Fascial Dehiscence

What is Fascial Dehiscence?

Fascial dehiscence is a serious complication that can occur after an open surgery. This issue can often require additional operations. It has a considerable impact on a patient’s recovery after surgery, and it can increase the risk of death. Its early detection and treatment are crucial to prevent complications that may appear soon or much later, like chronic wounds, hernias, or even internal organs bulging out (called evisceration).

Improving factors related to a patient’s overall health and fine-tuning surgical methods can help reduce the chances of fascial dehiscence happening. As a result, it can save the patient from the related health problems and the need for extra surgeries.

What Causes Fascial Dehiscence?

Things like injuries, infections after surgery, bad nutrition, other health issues (like diabetes, or long-term use of steroids), and long stays in intensive care can all increase the risk of the layers of tissue that keep your organs in place splitting apart. This is known as fascial dehiscence.

If this happens, it puts you at risk of developing hernias, which are bulges where an organ pushes through the muscle or tissue holding it in place. Hernias can come with their own problems, both short-term and long-term. These might include blockages or the tissue around the hernia becoming too tight and stopping blood flow, called strangulation.

Additionally, if the organs start coming out through the opening in your skin, this is a serious medical emergency. This is called evisceration and you would need immediate surgery.

Risk Factors and Frequency for Fascial Dehiscence

Fascial dehiscence, a complication of both planned and emergency surgeries, has varying occurrence rates. The complication can depend on the type of surgery, with more serious ones like trauma procedures showing higher rates. However, all types of open surgeries carry the risk of this complication, which can result in longer hospital stays, increased costs, and the need for further treatment.

• Fascial dehiscence is a possible complication of both planned and emergency surgeries.
• The rates for this complication after planned surgeries are between 1 and 3%.
• This rate increases for emergency surgeries, rising to between 5 and 50%.
• In case of trauma-related surgeries, the rates range from 5 to 10%.
• Dangerous procedures like those for trauma or emergency general surgery, may have fascial dehiscence rates of 13 to 50%.
• Every year, around 2 million open operations are performed in the U.S, meaning a significant number of patients could experience complications due to fascial dehiscence.
• This can lead to increased costs, longer hospital stays, and the need for additional treatment.

Signs and Symptoms of Fascial Dehiscence

When diagnosing a medical condition, a comprehensive review of the patient’s overall health and medical history is necessary. This can be tricky for critically ill patients, especially those recently out of surgery. In these cases, reports from bedside nurses can be very helpful. Warning signs of a complication called fascial dehiscence, in which the layers of the abdomen separate after surgery, could include an increase in the flow of liquid from the wound or an unusual bulge on the belly.

Doctors may also ask the patient if they are experiencing any symptoms related to the function of the gastrointestinal system, such as vomiting, feeling nauseous, or having difficulties with going to the bathroom. The patient might describe a sensation akin to something being pulled or ripped, and this might happen during actions that puts strain on the body such as coughing or retching.

Understanding the patient’s surgical history especially recent ones, is crucial as this condition commonly occurs during the first couple of weeks after surgery. It’s also important to discuss the individual’s medical history, focusing on issues such as diabetes, long-term steroid use due to conditions like COPD or adrenal insufficiency, disorders affecting the connective tissue, and malnutrition. The doctor also needs to be informed about the patient’s smoking history and all the medications they are currently taking.

A detailed examination of the patient’s abdomen takes place next. The doctor will check the patient’s recent incision site for signs of infection, like inflammation or fluid coming from the wound. If there is fluid, its character can give cues about what is going on underneath; for instance, pus often suggests an infection in the surgical site. Clear or watery fluid could mean that a seroma (a pocket of plasmatic fluid) is there, or it could be a normal part of the healing process if the amount is small. The distinct “salmon-colored” fluid can be a cause of concern as it might suggest the layers of the patient’s belly are separating. To check for any abnormal growths or bulging, the doctor will touch and feel the abdomen gently; these could be an indicative of a seroma, an abscess, or a hernia.

Typically, the doctor will find some sort of surgical closure, like staples, sutures, or negative pressure wound therapy devices. Unless a surgeon is present or imaging is needed, it is not advisable to remove these before as it could cause the abdominal layers to separate further, needing urgent surgical intervention. In certain cases, the doctor might probe between these closures with sterile cotton swabs to see whether the wound is healing properly.

In some cases, a separation of the fascial layers of the abdomen might be already obvious or suspected. It might have been noticed during a dressing change, when patients have been left to heal naturally by having superficial tissues grow back on their own. A defect in the fascial layers might be seen directly, with or without visual of the loops in the bowel. A diagnosis may therefore already be clear in such situations. If portions of the bowel are seen to have moved into abnormal locations, it’s an emergency worth immediate attention by the surgeon.

