Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Dehiscence of a laparotomy wound in the 
early stages of healing is a dreaded complication. 
Usually it means a return to the operating room for 
closure, with more surgical stress, danger of 
complications, and prolonged recovery.  
Wound dehiscence can be caused by 
technical factors (surgeon error) or by patient factors. 
Technical factors include failing to perform the 
fascial closure adequately, or closing the fascia with 
the wrong type of suture that absorbs too quickly 
(such as Polyglycolic acid, also known as Vicryl ®.) 
Another technical error is failure to consider patient 
factors such as those below, leading to failure to 
reinforce the closure appropriately when doing it for 
the first time.  
Patient factors are many and include obesity, 
intra-abdominal infection, emergency surgery, high 
abdominal pressure on closing, chronic cough, 
chronic steroid use, 
and collagen disorders 
(including those that predispose to abdominal aortic 
aneurysm formation.) Greater than all of these, and 
accompanying many of them, is malnutrition. This 
condition accompanies many surgical and non-
surgical 
diseases, 
including 
cancer, 
Human 
Immunodeficiency Virus infection, tuberculosis, 
achalasia, Zenker’s diverticulum, and a whole host 
of others. Nutritional assessment is discussed in a 
separate chapter.  
Wound dehiscence can present subtly. 
Sometimes the only clue is discharge of a large 
amount of serous fluid from the skin wound. If the 
skin wound has watery fluid discharge, gently probe 
the wound and feel the fascial closure underneath. If 
you can feel a gap in the fascia, it is dehisced. This 
will almost always be an indication to return to the 
operating room for closure, except in those situations 
described below.  
If you do not make the diagnosis at this stage, 
the problem will most likely present itself in a more 
dramatic fashion. During mobilization or a cough, 
the wound suddenly bursts open and the intestines 
appear, sometimes protruding from the abdomen. In 
this case, surgical re-exploration is mandatory and 
must be done very soon.  
 
Sometimes fascial dehiscence accompanies 
an intra-abdominal infection, either an abscess or an 
anastomotic leak. Purulent discharge from the skin 
incision may be a superficial wound infection, but if 
the amount of pus is very high, consider whether it is 
coming from the abdominal cavity. Gently probe the 
wound and feel for a defect in the fascia. If one is 
present, it is very unlikely that the patient will 
recover without another operation. If you are lucky, 
the intra-abdominal abscess is located only adjacent 
to the wound and you can manage it with operative 
exploration, drainage, and repeat closure of the 
fascia. Much more likely, the abscess cavity 
originated elsewhere in the abdomen and spread to 
the fascia where it burst through. In this case, a full 
and careful abdominal exploration and washout is 
needed before fascial closure.  
 
If feculent or bilious fluid come through the 
wound, the patient has an enterocutaneous fistula. 
This subject is covered more extensively in another 
chapter, but in brief the stages of management will 
be resuscitation, investigation, and intervention. 
Give IV fluids and antibiotics, then do a CT scan if 
you have one available. Otherwise perform bedside 
ultrasound yourself and try to assess where the fluid 
collections are. This patient will need an operation to 
wash out all of the abdomen, find the enterotomy, 
and either repair it with an omental patch or divert it 
through an ostomy.  
 
In some select cases you will decide not to 
close the fascia and to allow the wound to heal on its 
own. This is acceptable if the patient is very sick or 
frail, the diagnosis is terminal and they are on 
palliative care, and if the dehiscence is very small. 
Debride the wound gently, keep the bowel moist, and 
do not expose the bowel to wet plain gauze: use 
petroleum jelly (Vaseline ®) soaked gauze instead. 
A vacuum-assisted closure will help pull the wound 
edges together and make dressing changes less 
frequent, which makes bowel injury less likely. 
Ultimately if you do not operate, your goal is to 
either pull the skin together over the bowel with 
vacuum, or to sew the skin together once the wound 
is completely clean and has begun to granulate.  
 
Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
This patient with hypopharynx cancer presented with 
impending airway obstruction. She was very cachectic and 
frail. We performed awake tracheostomy and open gastrostomy 
tube placement. She developed dehiscence of her abdominal 
wound, about 4cm in length, without evisceration of the bowel. 
This wound can be managed with careful debridement followed 
by serial dressing changes. Skin closure is done when the 
wound is clean, facilitated by vacuum-assisted closure if 
available. At all costs, the exposed bowel must be protected 
with petroleum jelly-soaked gauze; plain gauze dressings will 
eventually erode into the lumen and cause a fistula. 
 
 
This patient with malnutrition due to HIV infection and an 
undifferentiated malignant neoplasm of the retroperitoneum 
developed wound dehiscence and evisceration while recovering 
from surgery. Despite his considerable risk factors, non-
operative management would have been inappropriate and we 
returned to the operating room for fascial closure. 
 
For this chapter we discuss only the steps and 
considerations of fascial closure; management of 
enterotomy and stoma formation are discussed 
elsewhere in this Manual. The steps of secondary 
closure of laparotomy wound dehiscence are: 
● Careful opening of the skin wound and 
exploration of the fascia 
● Opening all of the fascia that is not adequately 
closed 
● Gentle 
intra-abdominal 
exploration 
and 
irrigation 
● Placement of external retention sutures without 
tying them  
● Closure of the fascia 
● Tying of the retention sutures 
 
Steps: 
1. This operation is performed in the operating 
room under general anesthesia. You will not be 
able to adequately explore the abdominal cavity 
and reapproximate the fascia under local or 
spinal anesthesia.  
2. All of the skin incision is opened and the fascia 
is inspected carefully. Locate the fascial closure 
suture and trace it back to part of the fascia that 
has not dehisced. Debride any dead tissue.  
 
