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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 101-103
Outcome of primary closure of dirty abdominal wounds in children at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria


Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria

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Date of Web Publication5-May-2017
 

   Abstract 

Background: The management of dirty abdominal wounds has remained a challenge to surgeons because of the associated complications. Objective: This study was undertaken to determine the outcome of primary closure of dirty abdominal wounds in children. Design: A retrospective study (between 1st January, 2006 and 5th May, 2009) on the outcome of the primary closure of dirty abdominal wounds in children. Setting: Paediatric Surgery Division, Department of Surgery, Olabisi Onabanjo University Teaching Hospital, Sagamu. Materials and Methods: Cases of dirty abdominal wounds managed during the study period were retrieved from the medical records. Information regarding the age, sex, diagnosis, treatment, type of abdominal wound closure, duration of stay in hospital, complications arising from the abdominal wounds, and outcome was obtained and documented. Results: A total of 120 cases of dirty abdominal wound were managed during the study period. However, 90 case notes were retrieved and further evaluated for the proposed study. The age range of the patients studied was 2 months to 14 years. Males were 48 (53.3%), while females were 42 (46.7%). All the cases were acute abdominal emergencies. Differential diagnosis of dirty abdominal wounds managed during the study period are ruptured appendicitis/appendiceal abscess 30 (33.3%), intussusception 19 (21.1%), strangulated inguinoscrotal hernia 16 (17.8%), typhoid ileal perforation 14 (15.6%), and abdominal injuries 11 (12.2%). Healing without complications was seen in 70 (77.8%) patients, while complications occurred in 20 (22.2%) patients. The complications that occurred were wound infections 17 (68%), wound dehiscence 3 (12%), incisional hernia 3 (12%), enterocutaneous fistula 2 (8%), and duration of hospitalization 7-55 days and mortality of 4 (4.4%) was recorded.

Keywords: Dirty, abdominal wounds, outcome in children, primary closure.

How to cite this article:
Nwokoro CC, Salami BA, Bodunde OT. Outcome of primary closure of dirty abdominal wounds in children at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. Ann Trop Med Public Health 2017;10:101-3

How to cite this URL:
Nwokoro CC, Salami BA, Bodunde OT. Outcome of primary closure of dirty abdominal wounds in children at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 19];10:101-3. Available from: http://www.atmph.org/text.asp?2017/10/1/101/205532

   Introduction Top


Dirty surgical wounds are associated with a high rate of wound infection of over 40%. Postoperative wound infections have a significant impact on health resources and costs incurred by both patients and government. The sequelae of wound infection include septicemia, dehiscence, and resulting incisional hernia.[1]

Of the many risk factors influencing postoperative wound infection, the method of wound closure has been implicated as an important factor for poor or good outcome of surgical operations in contaminated emergency abdominal conditions.[2] Delayed primary closure and primary closure are the most commonly used methods but there is no consensus as to the optimal method to be preferred.[3],[4],[5]

While some authors showed that delayed primary wound closure carried some advantages over primary wound closure with regards to the occurrence of postoperative complications.[6],[7]

Other authors maintained that there was no benefit of delayed primary closure over primary closure of dirty abdominal wounds.[8],[9],[10] This study was carried out to determine the outcome of primary closure of dirty abdominal wounds in children at Olabisi Onabanjo University Teaching Hospital, Sagamu.


   Materials and Methods Top


The study was carried out between 1st January, 2006 and 5th May, 2009. A total of 90 children with dirty abdominal wounds from various abdominal conditions were recruited for the study.

The age, sex, clinical diagnosis, operative findings, methods of wound closure, complications, duration of hospital stay, and over all outcomes were retrieved from the case notes for analysis.

Technique of primary wound closure

Following adequate resuscitation, the patient was taken to the theater where the appropriate operation was carried out. Intraoperatively, the primary pathology was treated and the abdomen was lavaged with warm normal saline and mopped dry. Then intra-abdominal drains were placed in the peritoneal cavity and pelvis and brought out separate from the main abdominal wound.

