Otitis Externa

Burst abdomen is acute postoperative disruption of the abdominal fascial closure, usually involving most or all of a laparotomy incision. It is essentially major acute fascial dehiscence and may precede or accompany evisceration.

It typically occurs during the first postoperative week, when fascial healing is weak. Wound infection is one of the strongest precipitating factors.

The danger is loss of abdominal wall containment with progression to bowel evisceration, obstruction, strangulation and recurrent intra abdominal contamination.

The classic warning is a sudden gush of serous or salmon coloured fluid from the laparotomy wound.

Other findings include:

• Sudden wound separation
• Visible fascial defect
• New wound bulge
• Patient reporting that something gave way during coughing, vomiting or mobilisation
• Exposed bowel beneath the skin

Associated fever, purulent discharge or tissue necrosis suggests surgical site infection.

The patient may initially remain haemodynamically stable despite complete fascial failure.

Burst abdomen is primarily a clinical diagnosis.

If the skin remains intact and fascial failure is uncertain:

CT abdomen and pelvis: confirms fascial disruption and identifies herniated bowel or associated intra abdominal infection.

Do not delay intervention for CT when complete fascial disruption or evisceration is obvious.

Keep fasting, establish IV access and obtain urgent senior surgical and anaesthetic review.

Cover any exposed abdominal contents with warm sterile saline moistened gauze.

Do not attempt forceful bedside reduction of bowel.

Give IV analgesia and correct dehydration or electrolyte abnormalities.

If intra abdominal or wound infection is suspected, begin broad antimicrobial coverage. Following gastrointestinal surgery, a practical severe infection regimen is:

Piperacillin tazobactam 4.5 g IV every 8 hours using extended infusion, adjusted for renal function.

Definitive treatment is usually urgent return to theatre.

At exploration:

• Assess the entire fascial defect
• Inspect bowel for injury, strangulation or ischaemia
• Drain infection
• Debride nonviable tissue
• Correct any underlying intra abdominal cause

Primary fascial closure is preferred when healthy fascia can be approximated without excessive tension.

If closure would produce dangerous tension or abdominal compartment syndrome, use temporary abdominal closure and return later for definitive fascial closure.

Component separation is generally inappropriate during the acute contaminated phase and is better reserved for later reconstruction.