POLSKI

PRZEGLD CHIRURGICZNY
2012, 84, 11, 565573

10.2478/v10035-012-0094-0

Risk factors for wound dehiscence after laparotomy

clinicalcontrol trial*
Jakub Kenig, Piotr Richter, Sabina urawska, Anna Lasek,
KatarzynaZbierska
3rd Department of General Surgery, Jagiellonian University Collegium Medicum in Cracow
Kierownik: prof. dr hab. W. Nowak
Described in the literature dehiscence rate in the adult population is 0.3-3.5%, and in the elderly group
as much as 10%. In about 20-45% evisceration becomes asignificant risk factor of death in the perioperative period.
The aim of the study was to identify the main risk factors for abdominal wound dehiscence in the
adult population.
Material and methods. The study included patients treated in the 3rd Department of General Surgery,
Jagiellonian University Collegium Medicum in Cracow in the period from January 2008 to December
2011, in which at that time laparotomy was performed and was complicated by wound dehiscence in
the postoperative period. For each person in aresearch group, 3-4 control patient were selected. Selection criteria were corresponding age ( 2-3 years), gender, underlying disease and type of surgery
performed.
Results. In 56 patients (2.9%) dehiscence occurred in the postoperative period with 25% mortality.
The group consisted of 37 men and 19 women with the mean age of 66.8 12.6 years. Univariate
analysis showed that chronic steroids use, surgical site infection, anastomotic dehiscence/fistula in the
postoperative period and damage to the gastrointestinal tract are statistically significant risk factors
for dehiscence. Two first of these factors occurred to be independent risk factors in the multivariate
analysis. In addition, due to the selection criteria, agroup of risk factors should also include male
gender, emergency operation, midline laparotomy, colorectal syrgery and elderly age (> 65 years).
Logistic regression analysis did not show that aparticular surgeon, time of surgery or aparticular
month (including holiday months) were statistically significant risk factor for dehiscence.
Conclusions. Wound dehiscence is aserious complication with relatively small incidence but also
high mortality. Preoperative identification of risk factors allows for amore informed consent before
patients treatment and to take measures to prevent or minimize the consequences of complication
associated with it.
Key words: dehiscence, risk factors

Spontaneous durability of the wound in the

first day after surgery is virtually non-existent
and gradually increases with time. In third
week after surgery the durability equals 20%
of the initial strength, and after 6-12 weeks it
reaches 70-80% (1). Sutures placed during the
surgery should allow the tissues the necessary
time to regain structural and functional integ* This study was not sponsored

rity. If the healing process is disturbed, this

can lead to partial or complete dehiscence of
individual layers of the sutured wound or to
wound dehiscence along its entire depth, called
eventration. Usually dehiscence or eventration
occur 4 to 14 days after surgery (on the 8th day
on average). The incidence of this laparotomy
complication is estimated to be 0.33.5%, and

566

J. Kenig et al.

as much as 10% in elderly patients. In 2045%

of cases, wound dehiscence/eventration becomes the main cause of death (2, 3). A number
of papers on this subject identified various risk
factors which can lead to this condition. They
included age (>65 years), gender (male), tobacco smoking, obesity, chronic steroid treatment, anemia, jaundice, uremia, diabetes,
hypoalbuminemia, chronic obstructive pulmonary disease (COPD), neoplastic disease,
wound infection and emergency surgery. Furthermore, factors related to the surgery itself
were identified, and included the incision location, technique and type of the closing suture
as well as the degree of postoperative hypothermia, oxygenation and blood supply (4).
There are also papers indicating that in many
cases the operating surgeon themselves is a
risk factor for wound dehiscence (5). However,
the most important single factor leading to this
complication is wound infection. Studies indicate that the best technique for closing a vertical incision wound is to use a continuous
monofilament suture, non-absorbable or
slowly absorbable, applied through all layers
(except for the skin), with the suture length to
wound length ratio of 4:1 (6, 7).
The aim of this study was a detailed retrospective analysis of risk factors leading to
wound dehiscence/eventration in patients undergoing surgery in the 3rd Department of
General Surgery, Jagiellonian University Collegium Medicum in Cracow.

