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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 24  |  Issue : 2  |  Page : 93-98

Surgical wound dehiscence following cutaneous excisions: A retrospective study and review of the literature


1 Kansas City University of Medicine and Biosciences - Advanced Dermatology and Cosmetic Surgery, Maitland, FL, USA
2 Department of Dermatology, University of Central Florida College of Medicine, Orlando, FL, USA
3 Kansas City University of Medicine and Biosciences - Advanced Dermatology and Cosmetic Surgery, Maitland; Department of Dermatology, University of Central Florida College of Medicine, Orlando; Ameriderm Research, Ormond Beach, FL, USA

Date of Submission24-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication10-Nov-2020

Correspondence Address:
Dr. Jennifer Seyffert
27 SE 6th Street, Dania Beach FL 33004
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_71_20

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  Abstract 


Background: Surgical wound dehiscence (SWD) is the third most common adverse event following dermatologic surgery. There have been no previous studies investigating risk factors for SWD following dermatologic surgery. There are no formal recommendations or standards of care to minimize or prevent SWD following dermatologic surgery. Purpose: The purpose of this study was to identify risk factors associated with dermatologic SWD. Methods: Multicenter retrospective data mined from EMA electronic medical record were collected from 22,548 matched excisions and postoperative visits performed on patients ≥18 years between January 1, 2019, and September 27, 2019. Matched data analysis was performed using IBM SPSS Statistics 25 to elucidate factors associated with SWD. Results: The prevalence of SWD was calculated to be 0.55%. A wound reported as positive for presumed infection or postoperative bleeding had 14.48 and 20.15 times the odds, respectively, of also being positive for SWD. A wound located on distal extremities (arm, hand, and lower leg) had 1.86 times the odds of being positive for SWD. Increasing age was found to be statistically significant. Wounds on individuals 80 years of age or greater had 1.7064 times the odds of being positive for SWD. Data did not support a correlation between SWD and sex, SWD and diabetes, or SWD and provider type. Conclusion: Factors that contribute to SWD dehiscence include presence of presumed infection, presence of bleeding, age >80, and location on the distal extremity. Data did not support a correlation between SWD and sex, SWD and diabetes, or SWD and provider type. Dermatologic surgeon identification and reduction of risk factors contributing to this adverse event may prevent SWD.

Keywords: Adverse event, cutaneous surgery, dehiscence, dermatologic surgery, postoperative adverse event, postoperative complication, surgical complication, surgical wound dehiscence, wound healing


How to cite this article:
Seyffert J, Harding T, Sanghvi A, Bibliowicz N, Yungmann M, Camner S, Leavitt M, Solomon JA. Surgical wound dehiscence following cutaneous excisions: A retrospective study and review of the literature. J Dermatol Dermatol Surg 2020;24:93-8

How to cite this URL:
Seyffert J, Harding T, Sanghvi A, Bibliowicz N, Yungmann M, Camner S, Leavitt M, Solomon JA. Surgical wound dehiscence following cutaneous excisions: A retrospective study and review of the literature. J Dermatol Dermatol Surg [serial online] 2020 [cited 2020 Dec 5];24:93-8. Available from: https://www.jddsjournal.org/text.asp?2020/24/2/93/300394




  Introduction Top


Cutaneous surgery performed by dermatologists in the outpatient setting is generally considered safe with complication rates as low as 1%–2% with no serious adverse events such as hospitalizations or postoperative death.[1],[2],[3],[4],[5],[6] In a prospective study, the most commonly reported postoperative adverse events following dermatologic surgery were suspicion of infection (64%), postoperative hemorrhage (20%), and surgical wound dehiscence (SWD) (8%).[1] In medical dictionaries, SWD is defined as the separation of the layers of a surgical wound and can vary with respect to skin layers involved, ranging from partial or superficial separation to complete separation of all layers.[7],[8] The reported incidence of SWD in dermatologic surgery varies from <0.1% up to 2%, based on the type of procedure and presence of comorbidities.[1],[9] SWD delays wound healing time, leads to suboptimal esthetic outcome, and can impair the patients' psychosocial well-being. Despite much investigation into variables which contribute to dermatologic surgical wound infection[10],[11],[12] and bleeding risk,[13],[14],[15] the authors were unable to find any publications focused directly on identification of the variables leading to dermatologic SWD. This gap in the literature elucidates the importance of identifying both host and procedural factors which may contribute to SWD and poor wound healing with the goal of preventing SWD and improving surgical outcomes. Previous lack of ability to assess large numbers of surgeries may have contributed to this gap. Data extraction from an electronic medical record (EMR) utilized by over 150 dermatology offices with a database of 3.5 million patients has allowed the authors to begin to close the gap concerning SWD.