Testing for Fascial Dehiscence

If you think you might have an issue with the healing of a recent surgical procedure, it’s very important to get in touch with the surgeon who performed the operation as soon as possible. If you’re feeling relatively steady and there aren’t any significant problems with your wound, you’ll need to have an imaging test taken. This will help your medical team see how large any potential issues with the wound might be. A CT scan of the abdomen and pelvis with contrast is an excellent way to get detailed images and can also help identify other possible issues like abscesses (a swollen area filled with pus) under your skin and anything abnormal about your internal organs, such as if they’re herniating, or poking through your surgical cut.

It’s important to note that the incision should not be opened, even if it seems like it will help. If surgeons open the wound, it can actually make the situation much worse and cause a medical emergency. Instead, the imaging scans can offer valuable information to your doctors and surgeons, allowing them to decide if they need to perform an elective or urgent operation to fix the issue.

Treatment Options for Fascial Dehiscence

If a patient has something called a fascial dehiscence, this means that the layers of the abdominal wall have separated. It’s something that would be closely monitored by a doctor since it could lead to internal organs, like the bowel spilling out from the abdominal cavity, a condition referred to as evisceration. If this happens, an emergency abdominal exploration would be necessary, where the doctor would quickly put the organs back where they belong and then close the abdominal cavity.

For some patients who have a fascial dehiscence but don’t have other complications, such as infections, their doctors might opt not to perform surgery. They would be closely watched to prevent evisceration and it’s possible they won’t need future repair of the defect. When it comes to making this decision, doctors consider each patient’s specific condition and risk factors. In some cases, the fascial defect could evolve into a controlled hernia, which can get fixed later on.

Surgery would be considered necessary if there’s evisceration, or any sign that the bowel is becoming strangulated or blocked, or if there might be an infection. During the operation, the surgeon would make sure to restore the herniated bowel back to the abdominal cavity, remove any infections, and if any part of the bowel is beyond repair (ischemic), it will be removed.

For healing the fascial dehiscence, several options are available. If the separation is small and the surrounding tissue (fascia) is healthy, the surgeon may just clean the area and stitch it closed. In some instances, a special net-style material or mesh is used to close the separation and this has been shown to improve outcomes and reduce recurrence. However, it’s important to note that using mesh might not be appropriate in all cases, like when infection is present. Large separations might require more complex methods, including those that gradually close the wound, or in severe cases, tissue from other parts of the body (biological graft) might be used, along with skin grafting.

Abdominal wall reconstruction methods, like component separation, might be effective for some large separations, but there’s caution against utilizing these in the early stages as they can potentially affect future reconstructive options, especially for patients with a high chance of formation of incisional hernia, which is another separation that could occur in the same area. It is generally advised to postpone the repair to a later date, after the patient has fully recovered from their original surgery.

For individuals who develop a hernia, the surgeons may choose to close it at a later time to prevent complications. A delay of about two to three months is usually given to allow for the area to heal from the initial procedure, and the patient’s overall health should be optimized. This simply means making sure the patient is as healthy as possible before going in for the next procedure. It’s also worth noting that there’s no significant difference in outcomes between using continuous or interrupted sutures or with the type of suture material used to close the wound.

While using mesh to repair hernias might have complications such as abscess formation, fistula, bowel obstruction, and bowel erosion, the considerably lower risk of hernia recurrence with mesh use seems to outweigh these potential risks. Both open and laparoscopic repairs are effective when using a mesh, in comparison to just stitching the abdominal wall layers together without mesh.

What else can Fascial Dehiscence be?

When a doctor is examining a healing surgical wound, there are several complications they need to consider, which include:

• Postoperative subcutaneous seroma: This is when there’s a pocket of clear fluid that can drain through the wound if it’s under pressure from straining or if it gets big enough.
• Surgical site infection with abscess formation: This is where bacteria enter the wound and cause an infection, resulting in a pocket of pus (abscess). This can also happen alongside fascial dehiscence (where the layers of the surgical wound separate), as infections can cause wound healing problems.
• Pre-existing hernias that were not treated during the original surgery: If the belly bulges away from the surgical wound, it might be because of a hernia (where part of your intestines or belly muscle pushes through a weak spot).

Knowing about these possible complications helps doctors decide what tests to do and treatments to consider.

What to expect with Fascial Dehiscence

Fascial dehiscence, which is a surgical complication where the layers of the abdominal wall separate after surgery, significantly contributes to the risk of a patient’s illness and even death. The rate of additional complications after dehiscence can reach up to 75%, and the death rate recorded in several studies varies between 15-50%.

This condition is associated with prolonged hospital stays ranging from 15 to 26 days, increased need for intensive care, and higher healthcare costs. Despite promptly recognizing and treating this issue, it often presents a considerable strain on a patient’s health and survival rate, regardless of when subsequent treatments occur. Hence, it’s a serious concern in post-abdominal surgery care.

Possible Complications When Diagnosed with Fascial Dehiscence

The occurrence of fascial dehiscence, which is a complication where the edges of a surgical wound in the abdomen do not fully heal, can significantly impact the patient’s health and can even lead to death. An ensuing infection is a concern as it may occur in around 10% of such cases. It may be necessary to consider cleaning out the abdomen surgically and allowing the skin and subcutaneous tissues (tissues beneath the skin) to heal naturally where immediate reoperation is required especially when the surgeon comes across highly contaminated or dead tissues.