Material and methods

Study group
A retrospective analysis was performed on
data of patients treated in the 3rd Department
of General Surgery, Jagiellonian University
Collegium Medicum in Cracow, in the period
from January 2008 to December 2011. The
study included a group of patients who underwent laparotomy during this period, complicated by postoperative wound dehiscence. Indications and the scope of procedures are
listed in tab. 1.
Control group
For each person in a study group, 3-4 control
group patients were selected to undergo laparotomy at a similar time (time interval of 1 day
to 1 month). The selection criteria included
conformity of age (2-3 years), gender, underlying disease and the type of surgery performed.
Data
The database included factors related to the
patient, the condition that was the reason of
admission as well as the surgical treatment
performed. Particular emphasis was placed on

Table 1. Indications and procedure scope in the group of patients with wound dehiscence
Indications (number)
colon cancer + rectal cancer
stomach cancer
neoplasm of the pancreaticoduodenal region
gastrointestinal tract perforation
gastrointestinal tract obstruction
cholecystitis/choledocholithiasis
acute pancreatitis
abdominal injury
acute appendicitis
intestinal inflammatory diseases:
Crohns disease
ulcerative colitis
foreign body in the gastrointestinal tract
hernia in the laparotomy scar
closure of loop ileostomy
morbid obesity
embolism of the inferior mesenteric artery

9+9
2
2
6
6
4
1
4
4
4
1
3
1
1
1
1
11

Surgery (number)
stomach
small intestine
large intestine
gallbladder/bile ducts
liver
pancreas
splenectomy
abdominal wall plastic surgery
exploratory laparotomy (lysis of adhesions)

6
7
28
5
2
1
1
2
4

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Risk factors for wound dehiscence after laparotomy clinicalcontrol trial

analysis of risk factors already described in

papers, i.e.: age (>65 years), gender (male),
neoplastic disease, COPD or pO2 <60mmHg
and pCO2 <30mmHg, malnutrition (decreased
albumin level <30 g/l or decreased body weight
>=10%), presence of sepsis, obesity 30 kg/m2,
anemia (hemoglobin level <10 mg/dl), diabetes,
hypertensive disease, coronary heart disease,
chronic steroid treatment in the last 12 months
and tobacco smoking. Factors related to surgery included the operating surgeon as a risk
factor as well as the setting of surgery (elective
or emergency surgery), exact time of surgery,
procedure type, technique, suture type used
for closure of the layers and additional use of
anti-eventration sutures. Postoperative complications were analyzed in detail, with particular emphasis put on infection of the surgical site. A comparison was performed of dehiscence time, length of hospital stay, necessity
of treatment in the intensive care unit (including length of stay in the ICU) and number of
deaths.
Statistical analysis
To describe the study results qualitative
and quantitative data were used. Quantitative
parameters were expressed as the mean value
standard deviation. The remaining cases
were coded using Arabic numerals. The data
were analyzed using STATISTICA 10.0 software suite (StatSoft). The Shapiro-Wilk W test
and the Kolmogorov-Smirnov test with the
Lilliefors correction were used to verify the
normality of distribution of results. Depending
on the result of the normality of distribution,
the data were analyzed using parametric or

non-parametric tests. For all variables, both

qualitative and quantitative, a univariate regression analysis was performed. Variables
demonstrating statistical significance in the
univariate analysis were included in a multivariate analysis to determine independent risk
factors. The null hypothesis (H0) was rejected
at the established level alpha = 0.05.
Results
During the study period 1,879 laparotomies
were performed. Postoperative wound dehiscence was observed in 56 patients, that is in
2.9% of procedures. The group consisted of 37
men and 19 women, which means there was a
statistically significantly greater number of
men in this population (p < 0.05). The mean
age was 66.812.6 years. Postoperative wound
dehiscence occurred on average after 9.86.5
days (median: 8 days). Mortality in this group
reached 25%. There was a statistically significantly greater number of patients admitted
in an emergency setting: 45 (80.4%) vs. 11
patients admitted in an elective setting
(p<0.01). No statistically significant age difference was reported in patients undergoing
elective surgeries. On the other hand, in an
emergency setting women were statistically
significantly older than men (74.210.7 vs.
63.413.1 years; p < 0.05).
Comparison of female and male populations
with dehiscence
A comparison of the study group members
based on gender (tab. 2) did not reveal any

