An Experience of an Individual With a Chronic Wound in an Open Abdomen: A Grounded Theory

The open abdomen (OA) surgical technique has become an option for treating complex abdominal injuries; however, complications leading to late closure conditions might arise. In these cases the wound must be left open, which greatly impacts the patient’s life.Objective. The author aims to describe the experiences of individuals with a chronic OA wound. Methods. Qualitative design using grounded theory was utilized. This study was carried out with a group of 28 adults who were treated with OA technique and whose wound had remained open for more than a month in duration and only received outpatient wound care. Data were collected through open interviews and examined under continuous comparison. The average age of the respondents was 45 years, and their wound, treated with OA due to severe abdominal infection, remained open between 2 months and 8 years. Results. An emergent theory was developed to describe how people facing this experience undergo a process of 4 stages: 1) finding an OA wound upon waking, 2) feeling desperate about the healing process and the limitations involved, 3) regaining control of their life, and 4) taking advantage of their second chance at life with an OA wound. Conclusion. This study provides insight for nurses and other health care professionals into the experiences of patients with a chronic OA wound and proposes an emerging theory based on the conceptualization of these experiences.

Temporary closure of an open abdomen (OA) is required since the skin and fascia are not closed after laparotomy.¹ Therefore, it is necessary to help patients with therapeutical care in order to improve the prognosis of abdominal trauma, severe intra-abdominal infection,² intra-abdominal bleeding, intra-abdominal hypertension, and abdominal compartment syndrome as well as to manage or prevent possible postsurgical damage.³

An early OA wound closure is expected to occur as the abdominal fascia approaches, usually within 2 to 3 weeks after the abdomen is left open. When the abdominal fascia cannot re-approximate, a delayed closure is completed typically 6 to 12 months after the abdomen has been left open; therefore, it is necessary to administer synthetic grafts or organic meshes during the reconstructive surgery.⁴ If complications and reoperations occur, the options for deep reconstruction of the abdominal layers become progressively smaller.⁵

Prolonged maintenance of an OA for more than 1 year  may also lead to a reduced possibility of re-approximation of the fascia.⁶ The slowed recovery is associated with a mortality of 24.8% and several other related complications⁴ such as the development of a chronic ventral hernia, with an incidence of 13% to 80%⁷; wound infection; fistula formation; bleeding complications; disability; and loss of productivity.⁴

Many techniques for reconstruction of the abdominal wall have been described; however, most focus on the immediate care of the critical patient without the same consideration for the long-term sequelae.⁸ Treating the wound after OA largely is a clinical problem. Due to the torpid evolution of the healing process, the wound meets chronic classification criteria since it requires > 6 weeks to closure.⁹ These wounds are likely to have a negative impact on a patient’s life as documented for chronic wounds in legs.^10-12

The aim of this research was to describe the experience of an individual facing a chronic abdominal wound. Based on the literature review, this study takes into consideration, despite medical advancements describing pathophysiology and treatment,^13-15 the unknown impact of an OA on the patient. This knowledge allows nurses and other qualified health care providers to enhance their care of these patients.

The author carried out a qualitative study using grounded theory. Grounded theory is a qualitative method  based on symbolic interactionism,¹⁶ which inductively identifies a process the subject experiences and what it means for him/her. Herein, grounded theory describes both the impact this experience has on the individual and the process he/she goes through while having an OA. Data analysis followed the guidelines proposed by Strauss and Corbin.¹⁷ This method identifies the life course of an individual with an OA wound; while initially acute, wound healing fluctuates over time and the wound can become chronic due to the unpredictable course of life. 

This study was conducted in Bogotá, Colombia, from 2012 to 2014. Inclusion criteria consisted of people ≥ 18 years of age, who underwent surgical intervention with OA technique, who had an open wound lasting > 6 weeks, who had no abdominal reconstruction, and who had outpatient care and treatment. Individuals with wounds different from OA, who were hospitalized, and with cognitive impairments that would interfere with the development of the interview were excluded. 

