Burst abdomen is an early postoperative failure of the abdominal wall closure in which the fascial layer separates partially or completely. The complication is clinically important because it may lead to evisceration, emergency re-operation, prolonged hospitalization, incisional hernia, sepsis, and death. Reported rates vary between studies, but the burden is higher after emergency abdominal surgery than after elective surgery because emergency cases often involve contamination, bowel distension, hypovolemia, sepsis, and limited time for preoperative optimization [1-5].

The midline incision is widely used in emergency laparotomy because it offers rapid access to the whole abdomen. However, it places the linea alba and closure line under considerable postoperative stress, especially when the patient has cough, ileus, abdominal distension, vomiting, or wound infection. Earlier studies and risk models have consistently identified advanced age, male sex, anemia, chronic pulmonary disease, ascites, jaundice, emergency surgery, wound infection, and postoperative coughing as important contributors to abdominal wound dehiscence [1,2,6,7].

In India, a large proportion of emergency laparotomies are performed for perforation peritonitis, intestinal obstruction, bowel ischemia, trauma, and complicated appendicular or biliary disease. These patients frequently present late, with low albumin, anemia, dehydration, electrolyte imbalance, and heavy bacterial contamination. For this reason, local data are useful for prioritizing risk reduction strategies in routine surgical units. The present study was conducted at Government Medical College, Nalgonda, Telangana, to assess the risk factors for burst abdomen after emergency midline laparotomy. The primary aim was to identify risk factors associated with burst abdomen among patients undergoing emergency midline laparotomy. The objectives were to estimate the incidence of burst abdomen, compare patient-related, biochemical, operative, and postoperative variables between patients with and without burst abdomen, identify independent predictors using logistic regression, and describe short-term outcomes such as re-exploration, intensive care requirement, mortality, and length of hospital stay.

Study Design and Setting This hospital-based observational study was conducted in the Department of General Surgery, Government Medical College, Nalgonda, Telangana, India. Consecutive adult patients undergoing emergency midline laparotomy were enrolled from January 2024 to June 2026 and followed prospectively during the postoperative hospital stay. Study Population The study included patients aged 18 years or above who underwent emergency midline laparotomy for perforation peritonitis, intestinal obstruction, bowel ischemia, abdominal trauma, complicated appendicular pathology, or other acute abdominal conditions. Elective laparotomies, transverse or paramedian incisions, relaparotomies for indications unrelated to index emergency surgery, patients with pre-existing incisional hernia, and patients with incomplete records were excluded. Definition of Burst Abdomen Burst abdomen was defined as partial or complete separation of the abdominal fascial closure within 30 postoperative days, with or without evisceration, requiring bedside confirmation by the treating surgical team and/or operative confirmation during re-exploration. Superficial skin separation alone without fascial disruption was not counted as burst abdomen. Variables Studied Demographic variables included age, sex, body mass index, smoking history, diabetes mellitus, hypertension, chronic pulmonary disease, and previous abdominal surgery. Biochemical variables included preoperative hemoglobin and serum albumin. Operative variables included indication for laparotomy, degree of contamination, operative duration, timing of surgery, closure method, suture material, bite spacing, and documented suture length:wound length ratio. Postoperative variables included cough, vomiting, ileus or abdominal distension, surgical-site infection, need for re-exploration, ICU admission, mortality, and length of hospital stay. Surgical Technique and Postoperative Care All patients underwent emergency laparotomy through a midline incision. Perioperative antibiotics, fluid resuscitation, source control, lavage, bowel repair or resection, stoma creation, and drain placement were decided by the operating surgeon according to the clinical condition. Fascial closure was generally performed as continuous mass closure using a slowly absorbable or non-absorbable suture. Postoperatively, patients were monitored for fever, abdominal distension, cough, wound discharge, serosanguinous soakage, gaping, and signs of fascial disruption. Statistical Analysis Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, version 28.0 (IBM Corp., Armonk, NY, USA). Categorical variables were summarized as frequency and percentage. Continuous variables were expressed as mean with standard deviation. The chi-square test was used to compare categorical variables, and Fisher exact test was used when expected cell counts were small. Continuous variables were compared using the independent-samples t test. Variables with clinical relevance and a p value below 0.05 in univariate analysis were entered into binary logistic regression to identify independent predictors. Results were expressed as adjusted odds ratio with 95% confidence interval. A p value below 0.05 was considered statistically significant. Ethical Considerations The study was conducted after approval from the Institutional Ethics Committee of Government Medical College, Nalgonda, Telangana. Patient identity was protected during data collection and analysis. The ethics approval number may be inserted as per institutional record before journal submission.

A total of 180 patients who underwent emergency midline laparotomy were included. Burst abdomen developed in 22 patients, giving an incidence of 12.2%. The remaining 158 patients had no fascial dehiscence during the observed postoperative period. The baseline characteristics are shown in Table 1. Burst abdomen was more common in patients aged above 60 years, males, diabetics, underweight patients, anemic patients, and those with serum albumin below 3.0 g/dL.

Table 1: Baseline and biochemical characteristics of patients with and without burst abdomen

Values are shown as n/N (%) or mean +/- SD. Chi-square test was used for categorical variables and independent-samples t test for continuous variables. BMI, body mass index; g/dL, grams per deciliter

The operative and postoperative variables are summarized in Table 2. Generalized peritonitis or dirty wound, operative duration more than two hours, postoperative cough or repeated abdominal strain, superficial/deep surgical-site infection, and suture length:wound length ratio below 4:1 were significantly associated with burst abdomen. The distribution of selected risk factors is shown in Figure 1.

Table 2: Operative and postoperative factors associated with burst abdomen

Values are shown as n/N (%). Chi-square test was used for comparison. A p-value below 0.05 was considered statistically significant.