  Methods Top


Data source: This retrospective study was conducted using data collected from the Electronic Medical Assistant-Modernizing Medicine (EMA) EMR database utilized by over 150 dermatology offices located throughout the United States. The institutional review board approved this study, and all included patients signed a privacy policy consent form.

Inclusion and exclusion criteria

Consenting adult patients ≥18 years who underwent surgical excision with Current Procedural Terminology codes 11400-11426 or 11600-11626 with matched documented postsurgical evaluation from January 1, 2019, to September 27, 2019, were included in the study. Patients who did not have both surgical excision and postsurgical evaluation, those who did not have surgery performed within our network, those whose surgical records were not documented properly within the EMR, those who underwent biopsy, and those who underwent Mohs micrographic surgery were excluded.


  Data Collection Top


Uniform documentation protocol and templates using clickable documentation fields for surgical and postoperative visits were developed and introduced to the clinics utilizing the EMA EMR platform in December 2018 as part of quality assurance. Retrospective de-identified data were extracted from EMA on October 19, 2020, for all surgical excisions between January 1, 2019, and September 27, 2019, which met the inclusion and exclusion criteria. Data captured included patient gender (male and female), age range (18–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89, 90–99, and 100–109 years), anatomic surgical site, wound length, smoking history, diabetes, presence of infection, presence of bleeding, and provider type. Postoperative visits were matched with surgical visits, and redacted data were collected including wound assessment, presence of dehiscence, presence of presumed infection, and presence of bleeding. SWD was defined as any postsurgical event characterized as “dehiscence,” “dehisced,” “minimally dehisced,” or “focally not well approximated.”

Statistical analysis

Data were analyzed using IBM SPSS Statistics (IBM Armonk, New York, USA) 25. 4:1 matching of nondehisced to dehisced wounds was performed based on sex, age range, and anatomic location in an effort to control confounding factors. Categorical variables were analyzed using Chi-squared tests; continuous variables were analyzed using independent sample t-tests. Statistical significance was defined as P < 0.05 and a 95% confidence interval (CI) not including zero.


  Results Top


A total of 22,548 matched surgical excisions and postsurgical visits met the inclusion criteria and were analyzed. For the purposes of analysis, SWD was defined as any postsurgical event characterized as by the terms “dehiscence,” “dehisced,” “minimally dehisced,” or “focally not well approximated” in the medical record. SWD was present in 123 cases, with a calculated prevalence of 0.55%. Wounds were evaluated as being dehisced an average of 12.7 days following surgery. The median age range experiencing SWD was 60–69 years of age, and the mode age range experiencing SWD was 70–79 years of age. Increasing age was found to be statistically significant (P = 0.039). There is an association between age ≥80 years and SWD (χ2 [df = 1, n = 615] = 5.344, P = 0.021). Wounds on the individuals 80 years of age or greater had 1.7064 times the odds of being positive for SWD (P = 0.0218, 95% CI: 1.0810–2.693). The average length of a dehisced wound was 4.6 cm. Wound length was not statistically significant (t(22530) = 4.58, P < 0.001, 95% CI: 0.45–1.12). Current and former smokers did not have a statistically significant increased prevalence of SWD (P = 0.018, 95% CI: 1.162–7.637). Data did not support a correlation between SWD and sex (χ2[df = 1, n = 615) =2.49, P = 0.115), SWD and diabetes (χ2[df = 1, n = 600] =1.63, P = 0.202), or SWD and provider type (χ2[df = 1, n = 600] =2.96, P = 0.086). A complete analysis of surgical and demographic characteristics of dehisced and nondehisced wounds is outlined in [Table 1].
Table 1: Surgical and demographic characteristics of dehisced and nondehisced wounds

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A wound positive for presumed infection had 14.48 times the odds of being positive for SWD (P < 0.001, 95% CI: 4.6–45.2) and a wound positive for bleeding had 20.15 times the odds of being positive for SWD (P < 0.001, 95% CI: 7.4–54.7). Wounds located on the distal extremities including arm, hand, or lower leg had 1.86 times the odds of being positive for SWD (P = 0.002, 95% CI: 1.3–2.8). The odds ratios of select factors associated with SWD are outlined in [Table 2] (P = 0.002).
Table 2: Odds ratios of select factors associated with surgical wound dehiscence

