Surgical Wound Dehiscence Treatment With Low-Level Laser Therapy and Barbatimão: A Case Report

Surgical wound dehiscence (SWD), a rupture or splitting open of a previously closed surgical incision site, may occur after any type of surgery. SWD is classified as either a superficial or deep tissue injury.¹ Modern techniques and technologies, such as negative pressure wound therapy and synthetic or biological repair, can improve the management of SWD.² However, there are other alternatives, such as low-level laser therapy (LLLT).

Experimental approaches in animal models have shown the effective use of LLLT in wound healing, pain relief, reducing inflammation, and inhibition of fibroblast proliferation.^3-6 Case studies (n = 1 patient with SWD in each study) have shown that LLLT is a safe and efficient noninvasive wound care method.^7,8 A systematic review that investigated whether the clinical use of LLLT was effective in healing diabetic foot ulcers showed therapeutic outcomes and no adverse events, but the evidence was limited.⁹

LLLT can be combined with other alternative therapies. An in vitro study that investigated the effect of LLLT combined with guarana extract demonstrated antioxidant, anti-inflammatory, anti-apoptotic, and proliferative effects on fibroblasts.¹⁰ An in vivo study of the effect of LLLT and Policaju obtained from cashew tree (Anacardium Occidentale L.) gum and chitosan on the healing of skin wounds showed better wound contraction, more collagen, minor focal necrosis, and early epithelialization when compared to 0.1 mL of 0.9% NaCl as a control.¹¹

Stryphnodendron spp, popularly known as Barbatimão, a native Brazilian tree, is often used to treat wounds and infections.¹² Brazil has policies to promote the development of phytotherapy^13-15 because this type of therapy can provide care to economically challenged patients through the basic health care system.¹⁵ Given these policies and the broad use of ethnopharmacology, quality control, correct identification, and the conservation of species are essential requirements to ensure that treatment is accurate and to prevent toxicity or dilution of the dose with impurities.¹⁵

Previous in vivo studies suggested that Barbatimão modulated the proliferation of keratinocytes and improved wound healing when compared to treatment with a base ointment without extract.^16,17 A study carried out on rabbit wounds showed that Barbatimão stimulated collagen fiber production, promoted thicker crust formation on the wound, and, in the remodeling phase, favored the organization of collagen fibers.¹⁸ In clinical applications (n = 27 with 57 wounds), Barbatimão improved the healing of stage 1 and 2 pressure injuries between 3 and 6 weeks after beginning treatment.¹⁹ Furthermore, the cost of Barbatimão makes it accessible, and it has been indicated for the treatment of SWD, although there is insufficient evidence to support a definitive recommendation.

The purpose of this case study was to describe the outcome of using LLLT combined with Barbatimão gel in a patient with SWD. The study was reviewed and approved by the University Ethics Committee for Human Research (no. 4.488.315). The patient provided written consent, including the use of photographs.

A 54-year-old woman without comorbidities underwent aesthetic abdominoplasty 3 weeks previously at another health facility. The incision was red, hot, and swollen 8 days postoperatively. The patient presented to the authors’ institution on July 2, 2020, after an episode of syncope, abrupt dyspnea, and purulent exudate in the surgical incision 15 days after surgery. The wound showed necrotic sloughing. The patient was admitted to the authors’ institution.

Physical examination revealed that the patient was anicteric and acyanotic, with discolored mucous membranes (1+/4+) and dehydration (1+/4+). Vital signs were as follows: temperature, 36.6°C; blood pressure, 112/80 mm Hg; pulse rate, 110 beats/min; respiratory rate, 28 breaths/min; and oxygen saturation, 98% with nasal catheter 3 L/min. Physical examination revealed a dehisced surgical wound of almost 10 cm, with necrotic tissue of approximately 5 cm x 5 cm in the infraumbilical region, extending to the umbilical stump, and a greenish exudate without odor. Lower limb edema was present, but there were no signs of deep vein thrombosis. Bilateral pulmonary embolism of intermediate to severe risk was diagnosed by point-of-care ultrasound examination. Intravenous antibiotic and full anticoagulation therapies were started, and oxygen nasal catheter therapy was continued. The patient denied the use of continuous medications or comorbidities and reported that she had never smoked. On day 3 of the hospital stay, the patient’s condition improved and surgical debridement was performed under general anesthesia. After debridement, the wound was treated with topical 2% polyhexamethylene biguanide (PHMB) gel and rayon gauze (nonadherent gauze); the dressing was changed daily.