Table 2. Comparison of the female and male populations with dehiscence

Factor
Number
Age (years)
Surgery setting:
elective (11 patients)
emergency (45 patients)
Neoplastic disease
Concomitant diseases:
hypertensive disease
coronary heart disease
diabetes
COPD
other
Previous surgeries

Female
19
71,7+12,7

Male
37
64,312,4

P value
0,05
0,04

4 (21,1%)
15 (79%)
10 (52,6%)

7 (18,9%)
30 (81,1%)
15 (40,5%)

0,84
0,82
0,38

11 (58%)
10 (52%)
4 (36%)
2 (11%)
17 (89%)
8 (42,1%)

17 (45,9%)
14 (37,8%)
5 (13,5%)
8 (21,6%)
26 (70,3%)
18 (48,6%)

0,39
0,28
0,47
0,3
0,1
0,6

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J. Kenig et al.

Factor
Tobacco smoking
Chronic steroid treatment
Procedures involving opening of the gastrointestinal tract
Surgery type:
stomach/duodenum
gall-bladder
small intestine
large intestine
other
Time to wound dehiscence
Vertical incision
Stay in the ICU
Biochemical tests:
WBC
HCT
HGB
CRP
albuminy / albumin
biaka / protein
kreatynina / creatinine
Death

difference in the setting of surgery, presence/

lack of neoplastic disease and other concomitant diseases, time to dehiscence, tobacco
smoking, chronic steroid treatment, number
of previous surgeries, type of the present surgery, length of hospital stay (including length
of stay in the ICU), leukocyte count, hematocrit
level, hemoglobin level and protein level. Statistically significantly lower albumin level at
admission was reported in the female population compared with the male population
(33.313.4 vs. 254.2 g/l; p < 0.05), with no
difference in leukocyte count and CRP level.
On the other hand, opening of the abdomen
using a vertical incision was statistically significantly more frequent in the group with dehiscence than other types of opening (48 vs. 8
persons; p < 0.01). A comparison of the female

Female
5 (26,3%)
1 (5,3%)
16 (84,2%)

Male
10 (27%)
6 (16,2%)
31 (83,8%)

P value
0,7
0,2
0,46

3 (15,8%)
1 (5,3%)
1 (5,3%)
11 (57,9%)
3 (15,8%)
9,45+6,9
18 (95%)
8 (42,1%)

2 (5,4%)
4 (10,8%)
8 (21,6%)
17 (46%)
6 (16,2%)
10,5+5,9
30 (81%)
18 (48,6%)

0,2
0,5
0,2
0,6
0,9
0,56
0,16
0,64

13,65,6
34,75,5
10,81,7
152,2130,9
254,2
49,47,9
96,328,5

126,2
36,68
12,85,4
111,392,5
33,313,4
53,615,6
100,852,7

0,3
0,4
0,15
0,3
0,05
0,5
0,4

6 (31,6%)

8 (21,6%)

0,41

and male populations with dehiscence revealed

no statistically significant difference (p = 0.16).
Comparison of results in the study and
control groups
A comparison of the study group with the
selected control group demonstrated that the
study group was characterized by a statistically significantly greater incidence of surgical
site infection and greater incidence of circulatory failure in the postoperative period. The
patients also required a longer stay in the ICU,
and their hospital stay was statistically significantly longer (tab. 3). The remaining parameters listed in tab. 3 showed no statistically significant difference.

Table 3. Comparison of the study group with the selected control group
Factor
Number of patients (M/F)
Age (years)
Surgery setting:
elective (11 patients)
emergency (45 patients)
Surgery type:
stomach/duodenum
gall-bladder
small intestine
large intestine
other

Wound dehiscence

Control group

P value

56 (37/19)
66,613

168 (95/73)
66,812,8

0,2
0,87

11 (20%)
45 (80%)

44 (26,2%)
124 (73,8%)

0,27

5 (9,1%)
5 (9,1%)
9 (16,4%)
27 (49,1%)
10 (16,4%)

14 (8,3%)
13 (7,7%)
36 (21,4%)
83 (49,4%)
22 (13,1%)

