POLSKI

PRZEGLĄD CHIRURGICZNY 10.2478/v10035-012-0094-0

2012, 84, 11, 565–573

Risk factors for wound dehiscence after laparotomy

– clinical control trial*

Jakub Kenig, Piotr Richter, Sabina Żurawska, Anna Lasek,

Katarzyna Zbierska
3rd Department of General Surgery, Jagiellonian University Collegium Medicum in Cracow
Kierownik: prof. dr hab. W. Nowak

Described in the literature dehiscence rate in the adult population is 0.3-3.5%, and in the elderly group
as much as 10%. In about 20-45% evisceration becomes a significant risk factor of death in the periop-
erative period.
The aim of the study was to identify the main risk factors for abdominal wound dehiscence in the
adult population.
Material and methods. The study included patients treated in the 3rd Department of General Surgery,
Jagiellonian University Collegium Medicum in Cracow in the period from January 2008 to December
2011, in which at that time laparotomy was performed and was complicated by wound dehiscence in
the postoperative period. For each person in a research group, 3-4 control patient were selected. Selec-
tion criteria were corresponding age (± 2-3 years), gender, underlying disease and type of surgery
performed.
Results. In 56 patients (2.9%) dehiscence occurred in the postoperative period with 25% mortality.
The group consisted of 37 men and 19 women with the mean age of 66.8 ± 12.6 years. Univariate
analysis showed that chronic steroids use, surgical site infection, anastomotic dehiscence/fistula in the
postoperative period and damage to the gastrointestinal tract are statistically significant risk factors
for dehiscence. Two first of these factors occurred to be independent risk factors in the multivariate
analysis. In addition, due to the selection criteria, a group of risk factors should also include male
gender, emergency operation, midline laparotomy, colorectal syrgery and elderly age (> 65 years).
Logistic regression analysis did not show that a particular surgeon, time of surgery or a particular
month (including holiday months) were statistically significant risk factor for dehiscence.
Conclusions. Wound dehiscence is a serious complication with relatively small incidence but also
high mortality. Preoperative identification of risk factors allows for a more informed consent before
patient’s treatment and to take measures to prevent or minimize the consequences of complication
associated with it.
Key words: dehiscence, risk factors

Spontaneous durability of the wound in the
first day after surgery is virtually non-existent
and gradually increases with time. In third
week after surgery the durability equals 20%
of the initial strength, and after 6-12 weeks it
reaches 70-80% (1). Sutures placed during the
surgery should allow the tissues the necessary
time to regain structural and functional integ-
rity. If the healing process is disturbed, this
can lead to partial or complete dehiscence of
individual layers of the sutured wound or to
wound dehiscence along its entire depth, called
eventration. Usually dehiscence or eventration
occur 4 to 14 days after surgery (on the 8th day
on average). The incidence of this laparotomy
complication is estimated to be 0.3–3.5%, and

* This study was not sponsored

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566 J. Kenig et al.

as much as 10% in elderly patients. In 20–45% Material and methods

of cases, wound dehiscence/eventration be-
comes the main cause of death (2, 3). A number
of papers on this subject identified various risk
factors which can lead to this condition. They
included age (>65 years), gender (male), to-
bacco smoking, obesity, chronic steroid treat-
ment, anemia, jaundice, uremia, diabetes,
hypoalbuminemia, chronic obstructive pulmo-
nary disease (COPD), neoplastic disease,
wound infection and emergency surgery. Fur-
thermore, factors related to the surgery itself
were identified, and included the incision loca-
tion, technique and type of the closing suture
as well as the degree of postoperative hypo-
thermia, oxygenation and blood supply (4).
There are also papers indicating that in many
cases the operating surgeon themselves is a
risk factor for wound dehiscence (5). However,
the most important single factor leading to this
complication is wound infection. Studies indi-
cate that the best technique for closing a verti-
cal incision wound is to use a continuous
monofilament suture, non-absorbable or
slowly absorbable, applied through all layers
(except for the skin), with the suture length to
wound length ratio of 4:1 (6, 7).
The aim of this study was a detailed retro-
spective analysis of risk factors leading to
wound dehiscence/eventration in patients un-
dergoing surgery in the 3rd Department of
General Surgery, Jagiellonian University Col-
legium Medicum in Cracow.
Study group
A retrospective analysis was performed on
data of patients treated in the 3rd Department
of General Surgery, Jagiellonian University
Collegium Medicum in Cracow, in the period
from January 2008 to December 2011. The
study included a group of patients who under-
went laparotomy during this period, compli-
cated by postoperative wound dehiscence. In-
dications and the scope of procedures are
listed in tab. 1.
Control group
For each person in a study group, 3-4 control
group patients were selected to undergo lapa-
rotomy at a similar time (time interval of 1 day
to 1 month). The selection criteria included
conformity of age (±2-3 years), gender, under-
lying disease and the type of surgery per-
formed.
Data
The database included factors related to the
patient, the condition that was the reason of
admission as well as the surgical treatment
performed. Particular emphasis was placed on

