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Surgical Wounds - Part 3: Surgical wound dehiscence and enterocutaneous fistula

Surgical Wounds  Part 3
Photo: Surgical Wounds Part 3
This is the last article in my series on postoperative surgical wound complications. Part 2 introduced a variety of complications including surgical site infections (SSIs). This article will focus on surgical wound dehiscence (SWD) and enterocutaneous fistulae (ECF).

Surgical wound dehiscence is mostly associated with abdominal surgery where mechanical failure of wound healing results in the separation of all layers of the abdominal wall. However mechanical skin breakdown can occur in any location with increased pressure or tension at the wound (from oedema for example) as is often the case with hip and knee operations. Abdominal wound dehiscence confers a great degree of morbidity leading to increased length of hospital stay increasing the risk for hospital acquired infections and in some cases may result in death. Risk factors include wound infection, obesity, diabetes, male gender, anaemia, smoking, malnourishment, low albumin levels, pulmonary complications, steroid medications and increased pressure or tension at the surgical site. Increased abdominal pressure resulting from the patient’s postoperative activity can also place undue stress and strain on the healing wound. Excessive tension on the fascia due nausea and vomiting, trying to void or defecate, postoperative ileus or bowel obstruction; and coughing can cause the incisional wound to break apart. 
In addition, pulmonary complications such as atelectasis or hospital acquired pneumonia post surgery may increase the risk of dehiscence as poor oxygen delivery predisposes the wound to ischemia (devitalised tissue) and infection.1 Obesity is associated with increased risk of infection and technical difficulties associated with wound closure while some medications (long term steroids) decrease the tensile strength of the healing wound rendering it more susceptible to breakdown. People with diabetes are at a higher risk for wound infection and dehiscence due to the derangement of the normal healing cascade. They also produce less collagen with decreased collagen deposition in the wound bed reducing wound tensile strength. People with diabetes also have reduced leucocyte and neutrophil function interfering with wound healing particularly during the early stages of healing (inflammatory and proliferative stages).1

Signs and symptoms indicating your patient may develop SWD include a tearing sensation or the feeling that something has given way, increased exudate oozing from the wound, signs of inflammation and lack of a healing ridge beneath the surgical incision site (hardness that extends approximately 1 cm either side of the wound). Management usually involves healing by primary intention or delayed primary closure and incorporates the principles of postoperative wound care - maintaining a moist healing environment, managing exudate (use of appropriate dressings suited to the size, depth, location and level of exudate), removal of devitalised tissue, reducing the risk of infection or treating if clinically indicated and pain management.3 There is also a need to reassure the patient that their wound will heal and provide education to encourage self-care.

Enterocutaneous fistulae are an abnormal communication between the bowel lumen and skin often associated with infection and/or sepsis, fluid and electrolyte abnormalities, and malnutrition.2 Some fistulas are left to heal by secondary intention while others can be surgically closed (depending on the location and age of the fistula). Suitable drainage systems may need to be applied as it is important to protect the peri-fistula skin from the damaging effects of effluent (maceration, excoriation, cellulitis, cutaneous ulceration and necrosis). Accurate measurements of effluent output and its characteristics must be documented to ensure adequate fluid and electrolyte management.

Referral to the dietician is important to ensure adequate nutrition and hydration. Often patients with ECC and SWD may require nutritional supplementation such as total parental nutrition to rest the bowel while healing takes place. The dietician aims to prevent malnutrition while the bowel is rested and the fistula or SWD heals. The dietician will assess for nutritional deficiencies, calculate nutritional requirements, advise on feeding route, maximise individualised nutritional support and monitor nutritional intake and needs.

For patients with ECF and SWD of the abdomen with a leaky bowel odour control is an important aspect of care ensuring patient comfort and assists with maintaining quality of life.  The nurse may also be required to assess need for counselling, social worker or pastoral care input; and assessment of the patient and/or family members’ ability or desire to participate in their own care to promote independence and self-care.1, 2 It is important to encourage mobility as this will contribute to quality of life and limit further morbidity. For fistulae and SWD that can be surgically closed negative pressure wound therapy is often applied to aid healing or to facilitate granulation in the wound base prior to definitive closure.

Nursing assessment of ECF will focus on fistula location and complexity, maturity, volume and characteristics of drainage, condition if the peri-fistula skin, size of the fistula and/or surrounding wound, adequacy of the containment device and availability of supplies/devices (this will influence treatment options).2 The peri-wound skin has the potential to break down as a result of constant exposure to moisture. Skin and wound barriers will help protect the peri-fistula skin from excoriation, sealing healthy skin from body fluids preventing peri-wound maceration and breakdown that may result from exposure to corrosive effluent. Barriers can also help prevent the stripping of fragile skin by decreasing the separation force from aggressive adhesives/dressings.2

In closing, optimal management of postoperative patient with a surgical wound is paramount to preventing potential complications. The ward nurse plays a pivotal role in the provision of essential postoperative wound care including assessment and monitoring of nutritional intake, patient postoperative activities that may increase risk of SWD in addition to wound healing progression.  Knowledge of common postoperative wound complications and their management coupled with an understanding the principles of postoperative wound care will facilitate early referral and treatment should complications arise.  

References
1. Haler, B. (2006). Surgical wound dehiscence. Medsurg Nursing, 15 (5):296-300.
2. Schecter, W., Hirshberg, A., Chang, D., Harris, H, Napolitano, L., Wexner, D., & Dudrick, S. (2009). Enteric fistulas: principles of management. Journal of the American College of Surgeons, 209 (4):484-491. Doi:10.1016/j.am.collsurg.2009.05.025.
3. Vuolo, J. (2006). Assessment and management of surgical wounds in clinical practice. Nursing Standard, 20 (52):46-56.

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Bonnie Fraser

A mother to three girls, previously Bonnie was an educator in the NSW secondary school system for 20 years before retraining to become a registered nurse. Bonnie has a Bachelor of Science with a Graduate Diploma in Education from the University of New England; and several certificates from TAFE NSW including Certificate IV in Workplace Training and Assessment and a Graduate Diploma in Management Communication. In 2009 Bonnie  attained a Bachelor of Nursing from Newcastle University, and is currently undertaking a Masters Degree in Wound Care though Monash University, this being her final year.  Currently Bonnie is employed as a registered nurse at the Port Macquarie Base Hospital located on the mid north coast of NSW. During her time as an RN she has worked in the areas of orthopaedic and general surgical nursing and fulfilled the roles of both clinical nurse educator for new and transitioning nurses and clinical nurse specialist wound management.