0,84
0,74
0,41
0,94
0,56

569

Risk factors for wound dehiscence after laparotomy clinicalcontrol trial

Grupa rozejcia
rany / Wound
dehiscence
42 (76,4%)
24 (43,6%)

Czynnik / Factor
Procedures involving opening of the gastrointestinal tract
Neoplastic disease
Concomitant diseases:
hypertensive disease
coronary heart disease
diabetes
COPD
other
BMI:<20,5/20,5-30/>30 kg/m2 (n)
Previous surgery (n)
Tobacco smoking
Chronic steroid treatment
Surgical site infection
Anastomotic dehiscence/fistula
Circulatory failure (n)
Vertical incision (n)
Anti-eventration sutures (n)
Procedure time (n):
7-15.00
15.01-23.59
00.00-6.59
Stay in the ICU (n)
Length of hospital stay (days)
Biochemical tests:
WBC
HCT
HGB
CRP
albumin
protein
creatinine
Time to wound dehiscence (days)
Death

Risk factor analysis

Risk factor analysis performed by means
of univariate logistic regression in the group
with dehiscence and the control group
showed that chronic steroid treatment, surgical site infection, anastomotic dehiscence/
fistula, circulatory failure in the postoperative period and damage to the gastrointestinal tract are statistically significant risk

Grupa kontrolna /
Control group

P value

122 (72,6%)
71 (42,3%)

0,16
0,85

28 (50,9%)
23 (41,8%)
8 (14,5%)
9 (16,4%)
42 (76,4%)
12/31/13
25 (45,5%)
15 (27,3%)
7 (12,7%)
34 (61,8%)
5 (8,9%)
21 (37,5%)
47 (83,9%)
13 (23,2%)

92 (54,8%)
61 (36,3%)
28 (16,7%)
16 (9,5%)
116 (69%)
24/119/24
91 (54,2%)
41 (24,4%)
6 (3,6%)
23 (13,7%)
5 (3%)
43 (25,6%)
143 (85,1%)
27 (16,1%)

0,61
0,46
0,71
0,16
0,3
0,12
0,26
0,67
0,84
<0,01
1
0,04
0,95
0,2

24 (42,9%)
26 (46,4%)
6 (10,7%)
25 (45,5%)
38,327,1

81 (48,2%)
73 (43,5%)
14 (8,3%)
39 (23,2%)
15,812,9

0,68
0,73
0,89
0,001
<0,01

12,56,0
35,97,2
12,24,6
127,13108,2
30,212,9
52,4413,9
104,462,5
9,86,5
13 (23,2%)

11,65,9
37,76,4
12,42,2
111,49100,27
32,699,6
56,8513,8
91,9863,7
34 (20,2%)

0,3
0,1
0,7
0,5
0,3
0,2
0,3
0,6

factors for wound dehiscence. The remaining

factors, patient-, disease- and treatment
related (the surgeon, time of day and month
(including holiday months), performing of
the procedure, type of closure of the layers
(a continuous vs. single suture) and necessity of concomitant surgery of a different
organ) did not constitute statistically significant risk factors (tab. 4).

Table 4. Analysis of risk factors in the study group using logistic regression
Factor
Oncological procedure
Procedure involving opening of the
gastrointestinal tract
Organ undergoing surgery
Coronary heart disease

Regression
coefficient

Odds
ratio

0,17
-0,03

1,2
1,3

0,13
0,23

0,9
1,1

Odds ratio confidence

interval
min.
max.
0,7
2,0
0,4
4,1
0,4
0,7

2,1
1,8

P value
0,5
0,6
0,9
0,5

570

J. Kenig et al.

Czynnik / Factor
Hypertensive disease
Diabetes
Respiratory tract diseases
Previous surgery
Tobacco smoking
Chronic steroid treatment
Surgical site infection
Anastomotic dehiscence/fistula
Circulatory failure
Two-organ surgery
Vertical incision vs. other
Additional supporting sutures
Purulent material in the abdominal cavity
Damage to the gastrointestinal tract
Operating surgeon
Time of procedure:
month
time of day
Malnutrition (20.5)
Obesity (BMI 30)
Biochemical tests:
albumin
protein
leukocytes
CRP
hemoglobin
hematocrit
creatinine