Table 1. Indications and procedure scope in the group of patients with wound dehiscence

Indications (number) Surgery (number)

colon cancer + rectal cancer 9+9 stomach 6
stomach cancer 2 small intestine 7
neoplasm of the pancreaticoduodenal region 2 large intestine 28
gastrointestinal tract perforation 6 gall‑bladder/bile ducts 5
gastrointestinal tract obstruction 6 liver 2
cholecystitis/choledocholithiasis 4 pancreas 1
splenectomy 1
acute pancreatitis 1 abdominal wall plastic surgery 2
abdominal injury 4 exploratory laparotomy (lysis of adhesions) 4
acute appendicitis 4
intestinal inflammatory diseases: 4
– Crohn’s disease 1
– ulcerative colitis 3
foreign body in the gastrointestinal tract 1
hernia in the laparotomy scar 1
closure of loop ileostomy 1
morbid obesity 1
embolism of the inferior mesenteric artery 11

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 Risk factors for wound dehiscence after laparotomy – clinical control trial 567

analysis of risk factors already described in
papers, i.e.: age (>65 years), gender (male),
neoplastic disease, COPD or pO2 <60 mm Hg
and pCO2 <30 mm Hg, malnutrition (decreased
albumin level <30 g/l or decreased body weight
>=10%), presence of sepsis, obesity ≥30 kg/m2,
anemia (hemoglobin level <10 mg/dl), diabetes,
hypertensive disease, coronary heart disease,
chronic steroid treatment in the last 12 months
and tobacco smoking. Factors related to sur-
gery included the operating surgeon as a risk
factor as well as the setting of surgery (elective
or emergency surgery), exact time of surgery,
procedure type, technique, suture type used
for closure of the layers and additional use of
anti-eventration sutures. Postoperative com-
plications were analyzed in detail, with par-
ticular emphasis put on infection of the surgi-
cal site. A comparison was performed of dehis-
cence time, length of hospital stay, necessity
of treatment in the intensive care unit (includ-
ing length of stay in the ICU) and number of
deaths.
Statistical analysis
To describe the study results qualitative
and quantitative data were used. Quantitative
parameters were expressed as the mean value
± standard deviation. The remaining cases
were coded using Arabic numerals. The data
were analyzed using STATISTICA 10.0 soft-
ware suite (StatSoft). The Shapiro-Wilk W test
and the Kolmogorov-Smirnov test with the
Lilliefors correction were used to verify the
normality of distribution of results. Depending
on the result of the normality of distribution,
the data were analyzed using parametric or
non-parametric tests. For all variables, both
qualitative and quantitative, a univariate re-
gression analysis was performed. Variables
demonstrating statistical significance in the
univariate analysis were included in a multi-
variate analysis to determine independent risk
factors. The null hypothesis (H0) was rejected
at the established level alpha = 0.05.
Results
During the study period 1,879 laparotomies
were performed. Postoperative wound dehis-
cence was observed in 56 patients, that is in
2.9% of procedures. The group consisted of 37
men and 19 women, which means there was a
statistically significantly greater number of
men in this population (p < 0.05). The mean
age was 66.8±12.6 years. Postoperative wound
dehiscence occurred on average after 9.8±6.5
days (median: 8 days). Mortality in this group
reached 25%. There was a statistically sig-
nificantly greater number of patients admitted
in an emergency setting: 45 (80.4%) vs. 11
patients admitted in an elective setting
(p<0.01). No statistically significant age differ-
ence was reported in patients undergoing
elective surgeries. On the other hand, in an
emergency setting women were statistically
significantly older than men (74.2±10.7 vs.
63.4±13.1 years; p < 0.05).
Comparison of female and male populations
with dehiscence
A comparison of the study group members
based on gender (tab. 2) did not reveal any