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  Discussion Top


SWD describes the separation of the layers of a surgical wound and can vary with respect to skin layers involved, ranging from partial or superficial separation to complete separation of all layers.[7],[8] SWD delays wound healing time, leads to suboptimal esthetic outcome, and can impair the patients' psychosocial well-being. Identification of both host and procedural factors which may contribute to SWD and poor wound healing can help prevent SWD and improve surgical outcomes. Within the specialty of dermatology, previously reported incidence rates of SWD vary from <0.1% up to 2%, based on the type of procedure and presence of comorbidities.[1],[3],[9],[16] Our calculated SWD prevalence rate of 0.55% is consistent with these previous findings, however, this value may be inflated due to the broad definition of SWD utilized in this analysis.

Wounds were evaluated as being dehisced an average of 12.7 days following surgery, which is consistent with previous reports of SWD that generally occurs between postoperative days 4–14.[17] This timeline aligns with the time of suture removal, which generally occurs 7–21 days postoperatively. This likely occurs because the surgical wound has minimal inherent tensile strength at the time sutures are removed;[18] collagen reaches approximately 3% tensile strength after 1 week, 20% after 3 weeks, and 80% at 12 months when compared to the tensile strength of unwounded skin.[19],[20] Although SWD generally occurs during postoperative evaluation period, it is likely that some wounds dehisce after the evaluation period, resulting in underreporting of this adverse event. Continued data collection and analysis of the elapsed time from procedure to reported dehiscence will elucidate a more specific timeline for anticipated wound dehiscence.

Etiology of SWD can be categorized into three general categories: technical surgical issues, mechanical stress, and disruptions in wound healing. The bulk of published research on risk factors for SWD focuses on abdominal and sternal dehiscence with limited reporting across other surgical specialties.[21] Major risk factors for SWD reported by other specialties include obesity (BMI ≥ 35 kg/m2), diabetes mellitus, current or recent smoking, age >65 years, inadequate surgical closure, and wound infection.[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] Increasing age was found to be statistically significant (P = 0.039). There is an association between age ≥80 years and SWD (χ2 [df = 1, n = 615] = 5.344, P = 0.021). Wounds on the individuals 80 years of age or greater had 1.7064 times the odds of being positive for SWD (P = 0.0218, 95% CI: 1.0810–2.693). Current and former smokers did not have a statistically significant increased prevalence of SWD (P = 0.018, 95% CI: 1.162–7.637). Our current data do not support a correlation between SWD and sex, SWD and diabetes, or SWD and provider type. Ongoing research will allow for the further exploration of comorbid conditions, corticosteroid use, suture removal timeframe, and anticoagulation therapy as possible risk factors for SWD.

Surgical technique is a major contributing factor to SWD. Inadequate undermining of the wound during surgery may result in excess tension contributing to SWD.[35] Wound closure is achieved by various methods including sutures, staples, adhesive tapes, and tissue adhesives. Selection of the most appropriate closure material and technique is based on a number of factors including the anatomic location, tissue layers being closed, and the surgeon's experience and preference.[36] Slipped or unraveled knots, weak suture strength, or sutures placed under high tension resulting in breakage may result in SWD; a retrospective study evaluating SWD after laparotomy found that 8% of SWD was due to broken sutures and 4% to loose knots.[26] Optimal surgical technique should include gentle handling of tissues, meticulous hemostasis, preservation of blood supply, removal of devitalized or contaminated tissues, avoidance of dead space, and the use of appropriate closure technique.[37] Ongoing research will allow for the exploration of suture material and suture technique as possible risk factors for SWD.

The average length of a dehisced wound was 4.6 cm, while the average length of a nondehisced wound was 3.8 cm, but the difference was not statistically significant (t(22530) =4.58, P < 0.001, 95% CI: 0.45–1.12). Our analysis revealed that a wound located on distal extremities including arm, hand, and lower leg had 1.86 times the odds of being positive for SWD. Mechanical stress distributed over the surgical wound can rupture healing tissue or the material used for closure. Both internal and external mechanical stresses can contribute to SWD, including excessive forced tension during wound closure, swelling of the local tissues due to hematoma or infection, excessive tension on the wound edges caused by lifting or straining, or the wound being located on a highly mobile or high-tension area such as the back, shoulders, or legs.[35] Patients should be advised on appropriate activity levels, avoidance of overexertion and heavy lifting, dressing and wound care, as well as signs and symptoms of SWD and infection to prevent trauma and mechanical stress on the surgical wound.