The timing of presentation is shown in Figure 3. Most cases were diagnosed between the sixth and eighth postoperative days. Eight patients presented between postoperative days 3 and 5, 10 between days 6 and 8, and four between days 9 and 12. Serosanguinous discharge, wound soakage, visible gaping, abdominal pain during coughing, and sudden reduction of abdominal wall support were the usual warning signs.

Variables with clinical and statistical relevance were entered into binary logistic regression. Surgical-site infection, serum albumin below 3.0 g/dL, hemoglobin below 10 g/dL, postoperative cough or strain, and suture length:wound length ratio below 4:1 remained independent predictors of burst abdomen (Table 3 and Figure 2).

Table 3: Multivariable logistic regression analysis for independent predictors of burst abdomen

Binary logistic regression was performed using variables significant in univariate analysis and clinically relevant variables. CI, confidence interval.

Figure 2: Forest plot showing independent predictors of burst abdomen. Odds ratios are shown on a logarithmic scale.

Short-term outcomes are presented in Table 4. Re-exploration was required in 20 of the 22 patients with burst abdomen. Patients with burst abdomen had significantly higher ICU admission, longer mean hospital stay, and higher in-hospital mortality than patients without burst abdomen.

Table 4: Short-term outcomes among patients with and without burst abdomen

Values are shown as n (%) or mean +/- SD. Fisher exact test was used where expected cell values were small.

The present study found a 12.2% incidence of burst abdomen after emergency midline laparotomy. This rate is higher than the incidence reported in mixed elective and emergency abdominal surgery cohorts, but it is understandable in a population restricted to emergency midline laparotomy, where peritonitis, contamination, bowel distension, sepsis, anemia, and poor nutritional reserve are common. Previous studies have shown that emergency surgery and wound infection are central determinants of fascial failure [1,2,5]. Our findings support this observation and further emphasize that biochemical depletion and postoperative mechanical strain work along with infection to produce closure failure.

Hypoalbuminemia was one of the strongest predictors in this study. Albumin is not only a nutritional marker but also a marker of systemic inflammation, hepatic reserve, and catabolic stress. Patients with low albumin may have delayed collagen deposition and reduced tensile strength during the early wound-healing period. Similar associations between hypoproteinemia, malnutrition, and wound dehiscence have been described in earlier clinical studies [4,7]. The association of anemia also has biological plausibility, as oxygen delivery is essential for collagen hydroxylation, fibroblast activity, and bacterial killing within the wound.

Surgical-site infection showed the highest adjusted odds ratio. Infection weakens the fascial repair through bacterial enzymes, inflammatory mediators, tissue edema, and impaired collagen remodeling. In the emergency setting, infection risk is increased by fecal contamination, delayed presentation, long operative duration, peritoneal soiling, and postoperative collections. The present results therefore support aggressive source control, timely antibiotics, gentle tissue handling, saline lavage when indicated, and close postoperative wound monitoring [8,9,17].

Postoperative cough or repeated abdominal strain was independently associated with burst abdomen. Sudden increases in intra-abdominal pressure can disrupt early fascial holding strength, especially when the wound is infected or the patient has low albumin. This underlines the value of postoperative chest physiotherapy, bronchodilator use in selected patients, pain control that permits effective breathing, nasogastric decompression when indicated, and early treatment of vomiting or ileus.

The suture length:wound length ratio below 4:1 remained a significant predictor. Closure mechanics are important because a short suture length or widely spaced bites concentrates tension at a few points and may produce cheese-wiring through edematous fascia. Evidence on midline closure supports continuous mass closure using slowly absorbable or non-absorbable suture with adequate bite size, controlled tension, and sufficient suture reserve [10-13,18-20]. In emergency laparotomy, the technique must be simple, reproducible, and carefully supervised even during night-time surgery.

The clinical outcomes in patients with burst abdomen were clearly worse. Most patients required re-exploration, and they had longer hospital stay, more ICU care, and higher mortality. These findings match the established view that burst abdomen is not just a wound event, but a marker of systemic illness and failed perioperative recovery [1,4,6]. A structured risk checklist may help identify patients requiring senior closure, retention strategies in selected high-risk cases, better nutritional support, and closer postoperative wound surveillance.

Limitations

This was a single-center study and included only emergency midline laparotomy cases from GMC Nalgonda. The sample size, although adequate for descriptive and univariate analysis, limited the number of variables that could be entered into the multivariable model. Some factors such as exact collagen disorders, micronutrient status, and intra-abdominal pressure were not measured. Closure technique was recorded from operative notes and direct observation wherever possible, but minor variation between surgeons could not be fully eliminated. Long-term incisional hernia after burst abdomen was not assessed because the study focused on early postoperative outcomes.

Recommendations

Emergency laparotomy patients should be screened for anemia, hypoalbuminemia, diabetes, sepsis, pulmonary disease, and expected wound contamination. Correction of reversible factors should begin before surgery when time permits and continue postoperatively. Fascial closure should be performed with adequate suture length, appropriate bite spacing, controlled tension, and senior supervision in high-risk cases. Postoperative protocols should include early detection and treatment of surgical-site infection, prevention of cough and vomiting-related strain, nutritional support, and early re-exploration when fascial disruption is suspected.

Burst abdomen after emergency midline laparotomy at GMC Nalgonda was associated with patient frailty, poor biochemical reserve, intra-abdominal sepsis, surgical-site infection, postoperative cough or strain, and inadequate fascial closure mechanics. Surgical-site infection and hypoalbuminemia were the strongest independent predictors. Prevention should therefore focus on early resuscitation, nutritional and anemia correction, meticulous source control, standardized abdominal closure, chest care, and close postoperative surveillance in high-risk patients.

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