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11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
113
Therefore, together with future studies, our work
may contribute to the denition of early intervention [26, 35].
Summary
Early and aggressive emergency debridement of
necrotic and poorly perfused tissue (and all tissues that can be easily lifted off the fascia with
gentle pressure) removes the source of infection
and toxins, improves the penetration of antibiotic
therapy, and is a life-saving treatment [15–17].
Be sure to obtain gram stains and cultures from
the wound. Early surgical treatment is essential
and may minimize tissue loss and reduce the
need for extremity amputation; however, there
will still likely be a large area that needs covering
[15, 16]. After initial debridement, monitor the
wound every 24–48 hours, and if there is concern
about the tissue viability, the patient should be
returned to the operating room promptly for additional surgical debridement, necrosectomy, and
fasciotomy in cases presenting with the compartment syndrome [16, 17]. Enteral nutritional feedings should be initiated as soon as possible to
offset malnutrition, but parenteral nutrition support should be undertaken if more aggressive
therapy is warranted after multiple debridements.
If available, hyperbaric oxygen may be of benet
to a hemodynamically stable patient with certain
infections, particularly Clostridium species;
however, the evidence regarding the benet for
its use in non-clostridial infections is weak [15].
Postoperative Enterotomy Repair
andAnastomotic Leaks
Patient # 3
A 73-year-old female with history of multiple previous intra-abdominal surgeries and major
comorbidities undergoes laparoscopic exploration and partial laparoscopic lysis of adhesion
and repair of one small recognized enterotomy.
Postoperative day 5 she develops full-blown septic shock, and an emergent re-exploration reveals
a leak at the enterotomy site. She undergoes damage control surgery (DCS) and primary repair of
the leak. A few days later, she is taken back for
re-exploration and drainage of the leak site, but
you are unable to perform resection and anastomosis due to inammation and cocoon abdomen.
She left the hospital with a small manageable stula a couple of months later but continued to
have a persistent (Fig. 11.4a) drainage and multiple visits to various emergency departments,
always triggering work-up including CT scans.
ab
Fig. 11.4 (a) Persistent small stula; (b) resected. (Courtesy of Dr. Lati)
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T. Rosing and R. Lati
She was taken back to the operating room for
nal resection of the stula and of the anastomosis (Fig. 11.4b).
Patient # 4
A 62-year-old underwent post-multiple abdominal explorations, damage control surgery, direct
peritoneal resuscitation, and skin closure and
underwent ileostomy take-down, small bowel stapler anastomosis, and complex abdominal wall
reconstruction (CAWR) with biologic.
Postoperative day # 5, while clinically was doing
excellent, his drain output placed over the fascia
changed to bilious. Emergency CT scan revealed
a small anastomotic leak. On immediate reexploratory laparotomy, a pinpoint 3 mm leak
was identied, anastomosis was resected, and a
handsewn new anastomosis was performed.
CAWR was redone, and biologic was not removed
(Figs. 11.2 and 11.5).
One of the most dreaded complications of
general surgery is the anastomotic leak following
small or large bowl resection. These postoperative anastomotic leaks are serious complications
of colorectal surgery, and while their incidence is
reported to be below 20%, their associated mortality can be as high as 39% [35, 36]. Advanced
tumor stage, distal site (particularly with rectal
tumors), and need for postoperative blood transfusion have been independently associated with
increased rates of anastomotic disruption [35],
and the rates of anastomotic dehiscence are simi-
Fig. 11.5 Patient on Fig.11.2, nal re-reconstruction of
abdominal wall, without the need to remove the biologic
mesh. (Courtesy of Dr. Lati)
lar between open versus laparoscopic techniques
[36]. Those leaks that are diagnosed through
imaging, without signs or symptoms, are usually
considered subclinical, whereas clinical leaks
present with signs of peritonitis and/or septicemia [37], which represent a major surgical challenge often resulting in sepsis, reoperation, and
increased length of hospital stay [36–39].
