Surgical wound dehiscence is one of the most dreaded and costly of surgical complications. It is disturbing and frightening for the patient, who begins to mistrust and/or doubt the skill of the surgeon, for the physician who must continue to manage the doctor patient relationship and the challenging wound, and for the payor who now bears significant cost for extended wound care and/or repeat surgery. The spectrum of dehiscence is described by the World Union of Wound Healing Societies (WUWHS) Consensus Document on Surgical Wound Dehiscence (SWD) published in 2018, from mild (superficial skin separation) to severe (fascial dehiscence, exposure of viscera). Recent advances in incision management strategies mostly involve negative pressure wound therapy (NPWT). NPWT has achieved evidence-based reduction of surgical site infection (SSI) but has not clearly achieved reduction of SWD.
In addition, sometimes treatment of SWD is passive or repetitive. “Well, it fell apart like we thought it would, so it will be a long road to healing”. Or,” It fell apart, I’ll suture it again like I did before, hey, it fell apart again! “. We need better prevention and prompt effective treatment of SWD. So how can we move the needle in direction of better outcomes for our patients and reduce SWD and improve its’ treatment?
The Consensus Document outlines the 3 causes of SWD into 3 categories:
- Technical issues with the closure of the incision
- Mechanical stress on the incision postop
- Disrupted healing from comorbidities/risk factors
Tecnical - retrospective study of 363 patients with SWD following laparotomy attributed 8% of SWD to broken sutures and 4% to loose knots. These are surgeon-controlled factors.
Mechanical Stress - can disrupt either suture or tissue. Mechanical stress can result from excessive forced tension during wound closure (surgeon) or swelling of the tissues (patient) below the incision due to edema, hematoma, seroma or abscess, or physical force from a cough or motion.
Disrupted Healing - multiple comorbidities are known to impair normal healing including prior radiation, diabetes, immune drugs, poor perfusion and other.
We try to control all perioperative factors to achieve best outcomes. We have indirect control on mechanical stress and disrupted healing factors. Of course, we try to reduce edema, achieve hemostasis with minimal trauma to the tissues, splint or bind operated areas to reduce motion, and try to manage medical comorbidities in the best ways possible. But the one area we can directly control is technical.
SUTUREGARD Medical offers device based technical solutions for the prevention and management of SWD.
PREVENTION OF SWD: Our devices can either stretch or support the periwound skin to reduce risk. If the surgeon recognizes high tension areas on a closure intraoperatively, 15-30 minutes of SUTUREGARD® ISR (intraoperative skin relaxation) Retention Suture Device use can stretch/relax the skin and reduce wound closure tension. Alternatively, if the surgeon judges that high tension will persist after a closure, they may elect to use the HEMIGARD® Adhesive Retention Suture Device to support that closure. Or their experience may tell them, these are poor quality tissues. In both instances, the HEMIGARD®, used intraoperatively, can create a low tension healing environment and support the postoperative closure, staying in place for 10-14 days during the crucial early healing period when most SWD occurs.
MANAGEMENT OF SWD: If SWD is recognized early by increasing drainage or other symptoms, a return to the OR is often needed. An old adage in surgery states that “if plan A fails, do not make plan B identical to plan A”. SUTUREGARD devices are new tools in the surgeons’ kit, and can offer a truly different “plan B”, rather than just repeating the same technical closure that failed prior. Of course, the underlying issues that cause mechanical stress and disrupted healing must still be managed, but SUTUREGARD devices offer a technical advantage for a post SWD reclosure not presently embodied by existing wound closure materials. These devices allow a surgeon to be proactive in the management of SWD.
We offer the next step after NPWT in incision management, a new set of tools that surgeons can use based on their unique ability to judge wound closure tension, tissue quality and overall risk of SWD. Reducing SWD is the next step in incision management, and improving surgical outcomes. Let us help you experience these better outcomes with your patients.
Dan Ladizinsky, MD, Retired Plastic Surgeon of 30 years