The patient was discharged from the hospital on July 17, 2020, when the wound bed had 100% granulated tissue. Continuing topical therapy was recommended, but the patient was unable to afford this. Therefore, the hospital provided a free sample of 2% PHMB gel and recommended daily dressing changes.

Follow-up care of wound dehiscence was provided in the outpatient clinic. The patient was instructed to consult the service that had performed the abdominoplasty regarding treatment of the wound, but she expressed no interest in doing so. When the patient returned to the outpatient clinic on July 27, 2020, the wound bed showed no change after 10 days of conventional treatment with 2% PHMB gel and gauze dressings changed daily. After discussion with a team of doctors, nurses, and professors, it was decided to treat the wound with LLLT and topical 10% Barbatimão gel.

Laser therapy was applied on the wound bed and edge using a redwavelength probe containing seven (7) 625-nm wavelength light-emitting diodes (bandwidth, 5 nm), a spot area of 1 cm², and an optical power output of 25 mW. The radiation was applied by administering 4 J/cm². A total of 4 J/point was applied to central, medial, lateral, distal, and proximal points over the extent of the wound bed and edge. The laser was positioned 2 cm above and perpendicular to the surface of the wound bed and edge during irradiation.

Every week, the patient returned to the outpatient clinic, the wound bed was cleaned with 0.9% saline solution and measured, laser therapy was applied, and 10% Barbatimão gel was applied to the wound bed and covered with gauze. The lesion was photographed on each visit by the same examiner to evaluate wound closure. The wound area was measured using ImageJ software (National Institutes of Health). The patient was instructed to change the dressing daily, clean the wound with sterile saline solution, and apply the 10% Barbatimão gel. It was also recommended to change the secondary dressing whenever saturated, and the edges were protected with zinc oxide. After almost 3 months, the wound healed and the scar was barely visible (Figure 1 and Figure 2). The patient was discharged from the outpatient clinic.

The decision to combine herbal medicine and LLLT was based on the hypothesis that this combination could promote tissue repair. To the authors’ knowledge, this is the first case report in the literature using Barbatimão and LLLT together to treat SWD.

A previous study that investigated the management of SWD in a cohort of patients after discharge showed that 84% of patients with SWD experienced healing within 6 weeks and 15% within 3 months. However, in the group of patients who experienced healing within 6 weeks, 47% received topical antimicrobial dressings or treatment solutions because a wound infection was identified or clinically suspected.²⁰ In the group that experienced healing within 3 months, 63% received topical antimicrobial dressings or treatment solutions for infection.²⁰ In the current case report, the wound healed within 84 days. This suggests that topical 10% Barbatimão gel combined with LLLT is a potentially effective therapy for SWD management that could help heal these wounds.

The patient had no comorbidities, did not receive high doses of steroids, and never smoked. These factors suggest that it was only the infection at the surgical site that triggered the delay in the postoperative healing process and culminated in the dehiscence of the surgical site. Then, the treatment of the infection and subsequent topical care plus LLLT facilitated healing. Other reports in the literature have shown that the most common types of complications at the surgical site are infections following neurological, cardiovascular, gastrointestinal, and orthopedic surgical procedures, and in individuals with comorbidities, which thus differ from this case report.^21,22

The authors believe that, in the absence of access to modern techniques and technologies, the combination of 2 complementary therapies, LLLT applied once a week and Barbatimão gel applied daily to the wound, could be an option for the treatment of SWD.

A limitation of this study is the small sample size, which can influence the reliability of the results. In addition, the outcome of this case study cannot be generalized to other patients.

The outcome of this case report suggests that the combination of LLLT and Barbatimão gel could facilitate healing in patients with SWD. More research is needed to assess the effect of LLLT combined with Barbatimão for the correction of SWD in more complex conditions, in patients with comorbidities, and compared with other topical management strategies. Studies evaluating histological parameters to understand the molecular and cellular evolution of tissue repair mechanisms in response to this topical treatment are also important.

Ms Breder is a doctoral student, Dr Tsukumo is a doctor, Dr Pereira is an associate professor, and Dr Lima is an associate professor, School of Nursing, University of Campinas, Campinas, São Paulo, Brazil. Address all correspondence to: Maria Helena Lima, RN, PhD, Rua Tessália Viera de Camargo, 126 CEP 13083887, Campinas, SP, Brazil; email: mhmelolima@gmail.com.

This work was supported by the Sao Paulo Research Foundation FAPESP (grant 2020/04522-5).

None disclosed