Debride any dead tissue at the fascial edges, so that the 
anatomy is clear here for when you close again. If some of the 
fascia is still approximated, find the fascial suture holding it 
and secure with a hemostat. You will tie your closure suture to 
this when you reapproximate the fascia.  
 
3. Carefully inspect inside the peritoneum by gently 
pushing the bowel away from the anterior 
abdominal wall. This is especially important if 
Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
there is purulent, feculent or bilious discharge: 
you must find the source. If there is no sign of 
infection, do not endanger the patient by 
exploring more than you can easily do.  
 
Gentle downwards pressure on the bowel allows limited 
visualization inside the peritoneum. If there is no purulent or 
feculent discharge this exploration should not be very thorough, 
to avoid iatrogenic bowel injury.  
 
 
Following inspection, the peritoneal cavity is lavaged with 
warm saline.  
 
4. Place full thickness retention sutures using thick 
nonabsorbable monofilament or braided suture 
material.  These are about 3-4cm from the fascial 
edge and pass through the skin, subcutaneous fat, 
anterior rectus sheath, rectus muscle, posterior 
sheath, and peritoneum. Be sure you see the 
needle at all times to avoid iatrogenic injury. Do 
not tie these yet.  
 
Sutures are full thickness, passing through the skin and all 
layers of the abdominal wall.  Source: WHO Surgical Care at 
the District Hospital  
https://apps.who.int/iris/bitstream/handle/10665/42564/92415
45755.pdf;jsessionid=5FC58C4DC7F30CE58E5BB32FCDF0
6223?sequence=1 Accessed 13 April 2022 
 
 
For sutures that are placed far from the fascial edge, the 
surgeon must bend down and look under the fascia to see the 
needle pass into the peritoneal cavity. The assistant retracts the 
abdominal wall anteriorly and holds a wide malleable retractor 
to protect the bowels.  
 
 
Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
It is crucial to see the needle at all times. In this case, the 
surgeon retracts the abdominal wall anteriorly while passing 
the needle through it while the assistant holds the wide 
malleable retractor in place underneath the abdominal wall.  
 
 
Each suture, once it is placed, is clipped with a hemostat. When 
all the sutures have been placed, the wound is still open and the 
fascial edges can still be reached..  
 
 
5. Begin closing the fascia with running slowly-
absorbable or non-absorbable suture. If some of 
the suture from the previous closure remains, 
place and tie your new suture adjacent to it and 
then tie the previous suture to the new. Make sure 
the sutures are through fascia, not muscle. 
“Travel” very little, each suture should be deep, 
if necessary, but close to the previous one.   
 
Here, as the fascia has retracted, the surgeon has had to place 
the suture somewhat deep to get to intact fascia. As always, 
each suture is under direct visualization with a malleable 
retractor protecting the bowels underneath.  
 
 
As with all laparotomy closures, begin with a suture at each end 
of the wound and meet in the middle. The final sutures are 
placed without tension on the previously placed suture to allow 
the needle to be seen throughout its passage through the fascia.  
 
6. Once the fascial closure is complete, close the 
skin very loosely. Take sterile IV tubing and cut 
it into strips. Pass one end of each retention 
suture through a strip of IV tubing. Tie them 
down. You do not need excessive tension here.  
Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The suture is passed through the IV tubing. 
 
 
The sutures are tied without tightening too much.  
 
7. During the immediate postoperative period, be as 
aggressive with nutrition as possible. Give a high 
protein diet and a multivitamin.  
8. We routinely leave retention sutures in place for 
up to two months. The patient’s nutritional status 
can be assessed by the healing of their skin 
wound. Certainly the retention sutures should not 
be removed until this skin wound has been well 
healed for 3-4 weeks. Patients will complain 
about the retention sutures.  
 
Pitfalls 
● Retention sutures and a colostomy are difficult to 
manage together. It is crucial to have flat, healthy 
skin in a rim of at least 3cm around the ostomy 
for the appliance to adhere to, to prevent stool 
leakage. Place retention sutures with this in 
mind; it is acceptable to place them a little closer 
to the midline to preserve some space next to the 
ostomy. Avoid pulling these sutures too tight or 
they will “dimple” the skin. If you are placing the 
ostomy at the same setting, place it farther from 
the midline wound; consider not passing the 
ostomy through the rectus muscle at all, 
especially if you expect it will be temporary.  
● Missed intra-abdominal injury: be absolutely 
certain that the dehiscence was not because of 
intra-abdominal infection or enterotomy. If the 
fluid is cloudy or purulent at all, you must 
completely explore the abdomen, including 
extending the fascial incision if necessary.  
● Iatrogenic bowel perforation: this complication is 
more likely than during usual fascial closure, as 
you are taking bites farther from the edge of the 
wound, deeper in the abdomen. Be sure your 
lighting and assistance are excellent. If the 
patient is fighting, ask anesthesia to deepen or 
paralyze the patient. The anesthesia staff may be 
awakening the patient because they think you are 
almost finished; make sure they know that this 
fascial closure will take longer than usual.  
● Failure to update the family on the patient’s 
prognosis: if there was no technical error, burst 
abdomen is an extremely bad sign for the 
patient’s overall recovery. It indicates the degree 
of their illness, likely with concurrent severe 
malnutrition. The long term outcome is likely to 
be poor even if you do everything right. You are 
wise to explain this fact to the family (and the 
patient,) who may not have appreciated how ill 
their loved one was.  
 
 
Closure of Laparotomy Wound Dehiscence 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
May 2022 
