wound Dehiscence (Davis R.)

Role of Retention Sutures in Prevention (Prophylactic Use)

• Indication: Elderly patients, malignancy, bowel obstruction, contaminated wounds, malnutrition
• Evidence is mixed: Khorgami et al. (2013, RCT of 300 patients) showed a significantly lower wound dehiscence rate with retention sutures (4% vs. 13.3%); however, evisceration rates did not differ
• Rink et al. (2000) found no difference in wound failure but increased patient morbidity (discomfort) with retention sutures
• Modern trend favours mass closure (a single-layer, continuous technique taking large bites of fascia), which has made prophylactic tension sutures largely obsolete - associated with <1% wound dehiscence rate and 5-10% incisional hernia rate
• Campbell Walsh Wein Urology, p. 1457; Pye's Surgical Handicraft, p. 7262

Post-operative Care After Secondary Suturing

• Aggressive nutritional support: high-protein diet, multivitamins; treat any underlying malnutrition
• Treat sepsis and any causative condition aggressively
• Manage factors that raise intra-abdominal pressure (ileus, COPD, ascites)
• Remove retention sutures only after the skin wound has been well healed for at least 3-4 weeks (typically 6-8 weeks total)

Alternatives When Primary Re-closure is Not Feasible

• Vacuum-assisted closure (VAC/NPWT): Open abdomen management with negative pressure wound therapy, sometimes combined with mesh-mediated fascial traction
• Planned ventral hernia: Skin closure only, with later elective repair
• Biological or synthetic mesh bridging: For patients with true loss of abdominal domain

Retention Suturing for Burst Abdomen

A Detailed Seminar Guide

1. What is Burst Abdomen (Wound Dehiscence)?

Classic Presentation

• Pink/serosanguinous wound discharge (often precedes burst)
• Patient reports a "popping" or "giving way" sensation during coughing or straining
• Visible wound opening, with or without evisceration of bowel/omentum

2. Clinical Photo: Complete Fascial Dehiscence

Complete fascial dehiscence after failure of primary abdominal closure - Current Surgical Therapy, 14th ed.

3. Risk Factors (for Seminar Summary Box)

Key mechanism: Increased collagenolytic activity (collagenase) within 0.5-0.75 cm of the wound edge is the main biochemical driver of suture cut-through.

4. What Are Retention Sutures?

Their Purpose (Critical Point for Seminar)

Retention sutures do NOT prevent fascial dehiscence - they prevent evisceration if the fascial closure fails. This is a frequently tested distinction.

• Current Surgical Therapy, 14th ed., p. 1422; Sabiston Textbook of Surgery, p. 2059

5. Types of Retention Sutures

A. External (Full-Thickness / Through-and-Through)

• Pass through: skin → subcutaneous fat → anterior fascia → muscle → posterior fascia → peritoneum
• Tied over a bolster (IV tubing / red rubber catheter) on the skin surface
• Visible on the surface as a "ladder" or "railroad track" pattern
• More secure but creates an unsightly scar and more skin complications

B. Internal (Extraperitoneal / Subfascial)

• Pass through all layers except the skin - lie in the preperitoneal/extraperitoneal space
• Avoids the cheese-wire effect on bowel loops
• Does not produce a surface ladder-pattern scar
• Cannot be released without reopening the wound

Various abdominal closure techniques: CDLC, Small Bites, Retention sutures (shown top-right), Smead-Jones, Hughes suture, and others.

6. Layers of the Abdominal Wall (Anatomy Refresher for Seminar)

Cross-section showing peritoneum, posterior fascia, rectus muscle, anterior fascia, and fat - the layers traversed by a full-thickness retention suture.

7. Layered Closure Overview (Context)

Abdominal wall closure layers: (A) Peritoneum, (B) Muscle, (C) Anterior fascia, (D) Subcutaneous tissue, (E) Skin, (F) With external retention sutures visible.

