Egyptian Journal of Surgery Vol 28, No 3, July, 2009

ORIGINAL ARTICLE
BURST ABDOMEN: IS IT A PREVENTABLE COMPLICATION?
By
Wael Lotfy
General Surgery Department Faculty of Medicine Zagazig University

Email: [email protected]

Aim: to evaluate the effectiveness of supporting plastic tubes technique (new technique) in prophylaxis against burst
abdomen.
Methods: a total of 140 patients, 76 patients underwent emergency laparotomy and 64 underwent elective laparotomy
through midline laparotomy through a midline vertical incision. They were randomized to either mass closure alone or
mass closure plus supporting plastic tube technique. All patients were consented.
Results: There were 3 bursts out of 70 patients in the mass closure alone group (4.28% risk). while none of the patients in
the supporting tubes group underwent burst (0% risk).However, there were two cases in the later group developed
incisional hernia in the late post-operative period.
Conclusion: supporting plastic tubes method is a good prophylactic method against burst abdomen, not for incisional
hernia, and it is advised to be used in all risky patients.
Keywords: Wound dehiscence, supporting plastic tubes, laparotomy.

INTRODUCTION suture length: wound length ratio of 4:1. Continuous

running sutures ensure that tension is distributed evenly
Wound dehiscence / burst abdomen is a very serious along the length of the wound.(11-13)
postoperative complication associated with high
morbidity and mortality. It has a significant impact on Many trials and new techniques were developed to
health care cost both for the patient and the hospital.(1) prevent or at least reduce the risk of wound
dehiscence(8,9,14,15) but burst abdomen remains a
The incidence of wound dehiscence /burst abdomen formidable morbidity.
varies from center to another worldwide. While it is
recorded to be 1-3 % in most centers,(1-4) some centers in Supporting plastic tubes is a new technique developed
India recorded incidence of burst abdomen as high as by the author to circumvent the problem of burst
10-30%.(5-7) abdomen. Its practical usefulness was tested in
randomized control trial of wound closure of midline
Many risk factors were incriminated in causation of burst laparatomy.
abdomen including malnutrition, anaemia,
hypo-proteinaemia, pre and post operative prolonged PATIENTS AND METHODS
steroid therapy, peritonitis, malignancy, jaundice,
uraemia prolonged post operative abdominal distension A total of 140 patients presented to our department of
or cough.(2) general surgery Zagazig University hospitals from Mars
2005 to Mars 2009 were enrolled in this study. 76 patients
Wound dehiscence is related to the technique of closure were admitted to the causality unit for emergency
of abdomen and the sutures used. Numerous studies laparotomy and 64 patients were admitted to the in-
have been conducted evaluating a bewildering variety of patient surgical wards for elective laparotomy.
closure techniques and suture materials.(8-10)
Inclusion criteria: All patients prepared to a midline
The current opinion in the west centers for closure a laparotomy and have more than one risk factor for
midline incision is toward running mass closure with wound dehiscence (mentioned in Table 1).
non absorbable or slowly absorbable suture using a