The sampling criteria proposed by Strauss and Corbin¹⁷ was considered. Participants were contacted by nurses from different wound clinics through a person-to-person call strategy, which included people with different wound duration times, different educational levels and socioeconomic statuses, and severe infection as the leading cause of OA.

Meeting inclusion criteria was verified with each participant, and an appointment for the interview was arranged. Before the interview was conducted, participants were educated about the usefulness of this study, its purpose and significance, and the dynamics of the in-depth interview. All concerns were clarified. Subjects were instructed that the process could be interrupted at any time at their decision without consequence towards their treatment. Subsequently, written informed consent was obtained, data were registered in the sociodemographic file, and the recorded and transcribed interview was performed. This research considered national and international standards of ethics including resolution 008430 of 1993 of the Ministry of Health of the Republic of
Colombia, Nuremberg Code, and the Declaration of Helsinki and received approval from the Ethics Committee of the Faculty of Nursing of the National University of Colombia. The environmental policy of this university was also followed.¹⁸

The 2 questions that guided the interviews were as follows: What is the meaning of living with a wound in the abdomen; What does that mean for you? The interviews took 35 minutes on average, and they were stored on a voice recorder. Afterwards, for maintaining anonymity and confidentiality, the main researcher transcribed and codified the interviews. The codified and transcribed interviews were housed in Microsoft Word in ascending order as follows: E01, first interviewed patient; E02, second interviewed patient; and then consecutively until the entirety of the interviewed patients was complete. Each line of the interview transcripts was also listed. 

Data were analyzed manually following the coding criteria proposed by Strauss and Corbin.¹⁷ During the research process, scientific quality criteria established by Lincoln and Guba¹⁹ was taken into account. The terminology from the same patients were used during the construction of categories, and the consolidated information describing the experience was validated and returned to 5 of the subjects to verify the credibility of the findings. Furthermore, an outside expert on grounded theory, who carefully followed the analysis and interpretation of data, supported the process, supervised, and provided feedback to the researcher about the data interpretation. Memos were also written immediately after the completion of each interview.

Theoretical saturation was considered. The author consulted the proposals set forth by Munhall,²⁰ who points out that subjects who do not contribute new information in their interviews allow for a better understanding of their experience (in this case of having an OA wound) so it can be considered totally described.

Of the 28 subjects who participated in this study, there were 7 women and 21 men. All participants had been treated with the OA surgical technique and the wound remained open. By the time of the interview, OA wounds had been open between 2 months and 8 years.

Subjects described 6 categories related to the experience of having a chronic OA wound. These categories are not static, but vary over time and result in the formation of an emerging theory proposed by the author that describes an individual’s experience of living with an OA wound in 4 sequential phases called “a second chance in life with an open wound.” Some  examples of the original codes that formed the foundation to the theory are shown in the eTable. 

Stage I: realizing I woke up with a terrible wound in the abdomen. The person is in an unexpected health situation that requires emergency surgery, and from a surgicial complication the individual is left with an OA. Consequently, the individual requires multiple surgeries and support to address the OA and is hospitalized in intensive care and may remain unconscious for up to several weeks. 

When the patient wakes up and is fully aware, they notice the OA wound for the first time with shock. The individual fears opening the wound or causing additional damage to the OA as well as feels dependent on others for daily tasks (ie, bathing, eating, walking. With acknowledgment of the difficulties ahead of him/her, the patient experiences mixed emotions regarding the possible death he/she faced.