Table 2. Comparison of the female and male populations with dehiscence

Factor Female Male P value

Number 19 37 0,05
Age (years) 71,7+12,7 64,3±12,4 0,04
Surgery setting:
– elective (11 patients) 4 (21,1%) 7 (18,9%) 0,84
– emergency (45 patients) 15 (79%) 30 (81,1%) 0,82
Neoplastic disease 10 (52,6%) 15 (40,5%) 0,38
Concomitant diseases:
– hypertensive disease 11 (58%) 17 (45,9%) 0,39
– coronary heart disease 10 (52%) 14 (37,8%) 0,28
– diabetes 4 (36%) 5 (13,5%) 0,47
– COPD 2 (11%) 8 (21,6%) 0,3
– other 17 (89%) 26 (70,3%) 0,1
Previous surgeries 8 (42,1%) 18 (48,6%) 0,6

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568 J. Kenig et al.

Factor Female Male P value

Tobacco smoking 5 (26,3%) 10 (27%) 0,7
Chronic steroid treatment 1 (5,3%) 6 (16,2%) 0,2
Procedures involving opening of the gastrointestinal tract 16 (84,2%) 31 (83,8%) 0,46

Surgery type:
– stomach/duodenum 3 (15,8%) 2 (5,4%) 0,2
– gall-bladder 1 (5,3%) 4 (10,8%) 0,5
– small intestine 1 (5,3%) 8 (21,6%) 0,2
– large intestine 11 (57,9%) 17 (46%) 0,6
– other 3 (15,8%) 6 (16,2%) 0,9
Time to wound dehiscence 9,45+6,9 10,5+5,9 0,56
Vertical incision 18 (95%) 30 (81%) 0,16
Stay in the ICU 8 (42,1%) 18 (48,6%) 0,64
Biochemical tests:
– WBC 13,6±5,6 12±6,2 0,3
– HCT 34,7±5,5 36,6±8 0,4
– HGB 10,8±1,7 12,8±5,4 0,15
– CRP 152,2±130,9 111,3±92,5 0,3
– albuminy / albumin 25±4,2 33,3±13,4 0,05
– białka / protein 49,4±7,9 53,6±15,6 0,5
– kreatynina / creatinine 96,3±28,5 100,8±52,7 0,4
Death 6 (31,6%) 8 (21,6%) 0,41

difference in the setting of surgery, presence/
lack of neoplastic disease and other concomi-
tant diseases, time to dehiscence, tobacco
smoking, chronic steroid treatment, number
of previous surgeries, type of the present sur-
gery, length of hospital stay (including length
of stay in the ICU), leukocyte count, hematocrit
level, hemoglobin level and protein level. Sta-
tistically significantly lower albumin level at
admission was reported in the female popula-
tion compared with the male population
(33.3±13.4 vs. 25±4.2 g/l; p < 0.05), with no
difference in leukocyte count and CRP level.
On the other hand, opening of the abdomen
using a vertical incision was statistically sig-
nificantly more frequent in the group with de-
hiscence than other types of opening (48 vs. 8
persons; p < 0.01). A comparison of the female
and male populations with dehiscence revealed
no statistically significant difference (p = 0.16).
Comparison of results in the study and
control groups
A comparison of the study group with the
selected control group demonstrated that the
study group was characterized by a statisti-
cally significantly greater incidence of surgical
site infection and greater incidence of circula-
tory failure in the postoperative period. The
patients also required a longer stay in the ICU,
and their hospital stay was statistically sig-
nificantly longer (tab. 3). The remaining pa-
rameters listed in tab. 3 showed no statisti-
cally significant difference.