The decision on how to approach this potentially catastrophic complication is not entirely
straightforward. For patients with previous
surgeries and intestinal resection and/or obese
patients, an anastomotic leak may be lethal if not
recognized immediately. Patients with intraperitoneal leaks with clinical generalized peritonitis
or high-grade sepsis require immediate surgical
intervention after receiving appropriate resuscitation [37]. If evidence of ischemia at the site of the
anastomosis is recognized intraoperatively, the
anastomosis should be redone immediately
(Fig.11.2) and require redo of the anastomosis.
When identied postoperatively with signicant
peritoneal contamination, or if the anastomotic
defect is large, the patient should undergo a
resection of the anastomosis with the formation
of an end stoma [37]. If the leak is at the sigmoid
colon or rectum, a Hartmann’s procedure may
minimize the possibility of further abdominal
catastrophe. Some surgeons may instead opt to
perform a reanastomosis with a proximal section
of bowel, but this should only be attempted in
those patients who are not septic, well-nourished,
and do not suffer from inammatory bowel disease. In this situation, our preference is to divert
the patient, either with an end stoma or with a
loop diversion. Regardless of the technique, it is
important to ensure that both bowel ends allow
for a tension-free anastomosis. While others suggest the use of drains [37], this is not our
practice.
If the intraperitoneal leakage is instead accompanied with localized peritonitis or abscess, a
diagnostic imaging work-up using a triple-phase
computerized tomography (CT) scan of the abdomen and pelvis should be performed and appears
to be far more helpful than contrast enema in
diagnosing a leak [38]. If a large abscess or multiple abscesses are noted, then the patient should
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
be managed surgically as described before if the
site of the abscess is inaccessible for draining.
However, if the observed abscess is small
(<3cm), broad-spectrum intravenous antibiotics
are recommended instead [37]. Distinguishing an
anastomotic leak from a postoperative abscess
can be difcult [38]. If the patient has an extraperitoneal leak but is experiencing generalized
sepsis, they should be managed in a similar way
to those with intraperitoneal leaks.
The basic principles of patient management
are similar to stula management for the most
part. At times, the surgeon may get “too close” to
the patient and family over the long course of
their care, and it may be benecial to have a partner to look after the patient for a while. This is
not an abandonment of the patient but simply one
taking a “break” to gain some perspective and
Fig. 11.6 Neglected bowel ischemia, not developed full
blown gangrene, secondary to a pelvic adhesion. (Courtesy
of Dr. Lati)
later approach the case more objectively to prevent a potentially catastrophic event.
plications and mortality around 60% [39].
Patients are typically elderly, with clinical histories consisting of atrial brillation, recent myo-
Intestinal Ischemia
cardial infarction, congestive heart failure (CHF),
or other risks for superior mesenteric artery
Patient # 5
A 76-year-old female with long-standing recurrent abdominal pain, with multiple trips to the
emergency department, previous abdominoplasty, and hysterectomy, presents with worsening abdominal pain. A CT scan demonstrated a
long, enlarged, and fecalized loop of small bowel
in the pelvis and part of her bladder in the inguinal hernia, worsening kidney function, and severe
acidosis. Exploratory laparotomy revealed a
50cm gangrenous segment of small bowel secondary to a single band of adhesion in the pelvis
(Fig. 11.6). She underwent damage control surgery and resuscitation for 36 hours and subsequently, primarily abdominal closure. She
recovered nicely but was sent to a rehab center.
Every general surgeon has had a memorable
case of intestinal ischemia, because the surgeon
either missed the diagnosis altogether or simply
intervened too late (Fig. 11.6). Intestinal ischemia, due to an obstruction secondary to adhesions, but particularly major acute mesenteric
ischemia (AMI), is a complex problem commonly faced by general surgeons, with high com-
(SMA) embolism [40]. There are a number of
underlying causes for AMI, but arterial thrombosis is the most common pathophysiology,
accounting for about half of the cases [40]; other
causes include arterial or venous thrombosis and
nonobstructive causes (such as systemic coagulation disorders), leading to intestinal hypoxia, irreversible bowel damage, and potentially death
[39].