During hospitalization, the individual regains their strength and is determined to return home quickly; he/she learns to walk again, re-establishes eating habits, and becomes cognizant of their bodily changes from the OA. Information is provided on the necessity for the patient to return home with an OA until a second attempt at closure can be made instead of contracting a potential infection from remaining in the hospital. At this stage, a subject said:

“The day I woke up, I was there in the room. The doctor and a nurse came in, opened me, and I saw that thing just like that [the wound in the abdomen], it was big. That you have to be very careful when moving and all of that because the wound is big, so of course, that day I was really shocked ... for me, the consternation was huge. Imagine seeing everything completely red and naturally, resentful, as I tell you, that traumatized me a lot.” (E01)

Stage II: becoming desperate when seeing how the wound changes and limits my life. The person returns home with the OA wound, and the initial motivation that pushed him/her to fight to be discharged from the hospital starts to fade because of the relaxed setting at home. The patient is more aware of their bodily changes and limitations from the OA. Feelings of anger and sadness manifest when the patient looks at his/her body, and he/she may think of their body as deformed now. Moreover, while the wound remains open, the patient does not have a navel and scars are forming; these reminders of a forever-changed body sadden the patient. The wound constantly drains and produces a foul odor to the point where the patient withdraws from interacting with others and pulls back from society. 

The individual remains idle most of the time and limits their bodily movement for fear of worsening the OA. He/she limits time outside of the home and usually leaves only when accompanied by another individual to limit the possibility of others accidentally bumping into their OA, which also includes the patient’s anxiety towards using public transportation. The individual continues with the treatment to close the wound, but it remains open and they often wonder what else he/she could do to progress healing. Examples of the expressions that reflect this situation include:

“I left the hospital and in fact going out with the open abdomen is not very good, let’s say it in that way, and everything becomes more complicated.”  (E21)

“The discomfort of the wound and the despair that it is not closing, it is impossible that this thing is not closing.” (E01) 

“Wondering every single day why? Why isn’t it closing? Why not? It is now more than a year, and yesterday the doctor told me that another surgery might be needed, so that has already affected me a lot. It has affected me a lot.” (E04) 

Stage III: regaining control of my life. When the person understands the doctors can do nothing more to close the wound at that time and only with their own effort will they regain their life, he/she looks for ways to take control. The individual is often motivated by the progression of his/her wound towards closure, a support system in place, a strong faith, and, despite some limitations, improvement in daily activities (ie, walking). 

Because of this renewed energy, the patient identifies activities he/she can perform independently or with little help. Moreover, the individual begins to bathe (with consciousness of the dressing), monitor his/her nutritional intake, and walk without assistance. 

For someone in this recovery, to walk without help from others is an important step in taking control of their own life. Doing things for one’s self, adapting to be independent, and even helping in housework are useful in leaving behind feelings of being overwhelmed with socializing with others, doing things for one’s self, adapting to independence, and even helping in housework are useful in leaving behind the feeling of being overwhelmed. 

Patients with an OA wound expressed their altered perception of the bodily changes they have undergone and the emotions surrounding their intimate life with their partner. At this stage similar statements to the following arise: 

“Well, it’s like, you come back to your own chores and you feel good, I’m learning again; once more I’m taking control of my things, moving alone, and you start to be courageous enough. I can, I will do it.” (E26) 

Stage IV: a second chance in life. In this stage, the patient assumes all wound care responsibility for their OA with permanent compression bandage dressings, but when he/she is unable to do so, he/she moves cautiously, stabilizes nutritional intake, and continues to progress towards and learn about healing at home either on their own or with an experienced caregiver. In addition, the individual learns how to manage wound exudate (albeit decreasing but still persistent) and take better care of the wound, thereby preventing a foul odor. Incorporating these characteristics into his/her daily activities improves the patient’s overall quality of life. 

The individual achieves 2 crucial steps that show their recovered independence and ability to overcome the fear of being in contact with people: 1) attending follow-up appointments alone, and 2) driving a car or taking public transportation. Becoming independent through mobilization is part of the recovery process. Usually this change happens without excessive difficulty in performing physical activity.

Due to the positive progression of the wound, the patient (if faithful) feels gracious towards God for a second chance at life; the individual acknowledges he/she survived a serious illness. The relationship between the patient and their family improves. Likewise, personal reflection on his/her experience allows the individual to assess the challenges overcame and shows him/her new ways to enjoy life despite having limitations. Optimism leads the patient to believe their wound will close, and their future will improve. 