Table 3. Comparison of the study group with the selected control group

Factor Wound dehiscence Control group P value

Number of patients (M/F) 56 (37/19) 168 (95/73) 0,2
Age (years) 66,6±13 66,8±12,8 0,87
Surgery setting:
– elective (11 patients) 11 (20%) 44 (26,2%) 0,27
– emergency (45 patients) 45 (80%) 124 (73,8%)
Surgery type:
– stomach/duodenum 5 (9,1%) 14 (8,3%) 0,84
– gall-bladder 5 (9,1%) 13 (7,7%) 0,74
– small intestine 9 (16,4%) 36 (21,4%) 0,41
– large intestine 27 (49,1%) 83 (49,4%) 0,94
– other 10 (16,4%) 22 (13,1%) 0,56

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 Risk factors for wound dehiscence after laparotomy – clinical control trial 569

Grupa rozejścia
Grupa kontrolna /
Czynnik / Factor rany / Wound P value
Control group
dehiscence
Procedures involving opening of the gastrointestinal tract 42 (76,4%) 122 (72,6%) 0,16
Neoplastic disease 24 (43,6%) 71 (42,3%) 0,85
Concomitant diseases:
– hypertensive disease 28 (50,9%) 92 (54,8%) 0,61
– coronary heart disease 23 (41,8%) 61 (36,3%) 0,46
– diabetes 8 (14,5%) 28 (16,7%) 0,71
– COPD 9 (16,4%) 16 (9,5%) 0,16
– other 42 (76,4%) 116 (69%) 0,3
BMI:<20,5/20,5-30/>30 kg/m2 (n) 12/31/13 24/119/24 0,12
Previous surgery (n) 25 (45,5%) 91 (54,2%) 0,26
Tobacco smoking 15 (27,3%) 41 (24,4%) 0,67
Chronic steroid treatment 7 (12,7%) 6 (3,6%) 0,84
Surgical site infection 34 (61,8%) 23 (13,7%) <0,01
Anastomotic dehiscence/fistula 5 (8,9%) 5 (3%) 1
Circulatory failure (n) 21 (37,5%) 43 (25,6%) 0,04
Vertical incision (n) 47 (83,9%) 143 (85,1%) 0,95
Anti-eventration sutures (n) 13 (23,2%) 27 (16,1%) 0,2
Procedure time (n):
7-15.00 24 (42,9%) 81 (48,2%) 0,68
15.01-23.59 26 (46,4%) 73 (43,5%) 0,73
00.00-6.59 6 (10,7%) 14 (8,3%) 0,89
Stay in the ICU (n) 25 (45,5%) 39 (23,2%) 0,001
Length of hospital stay (days) 38,3±27,1 15,8±12,9 <0,01
Biochemical tests:
– WBC 12,5±6,0 11,6±5,9 0,3
– HCT 35,9±7,2 37,7±6,4 0,1
– HGB 12,2±4,6 12,4±2,2 0,7
– CRP 127,13±108,2 111,49±100,27 0,5
– albumin 30,2±12,9 32,69±9,6 0,3
– protein 52,44±13,9 56,85±13,8 0,2
– creatinine 104,4±62,5 91,98±63,7 0,3
Time to wound dehiscence (days) 9,8±6,5 -
Death 13 (23,2%) 34 (20,2%) 0,6

Risk factor analysis

Risk factor analysis performed by means
of univariate logistic regression in the group
with dehiscence and the control group
showed that chronic steroid treatment, sur-
gical site infection, anastomotic dehiscence/
fistula, circulatory failure in the postopera-
tive period and damage to the gastrointesti-
nal tract are statistically significant risk
factors for wound dehiscence. The remaining
factors, patient-, disease- and treatment
related (the surgeon, time of day and month
(including holiday months), performing of
the procedure, type of closure of the layers
(a continuous vs. single suture) and neces-
sity of concomitant surgery of a different
organ) did not constitute statistically sig-
nificant risk factors (tab. 4).

Table 4. Analysis of risk factors in the study group using logistic regression

Odds ratio confidence

Regression Odds
Factor interval P value
coefficient ratio
min. max.
Oncological procedure 0,17 1,2 0,7 2,0 0,5
Procedure involving opening of the -0,03 1,3 0,4 4,1 0,6
gastrointestinal tract
Organ undergoing surgery 0,13 0,9 0,4 2,1 0,9
Coronary heart disease 0,23 1,1 0,7 1,8 0,5

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570 J. Kenig et al.