The blood supply to the intestines is mainly
provided by three large vascular systems stemming from the abdominal aorta: the celiac axis,
the superior mesenteric artery (SMA), and the
inferior mesenteric artery (IMA). Arterial emboli
are more commonly localized in the SMA due to
its wider angle of origin compared with the celiac
artery and its parallel course to the abdominal
aorta [39]. The SMA and celiac axis systems
communicate via the gastroduodenal artery and
pancreaticoduodenal arcades at the pancreatic
head region, and since routine pancreaticoduodenectomy (PD) involves resection of these
branches, ischemic complications may also arise
in this patient group [41].
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T. Rosing and R. Lati
Timely diagnosis is critical to prevent ischemic complications and improve odds of survival; however, the diagnosis of patients with
AMI can be difcult, as the abdominal pain is
often accompanied by nonspecic symptoms
such as fever, vomiting, diarrhea, and loss of
bowel sounds. Therefore, the patient’s history is
important to consider, particularly if they are
elderly and have cardiovascular or peripheral
vascular disease [39]. Computerized tomography
(CT) scan is both highly sensitive and specic for
diagnosing AMI and can visualize both the occlusions and the consequences of the intestinal
hypoxia; in situations where it is not available,
mesenteric angiography or duplex ultrasonography can be utilized [39, 40].
Particularly difcult is the situation of a patient
with multiple abdominal surgeries, requiring signicant amounts of pain medication. When these
patients develop ischemia, it is difcult to discern
pain associated with ischemia from their “usual
pain.” Such an example is an obese patient with
multiple previous abdominal operations and large
ventral hernia (Fig.11.7), who presented with the
exacerbation of the abdominal pain.
Surgical exploration is warranted for all
patients who have any suspected mesenteric ischemia and signs of peritonitis, regardless of its
cause. These patients are high-risk for irreversible
Fig. 11.7 Patient with obese obesity post with multiple
previous abdominal operations and large ventral hernia.
(Courtesy of Dr. Lati)
bowel infarction and abdominal sepsis, and bowel
that is approaching irreparable necrosis can seem
normal in appearance. In contrast, bowel that may
appear “dusky” may be viable after revascularization. For these reasons, the priority of the surgeon
should be to reestablish vascularization and then
reassess the viability of before making decisions
about intestinal resection.
When toResect Intestines
andWhen toWatch?
Patient # 6
“A 52-year-old female with stage 3 kidney disease is evaluated in the ED with abdominal pain
and septic shock, requiring pressors. Exploratory
laparotomy reveals multiple points of ischemia
(Fig. 11.8a,b), veried by ICG. She has good
pulses of the mesentery. The surgeon decided to
continue with resuscitation and DCS. She was
brought back 24 hours later, and her ischemia
now has become worse, in a larger segment of
SB, but no clear zone of resection. Now the surgeon decides to place her on DPR and bring her
back 72 hours later. Her intestinal ischemia
improved dramatically (Fig. 11.8c), resection
was avoided, and her abdomen was closed”.
This case illustrates two of the biggest and
most difcult questions: (1) How much intestines
should one resect? and (2) When to perform an
anastomosis, in cases when ischemia is not clearcut like in patient # 5? (Fig. 11.8a,b). Until
recently, a good rule of thumb was to perform a
temporary abdominal closure (TAC) and return
to the operating room within 24–48 hours while
you continue resuscitating the patient, following
acid-base balance and lactate level. In recent
years the use of indocyanine green (ICG) dye to
evaluate perfusion has become popular [42, 43],
both robotically, laparoscopically, and in open
surgery. Use of ICG and direct peritoneal resuscitation (DPR) and DCS, when re-evaluation is
required [44], has become a standard practice.
Focal ischemia of small bowel can resolve using
DPR (Fig.11.8c) and resuscitation. Small bowel
ischemia if neglected and delayed laparotomy
may have catastrophic consequences (Fig.11.8).