There are several potential complications which include death, evisceration (the discharge of organs through a surgical incision), and associated infections. Other complications that might occur either in the short term or in the long term, include bowel herniation (protrusion of the intestine through the weak abdominal wall) and incisional hernias that can lead to bowel obstruction or strangulation. Any additional procedures to repair the hernia or defect, reduce or remove part of the intestines, and drain fluid collections can increase the risks associated with anesthetics, surgery, and hospitalization.

The risk factors for this condition can be both patient-related and technical in nature, and appropriate management of these factors can help improve patient outcomes. The issues associated with this condition, such as prolonged stay in the intensive care unit, hospital-acquired infections, physical deconditioning, and the need for rehabilitation care can greatly affect the length and quality of a patient’s life.

Here’s a simplified list of potential complications and issues:

• Death
• Evisceration (discharge of organs through a surgical incision)
• Associated infections
• Bowel herniation (protrusion of the intestine through the abdominal wall)
• Incisional hernias leading to bowel obstruction or strangulation
• Need for additional procedures
• Prolonged stay in the ICU
• Hospital-acquired infections
• Physical weakening or deconditioning
• Adhesive small bowel obstruction (blockage of the small intestine)
• Venous thromboembolic events (clots that can form in the veins and can be potentially dangerous)
• Need for short- or long-term rehab/nursing care

Preventing Fascial Dehiscence

There are many factors that we can change that impact the success of abdominal surgery, and to prevent complications related to the wound healing, especially when dealing with the abdominal wall separating or tearing. If you’re choosing to have a surgery, quitting smoking beforehand is usually the best course of action. It’s also important for patients to control their blood sugar levels before, during and after the surgery. Doctors usually recommend to avoid or minimize steroid use if you can; however, this might not be possible for patients who have been taking steroids for a long time.

Patients might require nutritional support if there is a risk of malnutrition before surgery. Any buildup of gas or fluid in the stomach or bowels, or urinary retention, should be managed with methods to relieve the pressure. Doctors also recommend measures to prevent the lung from collapsing and to ensure there’s enough oxygen in the body.

If your abdomen has to be left open or were in a damage-control situation, doctors recommend that it should be closed as soon as safely possible. More than four operations before closing has been associated with a significant increase in the rates of the abdomen wall not closing properly. Delaying the closure of the abdomen can result in swelling of the intestine, which increases pressure upon closing of the abdominal wall. This can lead to an inability for the edges of the abdominal wall to be brought close together without excessive tension, thus increasing the risk for breakdown of the closed area. When this happens, different strategies are used to aid in closing, including injecting a drug that weakens muscles, closing progressively with special devices, separating the parts correctly, increasing the air pressure in the abdomen gradually, and using special mesh.

It seems that the type of incision used in the surgery could be a risk factor for the development of wound separation. Data shows that horizontal or slanted incisions may have fewer complications than vertical ones, but this is not definitive. The type of incision suitable for the planned surgery often dictates the decision regarding incision placement and orientation.

For all abdominal wall closures, it’s important how the surgery is done. Care should be taken to bring the edges of the abdominal wall closer together without choking tissue. The stitches should be well tied. It has been found that single filament stitches have a lower chance of wound separating compared to multiple filament stitches. It doesn’t seem to make a difference if the stitches used are the type that gets absorbed by the body or not, or the way in which the stitches are done. Some evidence suggests a technique of small stitches of 5-8 mm placed every 5 mm may reduce complications. Studies have found that the internal layer of the abdomen does not seem to affect the chances of the wound separating. Having a ratio of 4:1 of stitch length to wound length when using a continuous stitch seems to reduce the chance of wound separation. While drains don’t seem to prevent wound separation, they should not be placed in the middle of the incision as it seems to increase the chance of problems.

The use of extra reinforcement stitches has been a talked-about topic in surgery. The old belief is that these stitches prevent the guts from coming out but do not serve to guard against the wound separating. However, a recent small study contradicts this, showing a decrease in wound separating in the group with extra stitches. Ultimately, the use of these stitches is up to the surgeon, and is probably only beneficial in patients at high risk of wound complications.

It’s important for patients to be educated about how to take care of their wound and what warning signs to look for. Many surgeons will ask patients to limit certain activities after abdominal surgery to prevent the wound from separating. These restrictions differ in length depending on the surgeon and procedure. Even though there’s not strong evidence to support these suggestions, as usual daily activities may create equal or higher pressures inside the abdomen, it might be a good idea to tell patients to avoid straining, heavy lifting, and activities that cause pain in the incision area for several weeks after surgery. Patients should also be told to look out for features that could mean complications are developing, such as increasing wound drainage, new bulging in the wound area, or signs of an infection in the wound. If they catch these early and let their surgeon know, they might be able to prevent more serious wound problems from developing later.