128 Egyptian Journal of Surgery

Exclusion criteria: pulling it from the other side.
1. Patients under 18 years of age.
All patients were followed up for 4 weeks. Burst
2. Patients who had incisional hernia or burst abdomen is diagnosed when intestine, omentum or other
abdomen at presentation. viscera are seen through the wound.
3. Patients who died shortly (within 2 weeks) after
surgery. Statistical analysis: The risk (cumulative incidence) of
All patients were explored through a midline laparotomy burst was calculated as number of burst in the
and each patient was serially numbered in the study and group/total number of patient in that group.
the patients were randomized into two equal groups.
Group І (patients with odd numbers) were closed using Also, Statistical analysis of the distribution of the risk
the classic mass closure running sutures. Group П factors between the two groups was performed to ensure
(patients with even numbers) were closed using the adequate randomization.
classic mass closure as above plus supporting plastic RESULTS
tubes (see below).
This study included a total 140 patients who underwent
Patients in group П were given explanation of the new midline laparotomy 76 patients for emergency
technique and signed a written consent form. All laparotomy and 64 patients for elective laparotomy. they
patients in this study were operated and closed by the were 103 males (73.64%) and 37 female (26.4%) the age of
author. patients range from 27 to 82 years with average age 43.12
years and a median age of 42 and a standard
Group І: Running continuous mass closure was deviation of 15.02. two patients died in the early
performed using No 2 vicryl (polyglycolic acid Ethicon) postoperative period and were excluded from the study
sutures. Sutures bites were placed 1.5-2 cm from the edge Table 2.
of linea alba and spaced about 1 cm from each other. The
edges were gently approximated without strangulation The patients were equally randomized into two groups
keeping the suture length: wound length ratio of about (group I) 70 patients were subjected to continuous mass
4:1 closure alone method and (group II) 70 patients were
subjected to supporting plastic tube method plus mass
Group П: Supporting plastic tubes technique using closure. The average age of patients in group I was 42.68
nasogasteric tubes No 10 Fr. which were mounted on the years. The average age of patients in group II was 43.56
metal trocars of the suction drains of No 12 Fr. years Table 2.
simulating a needle and thread, the trocar is introduced
into the abdominal wall at one side just lateral to the Statistical analysis of the risk factors revealed no
linea semilunaris outside-in through all layers, then the significant difference between the two groups that
trocar is introduced into the contra-lateral side from confirms adequate randomization of the patients into
inside-out to be extruded just lateral to linea semilunaris two groups Table 3.
in a point opposite the introduction one. So, we actually
take a through and through suture using plastic tube There were 3 bursts out of 70 patients 4.28%) in the mass
instead of the thread. The tubes are then cut with closure alone group while none of the patients in the
suitable lengths sufficient for closure and initially left mass closure plus supporting tubes underwent burst
untied. Then the process is repeated every 10 cm of the (0% risk).
wound (Fig. 1).
Out of the 76 emergency cases, two developed burst
All tubes are cut with suitable lengths and left untied abdomen (2.63 % risk) while only one burst is recorded
until the wound is classically closed with mass closure among the 64 elective cases (1.56 % risk).
running continuous sutures up to skin closure (Fig. 2).
Complications recorded with the technique
Care should be taken to stretch the greater omentum
1. Bad cosmoses of the wound due to scaring of the
under the plastic tubes crossing the wound not to
puncture sites and pressure of the tubes on skin
entangle viscera during tying of the plastic tubes. Also
before suturing the tube, the two ends of the tube are 2. Localized haematoma or ecchymosis at the trocar
grasped, pulled up and moved from side to side to site occurred in three cases
ensure that it is free from catching viscera in-between. 3. Trocar site malignant recurrence occurred in one
case with intra-abdominal disseminated colonic
Then they are tied by crossing their ends gently enough carcinoma
to approximate both sides of the wound without 4. Leak of postoperative ascites from the trocar site
strangulation and sutured side by side using silk suture after removal of the tubes occurred in two cases and
No 2/0 silk suture to hold them in place (Figs. 3,4). treated by control of ascites together with simple
The tubes are left for 15 days which is maximum risky suturing of the hole and the leak stopped
period of burst abdomen. They are removed like the 5. Incisional hernia at the laparotomy wound occurred
traditional sutures by cutting the tube on one side and in two cases about two months postoperatively.

EJS, Vol 28, No 3, July, 2009 129

 Table 1. Definition of risk factors for burst abdomen.

Risk factor Definition of its presence

1- Elderly Age over 60 years

2-Diabetes Fasting blood sugar >140 mg/dl or random blood sugar >200 mg/dl.
3-Malnutrition Weight <70 % of expected weight for height.
4-Obesity Body mass index >30
5-Anaemia Haemoglobin less than 10 gm %
6- Uraemia Blood urea > 50 mg /dl
7-Jaundice Serum bilirubin > 2 mg %
8-Hypoalbuminaemia Serum albumin < 3 mg %
9-Intra-abdominal malignancy detected during operative exploration
10- Intra-abdominal sepsis Presence of pus in the peritoneal cavity

Table 2. The results between the two groups.

Group 1 Group II
Total
Mass closure alone Mass closure + supporting plastic tubes
No of patient 70 70 140

Sex:
Male 46 57 103
Female 24 13 37

Average age (in years) 42.68 43.56 43.12

Indication of laparotomy:
Emergency 33 43 76
Elective 37 27 64

No of bursts 3 (Risk 4.28%) 0 (Risk is 0 %)

Table 3. Incidence of risk factors among the patients.