Normal wound healing occurs in four overlapping phases: hemostasis, inflammation, proliferation, and remodeling;[38] a multitude of local and systemic factors can disrupt this normal wound healing process to contribute to SWD. Local factors that may delay or impair wound healing include hypoxia/ischemia, devitalized or necrotic tissue, infection, or inflammatory conditions such as pyoderma gangrenosum or vasculitis.[39],[40] Systemic factors may include advanced age, diabetes, obesity, immunosuppression, medications, anticoagulation, previous radiotherapy, smoking, alcoholism, malnutrition, and connective tissue disorders.[39],[40],[41],[42] Infection is one of the most well-documented risk factors for SWD; during infection, degradative enzymes produced by immune cells and bacteria can disrupt healing and weaken wound tissues.[26] Our study supports the presence of infection as a risk factor for SWD; a wound the presumed infection had 14.48 times the odds of being positive for SWD (P < 0.001, 95% CI: 4.6–45.2). 76.4% of presumed infected wounds were positive for SWD and overall 10.8% of all wounds were positive for both SWD and presumed infection. Future investigations should also include culture and sensitivity testing to confirm the presence of infection and identify specific bacterial culprits that may contributory to SWD. Bleeding was also identified as a risk factor with its presence resulting in 20.15 times the odds of being positive for SWD (P < 0.001, 95% CI: 7.4–54.7). The cause of such bleeding needs further investigation but may be the result of anticoagulation, underlying hematologic abnormality, poor surgical hemostasis, or mechanical stress on the wound.

An understanding of the factors that increase a patient's risk of SWD can help guide appropriate preoperative, intraoperative, and postoperative care to prevent this adverse outcome. Reducing risk of SWD can be executed by preoperative modification of comorbidities, refined surgical technique, utilization of the appropriate closure method, minimization of surgical site infection risk, patient education, and postoperative monitoring. Ongoing data collection and analysis will allow for further exploration of these trends, while increasing sample sizes will improve the statistical power of the data. Further research will allow for the exploration of comorbid conditions, corticosteroid use, anticoagulation therapy, skin preparation, anesthesia type, lesion size (cm), lesion margin (cm), excision method, repair type, epidermal suture diameter and type, epidermal closure technique, and dermal suture diameter and type as possible risk factors for SWD.

Limitations

This study's main limitation is its reliance on medical assistants and providers to document information in the EMR with intra- and intertranscriber consistency. There are notable variations in medical documentation practices among clinics, which may have resulted in variability in reported data. However, company-wide documentation protocols were implemented before the start of data collection in an attempt to improve data quality and reliability. This study did not capture SWD that occurred after the postoperative visit or SWD that was not evaluated in the clinical setting. This study only analyzed data from cutaneous excisions; it did not include Mohs micrographic surgical data. Where possible, data analysis was performed controlling for age class, gender, and precise anatomic location. However, the authors were unable to adjust for other possible confounding factors, including body habitus, body mass index (BMI), and physical activity level. The authors were unable to account for patient counseling about activity limitation or measure patient compliance to these instructions. These findings do not elucidate direct causation of dehiscence due to innumerable, compounding host and procedural variables. Data provided here only highlight statistical associations which may prove to be possible causative risk factors.


  Conclusion Top


This is the first large-scale retrospective data analysis investigating host and surgical variables which may contribute to SWD. Dermatologic surgeons can use these data to assess risk, counsel patients, and modify surgical technique to minimize this postoperative adverse event. Our practice of 150 offices currently performs about 30,000 surgeries per year, and we continue to grow throughout the US. Among our offices, we utilize a single EMR (EMA-Modernizing Medicine) who has partnered with us to improve the ability to generate very specific outcome data from patient record documentation. Collaboration with supercomputer experts who are developing appropriate queries will expand our ability to hone in on which host and procedural factors contribute to SWD and other surgical complications. Within the next 3 years, we anticipate capturing data from at least 500 SWD, allowing for increased power and assessment of these relationships in much more detail. Further studies may elucidate more definitive relationships and contribute to the development of surgical standards of care to prevent SWD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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