The fascia was closed with nylon suture of appropriate size depending on the age and size of the patient. The subcutaneous tissue was usually closed with vicryl 2/0 or 3/0 as indicated, while skin apposition was via simple interrupted sutures with nylon of appropriate size. The surgical incision was covered with dry gauze and left untouched for 4 days when wound inspection was carried out.

However, in the presence of wound dressing soilage by blood or other effluents, wound dressing was changed as indicated. In the absence of features of wound infection, during inspection, the dressing would be changed and allowed to remain for 7 days for suture removal.

In the presence of infection, the wound dressing was changed; alternate sutures were removed to allow for egress of exudates. In such cases, dressing was continued as indicated, until complete healing was achieved.


   Results Top


The 90 cases evaluated revealed the following:

The age range of 2 months to 14 years.

48 (53.3%) males and 42 (46.7%) females.

Differential diagnosis of dirty abdominal wounds managed during the study period are as follows: Ruptured appendicitis/appendiceal abscess 30(33.3%), intussusception 19 (21.1%), strangulated inguino-scrotal hernia 16 (17.8%), typhoid ileal perforation 14 (15.6%), and abdominal injuries 11 (12.2%).

All the wounds were closed primarily and abdominal drains were used in all the cases.


   Outcome Top


Healing without complications was seen in 70 (77.8%) patients, while complications occurred in 20 (22.2%) patients. The complications that occurred were wound infections 17 (68%), wound dehiscence 3 (12%), incisional hernia 3 (12%), enterocutaneous fistula 2 (8%), and duration of hospitalization 7-55 days.

Mortality of 4 (4.4%) was recorded. The mortalities occurred in 2 patients with perforated typhoid ileitis, one case of strangulated hernia with septicemia and a case of intussusception with perforation of viscus and peritonitis.


   Discussion Top


In this study, we observed satisfactory outcome with primary closure of dirty abdominal wounds. Healing without complications occurred in 77.8% of patients, while complications were seen in 22.2% of patients studied. This satisfactory outcome was observed in spite of the fact that all the wounds managed resulted from dirty abdominal wounds and acute (emergency) abdominal conditions. Both conditions (dirty abdominal wounds and acute abdominal conditions) are associated with increase postoperative complications, such as surgical site infection, wound dehiscence, septicemia, and incisional hernia as shown in our study. This finding is similar to the reports of other workers.[1],[3],[11],[12],[13],[14] The financial impact and other sequelae of wound infection have been documented by several authors.[1],[3],[11],[12]

In order to avoid or reduce the occurrence of the above-mentioned complications, several methods of wound closure had been employed in the past; with most surgeons using either delayed primary closure or primary closure for dirty abdominal wounds.

Interestingly, opinion have remained divided over the best method for closure of dirty abdominal wound.[4],[5],[7],[15]

In recent times, several authors have compared the outcome of primary closure and delayed primary closure with no clear cut advantage of one over the other.[16],[17],[18]

In children, delayed primary closure is discouraged because of the psychological and physical pain that it inflicts on both patients and their parents.

The open wound before closure is usually frightening and is associated with pain during closure.

The study carried out in our center also showed a satisfactory outcome of primary closure of dirty abdominal wounds.

This agrees with reports from other centers.[5],[10]


   Conclusion Top


Primary closure of dirty abdominal wounds in children is feasible and has a good outcome as shown in our study.