8. Step-by-Step Surgical Technique

Step 1 - Anaesthesia and Theatre Setup

• General anaesthesia with full muscle relaxation is mandatory
• Cannot be done under local/spinal - adequate relaxation is needed to approximate retracted fascia
• Broad-spectrum antibiotics pre-operatively
• Position: supine; full sterile prep and draping

Step 2 - Wound Exploration and Debridement

• Open the entire skin incision
• Trace the fascial suture back to intact fascia at both ends
• Debride all non-viable tissue at fascial edges - fresh, bleeding fascia must be exposed for a good bite
• Identify and remove any infected or necrotic material

Step 3 - Abdominal Exploration and Lavage

• If purulent, feculent, or bilious discharge is present: find and manage the source (anastomotic leak, perforation)
• Gentle downward pressure on bowel for limited visualisation if no discharge
• Lavage with warm normal saline (2-3 litres minimum)
• Limit unnecessary exploration to avoid iatrogenic bowel injury

Step 4 - Place Retention Sutures FIRST (Before Tying)

• 3-4 cm lateral to the fascial edge (some texts say 4-6 cm)
• 3-5 cm apart from each other along the wound length
• Full thickness: skin → subcutaneous fat → anterior sheath → rectus → posterior sheath → peritoneum
• Pass extraperitoneally wherever possible to avoid bowel contact

• Always keep the needle in direct visual field
• Use a malleable retractor to depress and protect underlying bowel during each pass
• Never pass the needle blindly

Step 5 - Fascial Closure (Mass Closure Technique)

• Close the fascia using a non-absorbable suture (e.g., No. 1 Prolene or PDS)
• Large, consistent bites of fascia (1-2 cm from edge, 1 cm apart - Jenkins' rule: suture length = 4× wound length)
• Mass closure (single layer, all fascial layers together) is preferred over layered closure
• Interrupted sutures are preferred over continuous in high-risk/contaminated cases - single stitch failure then cannot open the whole wound
• Peritoneum closure is NOT required and does NOT contribute to wound strength
• Begin at each end and meet in the middle

Step 6 - Tie the Retention Sutures Over a Bolster

• Cut sterile IV tubing (or red rubber catheter, or commercial bolster) into 4-5 cm strips
• Thread each retention suture through a strip of IV tubing
• Tie down firmly but without excessive tension - overtightening causes pressure necrosis and skin cut-through
• The bolster distributes force over a wide area of skin, preventing the "cheese wire" effect

Step 7 - Skin Closure

• Close skin loosely (loosely approximated - not tight)
• In frankly infected wounds: leave skin open and pack with antiseptic/saline-soaked gauze
• In contaminated-but-not-infected wounds: loose interrupted skin sutures or clips
• Consider a superficial wound drain in the subcutaneous space

9. Retention Suture Configurations (Cross-Sectional Diagrams)

(A) Simple interrupted retention suture through all layers. (B) Smead-Jones far-near-near-far. (C/D) Modified mattress configurations with subfascial component.

10. Post-operative Management

11. Complications of Retention Sutures

Key evidence (PMC6114125): Retention sutures reduce abdominal wall compliance, which can paradoxically raise intra-abdominal pressure (IAH occurs in ~12% of post-operative patients). They should be used cautiously in patients already at risk of raised IAP.

12. Prophylactic vs Therapeutic Use

13. Alternatives When Primary Re-closure is Not Possible

1. VAC/NPWT (Vacuum-Assisted Closure) - negative pressure wound therapy; promotes granulation; used for open abdomen management
2. Dynamic retention sutures (ABRA system) - sequential tightening devices that gradually approximate fascial edges over days
3. Planned ventral hernia - skin closure only, elective mesh repair later
4. Mesh bridging - biological or synthetic mesh when primary fascial approximation is impossible

14. Video Resources for Your Seminar

1. Retention sutures (mass closure) - Burst abdomen - covers retention sutures specifically for burst abdomen with rectus anatomy
2. Secondary Suturing for Burst Abdomen - Dr Jay Mehta - a trained cancer surgeon demonstrating the actual operative technique (most directly relevant for your seminar)
3. How to Apply Retention Sutures - Dr Tayyab Riaz - focused tutorial on retention suture placement technique
4. Abdominal Wall Closure - Prof. Chintamani - describes mass closure / Jenkins rule in detail
5. Mass / Tension Closure for Midline Laparotomy - demonstrates tension suture technique for midline laparotomy closure

15. Summary Box for Seminar Slide

Secondary Retention Suturing - Key Points

• Burst abdomen = surgical emergency; return to theatre under GA
• Retention sutures = full-thickness, heavy nylon (No. 1-2), 3-4 cm from edge, 3-5 cm apart
• Placed BEFORE tying; fascia closed FIRST with mass closure
• Tied over bolster (IV tubing) - never overtight
• They prevent evisceration, NOT dehiscence
• Leave in situ 6-8 weeks; remove after skin fully healed
• Monitor for IAP rise, pressure necrosis, and pain post-op
• Aggressive nutrition is as important as the suture technique

Burst Abdomen Retention Suturing

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