An abdomen which bursts some days after you have sewn it up is a tragedy, because it is preventable, and because the patient has a 30% chance of death. His abdomen is likely to burst if: (1) It is swollen for any reason, such as ileus, intestinal obstruction, or a large tumour. (2) He has severe intra-abdominal sepsis, such as an infected Caesarean section, typhoid peritonitis, or a perforation of his large gut. (3) You have sutured his abdomen with catgut or some other absorbable suture, especially if this is of low quality or out of date, or if his abdominal wound becomes infected. (4) You have sutured it in layers, taking bites of tissue that are too small. (5) He has carcinomatosis, uraemia, or obstructive jaundice.
An abdomen will almost never burst if: (1) You suture it with a non-absorbable sutures, such as steel, nylon, or polyethylene. (2) You close its muscles with one layer of through-and-through sutures, which are not too tight and take wide bites of tissue (9.8). (3) You use delayed skin suture (9.8) if the wound is infected or potentially so.
Fig. 9-24 BURST ABDOMEN. A, a burst abdomen after Caesarean section. B, and C, the usual way of inserting the tension sutures that are sometimes used to prevent this tragedy. A better way of preventing it would have been to use the method of single-layer closure with monofilament shown in Fig. 9-21. D, to G, an alternative way of inserting tension sutures. See Section 9.8. H, a burst abdomen and an intestinal fistula. The tension sutures have broken down. This is a detail from Fig. 9-25. The alternative method was kindly contributed by Mr Brian Sterry Ashby.
BURST ABDOMEN DIAGNOSIS. If a patient's wound is painful about a week after the operation, and he has a thin reddish-brown discharge, his abdomen is probably going to burst. Treat him before it bursts!
TREATMENT. Take him to the theatre, prepared for general anaesthesia. If his abdomen has actually burst, give him a general anaesthetic. Only repair him under local anaesthesia if he is very unfit. If it is a long wound, have blood available. Prepare him for a laparotomy.
Remove the skin sutures in the area where you suspect the burst. Remove the dressings and gently explore the depths of his wound with a sterile gloved finger. Open it down its whole length by removing all the skin sutures. You will soon find out what has happened. If you confirm a burst abdomen, remove all sutures from the fascial layers. Try to insert your finger between his parietal peritoneum and his underlying gut and omentum. In this way you should be able to mobilize enough of his abdominal wall to take some more sutures.
Resuture his abdominal wall with interrupted steel or monofilament sutures, either intermittent or continuous (see Everett's method 9.8). Suture from within outwards through his peritoneum, posterior rectus sheath, rectus muscle, and anterior rectus sheath[md]but not through his skin. Hold all the sutures out on haemostats until you have placed the last one.
Some surgeons also insert tension sutures (9.8), and consider that this is the only indication for them.
If his skin is already infected, use delayed closure (9.8), and graft it later if necessary.
Fig. 9-25 AN INTESTINAL FISTULA. This patient was operated on for obstruction of his small gut by [f10]Ascaris [f11]worms, and a length of it was resected. The anastomosis broke down; a fistula developed. He died a few hours later.