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
ba
c d
117
Fig. 11.8 (a–c) When unclear margins of full-blown
ischemia, the patients should be observed and return back
for second or even third look. In this patient, as it is our
Summary
Dealing with real difcult situations in general
surgery is challenging and requires a thoughtful
and meticulous approach, yet expeditious action.
However, we cannot become paralyzed with the
practice, we initiated direct peritoneal resuscitation, and
patient did not require resection. (d) Catastrophic delay
addressing small bowel ischemia. (Courtesy of Dr. Lati)
fear of failing or having complications or a potentially negative laparotomy. Fistulas, necrotizing
soft tissue infections, and intestinal ischemia are
all dramatic and can have signicant mortality if
not addressed appropriately. As general surgeons,
we are expected to deal with situations that often
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T. Rosing and R. Lati
are very difcult. However, when we face a complicated patient, either during re-operative
surgery (when others have operated beforehand)
or for whatever reason your patients’ postoperative course gets truly complicated, then things get
difcult on more than one level. The situation
becomes personal. These personal complications
sometimes make it difcult to return to the operating room, but one must do it, to start the ght
again and remember that we must get back in the
saddle.
The Dicult Cholecystectomy:
Approaches andBailout Strategies
Patient Example 7
Patient is a 54-year-old female with no signicant past medical history who presents with right
upper quadrant abdominal pain for the past 3
days. Patient has had similar episodes of abdominal pain over the past 2 years. This time the pain
has progressively worsened, and she has associated nausea and emesis. Ultrasound is performed
which demonstrates cholelithiasis, no pericholecystic uid, and common bile duct measures
4mm. You take her to the operating room for a
laparoscopic cholecystectomy and discover a
tense gallbladder with signicant edema covered
with multiple dense adhesions. You attempt to
carefully dissect out the critical view of safety but
are unable to safely identify the cystic duct. You
must decide between performing a subtotal cholecystectomy or converting to an open procedure
in order to avoid the most feared complication,
an iatrogenic common bile duct injury.
In the multifaceted landscape of abdominal
surgery, navigating the intricacies of a stubborn
gallbladder presents an arduous challenge.
Regardless of the dexterity and prociency intrinsic in surgical practice, there inevitably arises an
occasion where continued dissection of the cystohepatic triangle becomes hazardous due to factors like dense adhesions, inammation, and
scarring. Distortion of the surgical dissection
planes creates a phenomenon known as “frozen
Calot’s,” limiting the possibility of safe identication of the biliary structures and rendering iso-
lation of the critical view of safety unattainable
[42]. Termed as encountering a “difcult gallbladder,” this scenario inherently carries a signicant threat for surgical mishaps secondary to
several factors including necrosis, gangrene,
empyema, Mirizzi syndrome, dense adhesions,
intraoperative bleeding, distorted anatomy, and
known perforation [43, 45]. Other occasions that
required transition to an open procedure included
discovering a cholecystoenteric stula, concern
for malignancy, common bile duct (CBD) exploration for stones, and iatrogenic enterotomy [45].
These factors have historically led to conversion
to open (Fig. 11.9), subtotal cholecystectomy
(Fig.11.10).
It is critical to acknowledge that the incidence
of confronting a “difcult gallbladder” is not a
rarity, with rates reported up to 26% [45].
Fig. 11.9 Open cholecystectomy. (Courtesy of Dr. Lati)
Fig. 11.10 Partial or near complete open cholecystec-
tomy. (Courtesy of Dr. Lati)
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
119
Moreover, procedure-related complications
include subhepatic uid collections requiring
drainage (7.7%), postoperative hemorrhage
requiring transfusion (4.8%), pneumonia (4.6%),
sepsis requiring vasopressor support (6%), and
wound infection (4.3%) [45].