Wspczynnik
regresji /
Regression
coefficient
-0,3
-0,4
0,2
0,7
0,3
0,7
1,3
0,1
0,09
0,1
0,1
-0,1
-0,6
0,7
0,13

Multivariate analysis demonstrated that

only chronic steroid treatment and surgical
site infection are independent risk factors for
postoperative wound dehiscence.
Discussion
Wound dehiscence is a serious postoperative
complication associated with high mortality
reaching 45%. Incidence reported in the literature is between 0.3 and 3.5%, but there are
individual reports of incidence as high as 10%.
In our study, wound dehiscence occurred in
2.9% of the cases, and mortality in this population was 25%, which did not significantly differ
from results found in the literature (8, 9, 10).
Patient-related factors
Most researchers agree that the male gender is a risk factor. Through analyzing the

Iloraz
szans
0,8
0,7
1,2
1,9
1,3
2,1
3,7
1,8
1,0
1
1,1
0,9
0,6
2,1
1,2

Przedzia ufnoci dla

ilorazu szans / Odds ratio
P value
confidence interval
min.
max.
0,5
1,2
0,2
0,4
1,2
0,2
0,7
2,2
0,4
0,8
4,8
0,1
0,8
1,7
2,1
1,1
4,5
0,05
2,4
5,7
<0,0001
1,4
2,0
0,05
0,43
2,73
0,8
0,4
2,2
0,9
0,5
2,2
0,9
0,3
1,2
0,8
0,6
5,9
0,1
1,2
4,4
0,05
0,7
1,6
0,6

0,02
-0,1
0,2
0,2

1
0,9
1,2
1,2

0,9
0,5
0,6
0,7

1,1
1,4
2,3
2,4

0,7
0,6
0,4
0,5

0,03
-0,05
0,001
0,001
0,007
0,015
0,005

1,0
0,9
1
0,9
1
1
1

0,9
0,8
0,9
0,7
0,8
0,9
0,9

1,1
1,1
1,1
1,2
1,3
1,1
1,1

0,4
0,3
0,4
0,8
0,5
0,1
0,3

group with dehiscence in our study, we found

statistically significantly greater number of
men than women (37 vs. 19 ratio of 2:1). In
one of the published studies, it was attributed
to tobacco smoking, which in most cases was
seen among men. In our study, tobacco smoking did not constitute a risk factor, and men
did not smoke more frequently than women.
Frequency comparison of factors predisposing
to wound dehiscence (tab. 2) also demonstrated no statistically significant difference between men and women, except for a lower albumin serum level in the female population.
Another explanation for this might be, reported in certain papers, increased pressure
inside the abdominal cavity generated by men,
which translates into greater forces exerted on
the main wound (11). On the other hand,
other studies associate the greater incidence
of dehiscence with lower collagen production
in the wound in the male population, which is
probably associated with the effect of estrogens
(12).

Risk factors for wound dehiscence after laparotomy clinicalcontrol trial

In most studies, age is also a risk factor

(13-17). In our study, logistic regression analysis showed no such relation, but, as has been
mentioned earlier, in line with the assumptions of this study, the control group members
were selected in accordance with the patients
age. While analyzing patients in the study
group, one can easily notice a significant overrepresentation of people over 65 years old (only
12 persons (21%) were younger than 65).
Chronic steroid treatment is also a frequently reported risk factor for wound dehiscence. It is believed that these drugs inhibit
healing of the original wound and delay granulation tissue formation, and their chronic use
increases the number of intra- and postoperative complications, which is associated, among
other things, with suppression of the hypothalamic-pituitary-adrenal axis (18). In our study,
multivariate regression analysis showed that
chronic steroid treatment is an independent
risk factor for wound dehiscence.
It has been demonstrated that tobacco
smoking results in abnormal wound healing
due to increased tissue hypoxia, impairment
of neutrophil-killing mechanisms, decreased
collagen production and disturbed ratio of
proteases and their inhibitors in the wound
itself, which may predispose to wound dehiscence. In our study, however, chronic tobacco
smoking was not found to be a risk factor for
wound dehiscence. Both the study and the
control groups had a similar percentage of
habitual smokers (12).
Interestingly, diabetes, anemia, neoplastic
disease, previous laparotomy, obesity and underweight were not identified as risk factors in
our study. Vascular changes resulting from
hypertensive disease, micro- and macroangiopathy associated with diabetes or an overall bad
condition caused by neoplastic disease should
predispose to wound dehiscence. Mixed opinions
are also seen in the literature (17, 19, 20).
Disease-related factors
Emergency surgery is another risk factor
for wound dehiscence identified in most studies. While analyzing the group with wound
dehiscence, we found a statistically significantly greater number of people admitted in
an emergency setting compared with people
admitted in an elective setting, which is in