Współczynnik Przedział ufności dla

regresji / Iloraz ilorazu szans / Odds ratio
Czynnik / Factor P value
Regression szans confidence interval
coefficient min. max.
Hypertensive disease -0,3 0,8 0,5 1,2 0,2
Diabetes -0,4 0,7 0,4 1,2 0,2
Respiratory tract diseases 0,2 1,2 0,7 2,2 0,4
Previous surgery 0,7 1,9 0,8 4,8 0,1
Tobacco smoking 0,3 1,3 0,8 1,7 2,1
Chronic steroid treatment 0,7 2,1 1,1 4,5 0,05
Surgical site infection 1,3 3,7 2,4 5,7 <0,0001
Anastomotic dehiscence/fistula 0,1 1,8 1,4 2,0 0,05
Circulatory failure 0,09 1,0 0,43 2,73 0,8
Two-organ surgery 0,1 1 0,4 2,2 0,9
Vertical incision vs. other 0,1 1,1 0,5 2,2 0,9
Additional supporting sutures -0,1 0,9 0,3 1,2 0,8
Purulent material in the abdominal cavity -0,6 0,6 0,6 5,9 0,1
Damage to the gastrointestinal tract 0,7 2,1 1,2 4,4 0,05
Operating surgeon 0,13 1,2 0,7 1,6 0,6
Time of procedure:
– month 0,02 1 0,9 1,1 0,7
– time of day -0,1 0,9 0,5 1,4 0,6
Malnutrition (≤20.5) 0,2 1,2 0,6 2,3 0,4
Obesity (BMI ≥30) 0,2 1,2 0,7 2,4 0,5
Biochemical tests:
– albumin 0,03 1,0 0,9 1,1 0,4
– protein -0,05 0,9 0,8 1,1 0,3
– leukocytes 0,001 1 0,9 1,1 0,4
– CRP 0,001 0,9 0,7 1,2 0,8
– hemoglobin 0,007 1 0,8 1,3 0,5
– hematocrit 0,015 1 0,9 1,1 0,1
– creatinine 0,005 1 0,9 1,1 0,3

Multivariate analysis demonstrated that
only chronic steroid treatment and surgical
site infection are independent risk factors for
postoperative wound dehiscence.
Discussion
Wound dehiscence is a serious postoperative
complication associated with high mortality
reaching 45%. Incidence reported in the lit-
erature is between 0.3 and 3.5%, but there are
individual reports of incidence as high as 10%.
In our study, wound dehiscence occurred in
2.9% of the cases, and mortality in this popula-
tion was 25%, which did not significantly differ
from results found in the literature (8, 9, 10).
Patient-related factors
Most researchers agree that the male gen-
der is a risk factor. Through analyzing the
group with dehiscence in our study, we found
statistically significantly greater number of
men than women (37 vs. 19 – ratio of 2:1). In
one of the published studies, it was attributed
to tobacco smoking, which in most cases was
seen among men. In our study, tobacco smok-
ing did not constitute a risk factor, and men
did not smoke more frequently than women.
Frequency comparison of factors predisposing
to wound dehiscence (tab. 2) also demonstrat-
ed no statistically significant difference be-
tween men and women, except for a lower al-
bumin serum level in the female population.
Another explanation for this might be, re-
ported in certain papers, increased pressure
inside the abdominal cavity generated by men,
which translates into greater forces exerted on
the main wound (11). On the other hand,
other studies associate the greater incidence
of dehiscence with lower collagen production
in the wound in the male population, which is
probably associated with the effect of estrogens
(12).