Upon seeing their physical appearance, the individual now remembers their proximity to death rather than their negative feelings towards the wound. This new sentiment allows the patient to face regrets, push vanity aside, and learn how to enjoy life.

Both faith and hope that the wound closes are basic requirements for the person to be ready to receive a new surgery to attempt OA wound closure. This new surgery would force them to become dependent again, but they know the process is transient as it was in their initial surgery. A couple accounts of subjects with an OA reported the following: 

“God gave me a second chance by putting me in the hands of these doctors and nurses who were very devoted to me. And I have been able to become strong enough to carry on, and the support of my family has always been there thanks to God.” (E18) 

“I do not know. I think God has a purpose and things just do not happen, God gave me another chance to be, as the saying goes, ‘telling stories.’” (E23)

According to the literature, people can have an open wound up to 300 days⁴; however, the present study found that some people had an open wound for up to 8 years. This study shows the effect living with an OA wound has on the patient and validates studies reporting that the acute impact of an injury after suffering a trauma causes a decrease in the quality of life, in which the recovery takes a minimum of 1 year to return to baseline.^21-23

With feelings of lost independence, the individual with an OA views themselves as unprotected, exposed, and helpless. The patient accounts described herein are comparable to the findings of Goldberg and Beitz²⁴ and Beitz and Goldberg,²⁵ which describe the experiences of individuals living with chronic wounds caused by diseases where the loss of mobility and independence as well as the lengthy recovery process comprise part of the results. There were also excerpts describing experiences of some stressful stages such as the individual’s stay in the intensive care unit,²⁶ proximity to death, lack of knowledge about the disease, and negative self-image that can lead the patient to mourn their previous life and appearance — similar to mourning the death of a loved one.²⁷

Similar to the limitations patients experienced regarding mobility in this study, González-Consuegra and Verdú¹¹ studied individuals with leg ulcers and indicated that they also reduce mobility, to avoid pain; however, patients with an OA do so out of fear of worsening their wound. 

All of this causes the person to undergo a transformation involving a significant change of values, identity, and activities that can be described as more important than returning to a normal state.²⁸

This study reinforces results that demonstrate the condition of individuals suffering with a chronic illness as well as the importance of taking care of the totality of the human being.²⁹ Moreover, these results invite researchers to review the mechanisms that establish how people take the positive aspects of an illness, and, despite adversity, look for positive aspects and try to maintain self-care.³⁰

The findings of this study are derived from a small sample of participants from a city in Colombia. All participants in this study live in the urban area, which means their experience may be different from a person living in a rural area where accessibility to the health care system is different.

Living with a chronic OA wound forces the patient to regain control of their life after their near-death experience; this makes the individual feel vulnerable and dependent on others unexpectedly. The patient also must overcome adversity when living with the aforementioned bodily changes, requiring help from others, and facing dramatic lifestyle changes such as caring for the wound, being cognizant of physical movements, and interacting with others. This study provides the narration of patients with OA wounds who have overcome their mixed emotions and fears of living with a chronic, open wound as well as regained and established a new life following this experience and surgical complication.

In terms of a patient’s discipline with caring for the wound, comprehensive care is provided by a support team of clinicians, nurses, and loved ones. It should be noted that caring for an individual with an OA wound is not only about treating the wound but also the patient. Caregivers must consider all aspects affecting the patient that have been described herein.

This study is a contribution to understanding the experiences of people living with an OA wound in order to add to the current knowledge. Further research in the same vein is needed to better understand the impact of an OA wound on an individual and increase the awareness for professional developments in nursing.

From the Universidad de La Sabana, Chía, Cundinamarca, Colombia

Address correspondence to:
Alejandra Fuentes-Ramírez, PhD
Universidad de La Sabana 
Campus del Puente del Común 
Km 7, Autopista Norte de Bogotá
Chía, Cundinamarca
Colombia
alejandra.fuentes@unisabana.edu.co

Disclosure: The authors disclose no financial or other conflicts of interest.