Addressing a difcult gallbladder requires a
strategic approach combined with technical
expertise. Despite the challenges presented, contemporary surgical practice favors continued
laparoscopic dissection over conversion to open
surgery, especially in the modern era where open
cholecystectomies in training programs are
diminishing in frequency. Converting to an open
cholecystectomy has become a rarity and now
presents new unfamiliar technical challenges for
ascending surgeons than the more familiar laparoscopic dissection. Despite the opposition of a
bad gallbladder, difcult cholecystectomies have
a laparoscopic completion rate of 96%, with rates
of conversion to open procedures nearing
4–10.5% [46].
Persisting laparoscopically in the face of a
challenging gallbladder can dispose one to catastrophic injuries including vascular injury to the
hepatic arteries, or injury to the extrahepatic biliary tree [43]. Therefore, knowing when to abort a
completion laparoscopic cholecystectomy is crucial to every surgeon, and the strategic utilization
of bailout techniques becomes essential when
faced with this hazardous situation. According to
several studies, employing a laparoscopic
subtotal cholecystectomy technique is not only a
suitable alternative to completed laparoscopic
cholecystectomy but in current practice has
become the preferred a bail-out technique to
replace conversion to open.
Preoperatively diagnosing challenging gallbladders and their pathologies can support operative planning by employing the 2018 Tokyo
Guidelines which delineate specic criteria for
the diagnosis of acute cholecystitis [47]. These
guidelines include a combination of the following quantications: (A) local signs of inammation, either Murphy’s sign or Right Upper
Quadrant (RUQ) tenderness or mass; (B) systemic signs of inammation including fever, elevated CRP, and leukocytosis; and (C) imaging
ndings suggestive of acute cholecystitis [47].
High suspicion for acute cholecystitis arises if
criteria is present in categories A and B, while
denitive diagnosis mandates that all three categories’ criteria have been involved [47].
Additionally, the guidelines introduce a severity
scale, categorizing the disease into mild, moderate, and severe based on systemic effects and
end-organ damage that coincide with 30-day
mortality rates of Grade I (1.1%), Grade II
(0.8%), and Grade III (5.4%) [47].
Additionally, the 2018 Tokyo Guidelines also
propose management bundles for treatment of
acute cholecystitis [48]. Per these guidelines,
patients should undergo assessment every 6–12
hours utilizing the previously discussed diagnostic criteria until the diagnosis is rmly established
[48]. Abdominal ultrasound serves as the standard
imaging modality for diagnosis, with CT and
MRI reserved for cases that remain inconclusive
[48]. The severity scale aids in quantifying disease severity and guiding further treatments.
Grade I recommendations are to perform a laparoscopic cholecystectomy within 7 days of diagnosis but preferably within 72 hours [48]. For Grade
II patients, urgent laparoscopic cholecystectomy
is recommended for suitable surgical candidates,
while early drainage followed by delayed laparoscopic cholecystectomy is advised for those
deemed unsuitable [48]. In Grade III disease,
patients that are good surgical candidates should
be taken for emergent laparoscopic cholecystectomy, while immediate drainage is recommended
for those unable to tolerate surgery [48].
Additionally, cultures from blood, bile, or both
should be acquired for Grade II and higher cases
[48]. In cases where urgent drainage, laparoscopic
cholecystectomy, or ICU facilities are unavailable, patients should be promptly transferred to
capable facilities [48]. Adherence to these guidelines can aid surgeons in diagnosing, treating, and
surgical planning for complex gallbladder cases.