571

accordance with reports in published papers.

It stems from numerous factors, such as a
general worse condition (including worse nutrition) and greater risk of surgical field contamination in case of patients undergoing
emergency surgery. Some studies raise also
the issue of the time when such surgeries take
place, which is often at night, potentially leading to suboptimal management of the abdominal wall layers (17, 21, 22). A comparison of
elective surgery and emergency groups participating in our study demonstrated no statistically significant difference between analyzed factors, except for a statistically significantly lower albumin level and total protein
level as well as a higher CRP serum level,
which is associated with severity of disease
being the cause of admission in an emergency
setting. An interesting observation is the fact
that among patients with wound dehiscence
admitted in an emergency setting there were
statistically significantly fewer people with an
oncological disease, while among patients with
wound dehiscence admitted in an elective setting there were statistically significantly more
people with an oncological disease (p < 0.01).
This might be associated with the fact that
most oncological patients admitted in an emergency setting underwent a resection with
creation of a stoma (a procedure of shorter
duration and associated with fewer perioperative complications compared with resection
with one-step restoration of the gastrointestinal tract continuity).
Treatment-related factors
Logistic regression analysis did not show
that a particular surgeon (also resident vs.
specialist), the time of surgery or a particular
month (including holiday months) were statistically significant risk factors for dehiscence.
As far as we are concerned, it is the first monograph analyzing the above factors in such
detail. The literature features also papers indicating a higher risk of wound dehiscence in
case of opening the fascia by means of electrocoagulation, due to formation of marginal
necrosis. On the other hand, the recommended
technique of fascia closure involves the use of
a continuous suture, with the suture length to
wound length ratio exceeding 4:1 (23, 24). In
our study, we found no statistical relationship

572

J. Kenig et al.

between dehiscence and incision techniques

(electric knife vs. scalpel) as well as fascia
suturing techniques (single sutures vs. a continuous suture). Analysis of the literature reveals that opinions are still mixed, although
most papers, like ours, do not consider the
surgical technique (of course if properly performed) to be a risk factor for wound dehiscence (11, 25, 26). It is also interesting that
additional anti-eventration sutures were
placed during the first procedure in 25% patients with wound dehiscence, but their role,
in the light of EBM, is still to be determined.
When it comes to opening the abdominal cavity by means of a vertical incision, logistic regression analysis did not prove this technique
to be a risk factor, but this results solely from
the study methodology. Similarly as in other
papers, 86% of patients in the group with
wound dehiscence underwent laparotomy in
the midline of the body (11, 24).
The most important risk factor for wound
dehiscence remains surgical site infection. According to published data, it is associated with
an inflow of bacterial metalloproteinases and
endotoxins (stimulating production of collage-

nases), which cause degradation of collagen,

prolongation of the inflammation stage and
activation of fibroblasts. Most published studies concerning this subject support similar
conclusions (14, 16, 21, 25, 27).
Conclusions
The results show that wound dehiscence is
a complex process, influenced by both general
and local as well as pre-, intra- and postoperative factors. Only concurrence of several factors
can lead to this complication. Most risk factors
do not depend upon the surgeon but mostly on
the patients gender, age, type of disease
treated in an emergency setting, and steroid
use. The most important risk factor for wound
dehiscence is surgical site infection. Therefore
the surgeon, along with the entire team caring
for the patient, should make every effort to
reduce the risk of this complication.
One should also remember that a knowledge
of the above factors may allow a more detailed
preoperative assessment and more informed
patients consent to the surgery.

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Received: 29.10.2012r.
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