Therefore, it should be recommended for use to other centers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dipesh DD, Jagtap J, Bithik D, Ujjwal B. Management strategy for dirty abdominal incision: primary or delayed primary closure. Surgical Infect 2009;10:129-36.  Back to cited text no. 1
    
2.
Aziz I, Baloch Q, Zaheer F, Igbal M. Delayed Primary Wound Closure versus Primary Wound Closure - A Dilemma in Contaminated Abdominal Surgries. J Liaquat Uni Med Health Sci. 2015;14:110-14.  Back to cited text no. 2
    
3.
Cohn SM, Giannotti G, Ong AE. Prospective randomised trial of two wound management strategies for dirty abdominal wound. Ann Surg 2001;233:409-13.  Back to cited text no. 3
    
4.
Syed MA, Syed HM, Muhammad FU, Abdullah EM. Comparative study of wound healing in primary versus delayed primary closure in contaminated abdominal surgery. Pakistan J Surg 2009;25:115-8.  Back to cited text no. 4
    
5.
Usang UE, Sowande OA, Ademuyiwa AO, Bakare TI, Adejuyigbe O. Outcome of primary closure of abdominal wounds following typhoid perforation in children in lle-lfe. Afr J Paediatric Surg 2009;6:31-4.  Back to cited text no. 5
[PUBMED]    
6.
Bender JS, Stephen SR. Factors influencing outcome in delayed primary closure of contaminated abdominal wounds: A prospective analysis of 181 consecutive patients. Am Surg 2003;69:252-6.  Back to cited text no. 6
    
7.
Duttaroy DD, Jitendra J, Duttaroy B, Bansal U, Dhamega P, Patel G, Modi N. Management strategy for dirty abdominal incisions:primary or delayed primary closure? A randomized trial. Surg Infect (Larchmt) 2009;10:129-36.  Back to cited text no. 7
    
8.
Henry CW, Moss RL. Primary versus delayed wound closure in complicated appendicitis. An international systematic review and meta-analysis. Pediatr Surg Int 2005;21:625-30.  Back to cited text no. 8
    
9.
Burnweit C, Bilik R, Shandling B. Primary closure of contaminated wounds in perforated appendicitis. J Pediatr Surg 1991;26:1362-5.  Back to cited text no. 9
[PUBMED]    
10.
Ussiri EV, Mkony CA, Aziz MR. Sutured and open clean contaminated and contaminated laparatomy wounds at muhimbili National Hospital: A comparision of complications. East Central Afr J Surg 2009;9:89-95.  Back to cited text no. 10
    
11.
Satyanarayana V, Prashant HV, Basavaraj B, Kavyashree AN. Study of surgical site infections in abdominal surgeries. J Clin Diagn Res 2011;5:935-9.  Back to cited text no. 11
    
12.
Renvall S, Niinikoski J, Aho AJ. Wound infection in abdominal surgery. A prospective study on 696 operations. Acta Chir Scand 1980;146:25-30.  Back to cited text no. 12
[PUBMED]    
13.
Ameh EA, Mshelbwala PM, Nasir AA, Lukong CS, Ba Jabo, Anumah MA. et al. Surgical site infection: prospective analysis of the burden and risk factors in a sub-Saharan African setting. Surg Infect 2009;10:105-9.  Back to cited text no. 13
    
14.
Eriksen HM, Iversen BG, Aavitsland P. Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003. J Hosp Infect 2005;60:40-5.  Back to cited text no. 14
[PUBMED]    
15.
Mukhtar A, Kishwar A, Humera L, Samon N, Khalid S. Comparison of primary wound closure with delayed primary closure in perforated appendicitis. J Ayub Med Coll AbboHabad 2014;26:153-7.  Back to cited text no. 15
    
16.
Lemieur TP, Rodriguez JL, Jacobs DM, Benett ME, West MA.Wound management in perforated appendicitis. Am Surg 1999;65:439-43.  Back to cited text no. 16
    
17.
Benard HR, Cole WR. Wound infection following partially contaminated wounds: Effects of delayed primary closure of skin and subcutaneous tissue. JAMA 1963;184:290-2.  Back to cited text no. 17
    
18.
Adesunkanmi AR, Ajao OG. Typhoid ileal perforation: The value of delayed primary closure of abdominal wounds. Afr J Med Sci 1996;25:31-5.  Back to cited text no. 18
[PUBMED]    

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Correspondence Address:
Dr. Collins Chigbundu Nwokoro
Nipost, Sagamu, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.205532

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