The integration of indocyanine green (ICG) as
an adjunctive tool in cholecystectomy procedures
has recently gained traction, particularly for
enhancing visualization and identication of the
extrahepatic biliary ducts during dissection of the
hepatocystic triangle [49]. As laparoscopic sur-
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T. Rosing and R. Lati
gery has become the standard of care, there has
been a concordant increase in common bile duct
(CBD) injuries, primarily accredited to inadequate visualization of the extrahepatic ducts. ICG
has emerged as a validated supplemental tool to
enhance bile duct visualization and has demonstrated noteworthy reductions in CBD injury
rates during laparoscopic procedures as well as
decreasing the necessity for conversion to open
procedures [50]. The utilization of ICG results in
a 4-fold decrease in bile duct injuries and a
17-fold decrease in the requirement for conversion to open procedures [50]. Deliberation
regarding the optimal dosing and timing of ICG
administration has led to more standardized
guidelines. A comparative study assessed the
administration of ICG between 20 and 30 minutes prior to anesthesia induction, 2–6 hours
prior, or over 6 hours prior. The group receiving
ICG 2–6 hours prior to surgery achieved successful visualization of the CBD in 97.1% of cases,
compared to 85.4% in the group receiving ICG at
the time of anesthesia. This contrasted with the
group-administered ICG greater than 6 hours
prior to surgery with visualization of the CBD
achieved only 65.5% of the time [49]. This evidence concludes that ICG administration in the
preoperative area up to 30 minutes prior to the
operation adequately facilitates successful visualization of the extrahepatic ducts during a difcult dissection. Additionally, a comparison of
dosing strategies between weight-based
(0.05mg/kg) and a standardized dose of 1cc of
25mg diluted in 10mL saline (2.5mg/mL) identied the standardized dose as superior, achieving
CBD visualization in 87.3% of cases [49]. This
suggests that utilizing a standardized dose of
2.5mg/mL is sufcient to achieve adequate visualization of the extrahepatic ducts particularly in
the presence of inammation, anatomical distortions, and aberrant anatomy. When grappling
with a difcult gallbladder, adjuncts like ICG
should be utilized to accurately identify anatomical variations and ensure a safer dissection
process.
The introduction of robotic surgery has repre-
sented a signicant technological advancement
to the minimally invasive cholecystectomy.
However, the role of robotic technology in emergency surgery, particularly in cases of acute cholecystitis, is still being deliberated. The World
Society of Emergency Surgery does not consider
emergency surgery a specic contraindication for
utilizing a robotics approach, with the caveat that
the operating room is fully staffed with robotically trained personnel and that the surgeon has
sufcient robotic experience [51]. The technological capabilities of robotic platforms, including 3D stereoscopic vision, instrument
stabilization, and wrist technology, enhances dissection of inamed or aberrant anatomy, potentially averting iatrogenic injury, or the need for
conversion to an open procedure [51]. One study
examining single-port robotic cholecystectomy
in both emergent and elective cases reported a
low CBD injury rate (0.7%), an overall complication rate of 8.7%, and an increased operative time
(95 +/− 4.4 minutes) for robotic cholecystectomies in the emergent setting compared to elective
cases [52].
We believe that robotic technology has been
ultimately the most important advancement that
is ideal for “bad” gallbladders. Ultimately, the
decision to opt for robotic cholecystectomy in
urgent cases of acute cholecystitis hinges on the
surgeon’s expertise and the availability of support personnel, pending further research to establish comparative outcomes. A signicant number
of acute care surgery services continue to adopt
robotic cholecystectomy, as the training of nursing and technical staff is expanding.
Open Cholecystectomy
Although the current standard of care favors laparoscopic approaches, open cholecystectomy
remains relevant in select scenarios as an indication of strong surgical judgment to mitigate iatrogenic injuries. Risk factors for conversion to an
open procedure have been reported including
gallbladder wall width >4 mm, pericholecystic
uid, male sex, age >60 years old, acute cholecystitis, neurologic disorders, and diabetes [53,
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
54], but ultimately the determining factor is the
individual surgeon who makes the surgical decision to convert. The three main reasons identied
for surgeons deciding to convert to an open
procedure include unusual anatomy, inammatory adhesions, and prolonged dissection [55].
The senior author prefers early conversion to
open cholecystectomy if the operations do not
ow as expected and one does not make progress.
The decision to convert to open, while decided
early, should not be made until after four ports
have been placed and the gallbladder has been
identied with the fundus grasped and elevated
[55]. At this point should dissection prove to be
too difcult or risky, early conversion to an open
approach prevents longer operating times and
Fig. 11.11 Difcult, but doable laparoscopic cholecystectomy. (Courtesy of Dr. Lati)
decreases the risk of iatrogenic injury. While contemporary trends may veer toward minimally
invasive techniques, open cholecystectomy con-
The Burst Abdomen
tinues to remain a valuable adjunct in the armamentarium of surgeons navigating the difcult
gallbladder. However, just the fact that you have
converted to open may not make the procedure
any easier.
