Postoperative abdominal wound separation and evisceration

Abstract

N EWER knowIedge of nutrition, infection, shock, pulmonary compIications, phIebitis and wound healing which has been added to the doctor’s armamentarium during the past ten years has definiteIy reduced morbidity and mortaIity in surgery. Many of us have been sIow in applying this information to the probIem of wound heaIing generally and evisceration in particuIar. In the Iaparotomized patient many factors influence the behavior of the wound. As Downs has pointed out, there are four factors to be considered in the healing of wounds: first, the patient; second, the wound; third, the suture materiaIs and fourth, the technic. Of these the patient is of paramount importance. Healthy tissues heal in heaIthy people. Chronic diseases diminish the urge to heal. Varco emphasizes the importance of restoring these patients to as normaI a state as possible before surgery, thus not only reducing the operative hazard but also making it possible for the wounds to heal at a more normal rate. As Howes classifies the healing of wounds, the first or Iag period is characterized by inflammation and exudation and Iasts four or five days. The regenerative phase is characterized by fibroplasia. OgiIvie has shown that the wound loses tensile strength during the Iag period.The strength of a well sutured wound is 40 per cent of that of the uncut tissues. Where absorbabIe suture is used, the tensiIe strength drops from 20 to 25 per cent of the origina by the fourth postoperative day. FibropIasia begins on the fifth day and by the sixth day the wound has regained 50 per cent. By the tenth day 90 per cent of its normal strength has been regained. Abbott points out that protein synthesis occurs at the site of wound healing, that this process is dependent upon available amino acids and that if the patient is in a state of negative nitrogen baIance, wound disruption may result. Thompson, Ravdin and Frank found that a high percentage of dogs with we11 advanced hypoproteinemia suffered wound breakdown and evisceration foIIowing Iaparotomy. BIood protein determination aids in estimating the state of the patient. However, as Abbott has shown, it is not a true index of nitrogen metaboIism since it does not indicate the degree of depIetion that has occurred in the body reservoir. This can probabIy be better estimated by such cIinica1 manifestations as weight 10s~. CIarke and Arty have demonstrated that a high protein diet actuaIIy decreases the Jag period and accelerates fibrobIastic activity. A reIationship between adequate nutrition and IocaI tissue immunity is indicated by the work of Cannon. Patients with fevers, fIstuIas, diarrhea and obstructions are prone to dehydration. Caller and Maddock have shown that the insensibre fluid Ioss is increased in fever so that a patient with a temperature of 102'~. loses a minimum of 2,000 cc. daiIy. The surgeon must be aware of this added fluid Ioss Iest dehydration occur which, as WhippIe has emphasized, proIongs the lag period of wound healing. HoIman found that a vitamin C deficient diet retards wound heaIing in approximateIy one-haIf of the patients studied. Hunt showed that vitamin C deficiency is particuIarIy prevalent in gastrointestinal cases. Vitamin C reserves in the tissues, not the bIood pIasma IeveI, are the determining factors in wound heahng according to Lund and Crandon. Vitamin C satura-