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 Risk factors for wound dehiscence after laparotomy – clinical control trial
In most studies, age is also a risk factor
(13-17). In our study, logistic regression anal-
ysis showed no such relation, but, as has been
mentioned earlier, in line with the assump-
tions of this study, the control group members
were selected in accordance with the patients’
age. While analyzing patients in the study
group, one can easily notice a significant over-
representation of people over 65 years old (only
12 persons (21%) were younger than 65).
Chronic steroid treatment is also a fre-
quently reported risk factor for wound dehis-
cence. It is believed that these drugs inhibit
healing of the original wound and delay gran-
ulation tissue formation, and their chronic use
increases the number of intra- and postopera-
tive complications, which is associated, among
other things, with suppression of the hypotha-
lamic-pituitary-adrenal axis (18). In our study,
multivariate regression analysis showed that
chronic steroid treatment is an independent
risk factor for wound dehiscence.
It has been demonstrated that tobacco
smoking results in abnormal wound healing
due to increased tissue hypoxia, impairment
of neutrophil-killing mechanisms, decreased
collagen production and disturbed ratio of
proteases and their inhibitors in the wound
itself, which may predispose to wound dehis-
cence. In our study, however, chronic tobacco
smoking was not found to be a risk factor for
wound dehiscence. Both the study and the
control groups had a similar percentage of
habitual smokers (12).
Interestingly, diabetes, anemia, neoplastic
disease, previous laparotomy, obesity and un-
derweight were not identified as risk factors in
our study. Vascular changes resulting from
hypertensive disease, micro- and macroangiopa-
thy associated with diabetes or an overall bad
condition caused by neoplastic disease should
predispose to wound dehiscence. Mixed opinions
are also seen in the literature (17, 19, 20).
Disease-related factors
Emergency surgery is another risk factor
for wound dehiscence identified in most stud-
ies. While analyzing the group with wound
dehiscence, we found a statistically signifi-
cantly greater number of people admitted in
an emergency setting compared with people
admitted in an elective setting, which is in
571
accordance with reports in published papers.
It stems from numerous factors, such as a
general worse condition (including worse nutri-
tion) and greater risk of surgical field con-
tamination in case of patients undergoing
emergency surgery. Some studies raise also
the issue of the time when such surgeries take
place, which is often at night, potentially lead-
ing to suboptimal management of the abdom-
inal wall layers (17, 21, 22). A comparison of
elective surgery and emergency groups par-
ticipating in our study demonstrated no sta-
tistically significant difference between ana-
lyzed factors, except for a statistically signifi-
cantly lower albumin level and total protein
level as well as a higher CRP serum level,
which is associated with severity of disease
being the cause of admission in an emergency
setting. An interesting observation is the fact
that among patients with wound dehiscence
admitted in an emergency setting there were
statistically significantly fewer people with an
oncological disease, while among patients with
wound dehiscence admitted in an elective set-
ting there were statistically significantly more
people with an oncological disease (p < 0.01).
This might be associated with the fact that
most oncological patients admitted in an emer-
gency setting underwent a resection with
creation of a stoma (a procedure of shorter
duration and associated with fewer periopera-
tive complications compared with resection
with one-step restoration of the gastrointesti-
nal tract continuity).
Treatment-related factors
Logistic regression analysis did not show
that a particular surgeon (also resident vs.
specialist), the time of surgery or a particular
month (including holiday months) were statis-
tically significant risk factors for dehiscence.
As far as we are concerned, it is the first mono-
graph analyzing the above factors in such
detail. The literature features also papers in-
dicating a higher risk of wound dehiscence in
case of opening the fascia by means of electro-
coagulation, due to formation of marginal
necrosis. On the other hand, the recommended
technique of fascia closure involves the use of
a continuous suture, with the suture length to
wound length ratio exceeding 4:1 (23, 24). In
our study, we found no statistical relationship
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572 J. Kenig et al.
between dehiscence and incision techniques
(electric knife vs. scalpel) as well as fascia
suturing techniques (single sutures vs. a con-
tinuous suture). Analysis of the literature re-
veals that opinions are still mixed, although
most papers, like ours, do not consider the
surgical technique (of course if properly per-
formed) to be a risk factor for wound dehis-
cence (11, 25, 26). It is also interesting that
additional anti-eventration sutures were
placed during the first procedure in 25% pa-
tients with wound dehiscence, but their role,
in the light of EBM, is still to be determined.
When it comes to opening the abdominal cav-
ity by means of a vertical incision, logistic re-
gression analysis did not prove this technique
to be a risk factor, but this results solely from
the study methodology. Similarly as in other
papers, 86% of patients in the group with
wound dehiscence underwent laparotomy in
the midline of the body (11, 24).
The most important risk factor for wound
dehiscence remains surgical site infection. Ac-
cording to published data, it is associated with
an inflow of bacterial metalloproteinases and
endotoxins (stimulating production of collage-
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nases), which cause degradation of collagen,
prolongation of the inflammation stage and
activation of fibroblasts. Most published stud-
ies concerning this subject support similar
conclusions (14, 16, 21, 25, 27).
Conclusions
The results show that wound dehiscence is
a complex process, influenced by both general
and local as well as pre-, intra- and postopera-
tive factors. Only concurrence of several factors
can lead to this complication. Most risk factors
do not depend upon the surgeon but mostly on
the patient’s gender, age, type of disease
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One should also remember that a knowledge
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