Patient 7
Patient is an 84-year-old female with past medical history of hypertension and diabetes who is
status post-screening colonoscopy 1 day ago presenting now with abdominal pain. She has diffused pain across the abdomen and leukocytosis
Summary
of 13.2, associated with free air on CT. She
underwent an exploratory laparotomy and dis-
The successful management of difcult gallbladder cases hinges on a balanced integration of technical prociency and strategic decision- making.
At times, the gallbladder may look difcult, but if
it continues to make progress, then the operation
can be safely completed (Fig. 11.11). Subtotal
cholecystectomy, whether employing a fenestrated or reconstituted approach, is an acceptable
and safe alternative. Advances in technology,
especially robotic surgery, have revolutionized
acute care surgery, particularly common procedures such as cholecystectomy and colon surgery
[51]. Adjuncts such as ICG are now indicated to
aid the surgeon in visualization of complex anatomy. Finally, utilization of the open approach
remains a gold-standard technique in the toolbox
of any surgeon approach to safely managing the
difcult gallbladder.
covered a perforation in the sigmoid colon. You
perform a segmental sigmoid resection with primary anastomosis. The procedure is uncomplicated. On postoperative day # 3, her GI functions
return of and tolerating a soft diet. Her leukocytosis has resolved to 9.8. She is cleared for discharge and pending placement. On POD #5 has
a rising leukocytosis of 12.3, but she is afebrile.
Her midline wound has new “soupy pink” discharge. You remove a couple of staples and wash
out the incision leaving wet to dry packing. The
next day you get a call from the nurse that the
patients’ incision has opened. On examination
her midline incision has completely dehisced,
exposing matted bowel (Fig. 11.12). You take her
urgently back to the operating room. She made
your surgical decision very easy. The diagnosis:
A burst abdomen.
121
122
Fig. 11.12 Wide dehiscence of the abdominal wound.
(Courtesy of Dr. Lati)
Consequences ofBurst Abdomen
The burst abdomen is dened by the breakdown
of reapproximated wound edges of a closed surgical incision and represents a grave complication with signicant morbidity and mortality
[56]. The acute burst of the abdomen when intestines are found in the dressing, while very dramatic for the patient and nursing staff, is not
common, although it may often occur in patients
with temporary closure with wound VAC on a
ventilator and not properly sedated (Fig.11.13,
Courtesy of Firas Madbak, MD). More commonly it is as a result of infection, followed by
dehiscence and eventually a burst abdomen
(Figs. 11.3 and 11.12). Surgical wound dehiscence can be classied as either supercial or
deep and can involve an infectious etiology or not
T. Rosing and R. Lati
Fig. 11.13 Evisceration of the abdominal content in a
patient with temporary abdominal closure, due to lack of
proper sedation. (Courtesy of Firas Madbak, MD)
[56]. The incidence of abdominal wound dehiscence is around 1% within the 30-day postoperative period but has very high mortality rates of up
to 40% [56]. Wound dehiscence typically manifests between the 5th and 12th postoperative
days, with the initial presentation often including
drainage of serosanguinous “salmon-colored”
uid from the wound [57].
While there are multiple factors contributing
abdominal wound dehiscence, decreased tissue
strength and infection are the most common
[53]. However, infection is the most common
factor predisposing patients to abdominal
wound dehiscence [53, 57]. Increased rates of
wound infection are often associated with an
emergency operation [57]. Specic risk factors
include age over 50, male gender, peritonitis,
and emergency laparotomy [53]. Additionally,
postoperative increases in intra-abdominal pressures with coughing, vomiting, and distention
from ileus, along with comorbidities such as
hypoproteinemia, sepsis, ascites, and steroid
use, further predispose individuals to this complication [57].