No of patients with RF No of patients without RF

Risk factor (RF) Χ2 P
Group I Group II Total Group I Group II Total
1- Elderly 41 37 78 29 33 62 0.46 0.49

2-Diabetes 32 31 63 38 39 77 0.03 0.86

3-Malnutrition 16 8 24 54 62 116 3.22 0.07

4-Morbid obesity 25 23 48 45 47 92 0.13 0.72

5-Anaemia 46 47 93 24 23 47 0.03 0.85

6- Uraemia 1 5 6 69 65 134 2.79 0.09

7- Jaundice 11 7 18 59 63 122 1.02 0.31

8- Hypoalbuminaemia 15 20 35 55 50 105 0.95 0.32

9-Intra-abdominal malignancy 24 19 43 47 51 97 0.74 0.39

10- Intra-abdominal sepsis 20 13 33 50 57 107 1.94 0.16

130 Egyptian Journal of Surgery

 Fig 3.
Fig 1.

Fig 2. Fig 4.

DISCUSSION Sirvasta A et. al. in 2004(8) where they reported three

bursts out of 98 patients (3.06% incidence) with their
Burst abdomen remains a terrifying postoperative event technique while the risk of burst was eliminated by our
that carries high morbidity and mortality for laparotomy new technique.
patients. This fact makes prevention of burst abdomen a
holly goal, for which every effort should be done. The lower incidence of burst abdomen in the elective
cases (1.56%) compared to 2.63 % in the emergency cases
The idea of this technique is that by approximating the can be explained by that, in elective cases we have time
two recti without strangulating the tissue, we release to correct or control their risk factors such as anaemia,
tension over the midline sutures and giving the wound a diabetes malnutrition hypo-proteinaemia….etc. Also
better chance to heal with no tension or cutting through. they have no abdominal sepsis. Moreover increased
intra-abdominal pressure is much less recorded in the
In this research, patients whose laparotomy incisions
elective cases
were closed with mass closure plus supporting plastic
tubes never developed wound dehiscence in comparison Regarding complications recorded with the technique,
to three bursts in the mass closure alone group. So, this most of them can be avoided by proper application of the
technique appears to be totally protective against burst technique, strict selection of the trocar size and sites and
abdomen. by avoiding much tension on tying the plastic tubes But
because these complications, this technique is not
In comparison to the X- sutures technique developed by
recommended for routine use and should be restricted to

EJS, Vol 28, No 3, July, 2009 131

patients with high risk for burst abdomen. 6. Singh A, Singh S, Dhaliwal US, Singh S. Technique of
abdominal wall closure: a comparative study. Ind J Surg
Regarding the two cases of incisional hernia in the 1981;43:785-90.
research, they developed due to chronic yielding of the
scar in front of intra abdominal pressure not on the top 7. Choudhary SK, Choudhary SD, Mass closure versus layer
closure of abdominal wound: a prospective clinical study.
of partial burst because:
J Indian Med Assoc. 1994;92:229-32.
1- They developed at two and three months
post-operatively. 8. Anurag Sirvastava, Sapandeep Roy; K.B. Sahay, Vathaluru
seenu, Arvind Kumar, Sunil Chumber, et.al Prevention of
2- No sero-sanguinous discharge (warning sign of burst abdominal wound by a new technique: A
burst) was noted in these two cases in the early post randomized trial comparing continuous versus
operative period and the patient recovered very well interrupted X- suture Indian J Surg. 2004;66:19-27.
and their wounds healed perfectly.
9. Trimbos JB, Smit IB, Holm JP, Hermans J. A randomized
It is worth to mention that the supporting tubes method clinical trial comparing two methods of fascia closure
is prophylactic only for burst abdomen not for incisional following midline laparotomy. Arch Surg.
1992;127:1232-4.
hernia.
10. Grantcharov TP, Rosenberg J. Vertical compared with
In conclusion supporting plastic tubes method provides
transverse incisions in abdominal surgery. Eur J Surg.
good prophylaxis against burst abdomen after midline 2001;167:260-7.
laparotomy and it is advised to be used in all cases with
high risk for burst abdomen. 11. Rucinski j, Margolis M, Panagopoulos G, Wise L. closure
of the abdominal midline fascia: Metanalysis delineates
Further studies are recommended on a large scale of the optimal technique Am J surg. 2001;67:421-6.
patients to evaluate the effectiveness of the technique or
possible modifications of it. Also I hope that a special 12. Van't Riet M, Steyerberg E W, Nellensteyn j,Bonjer Hj,
manufactured set will be available to apply this Jeekel J. Meta-analysis of techniques for closure of midline
technique instead of using naso-gastric tubes and non abdominal incisions Br. J surg. 2002;89:1350-6.
specific trocar.
13. Colombo M, Maggioni A, Pama G, Scalambrinio S, Milani,
A randomized comparison of continuous versus
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