Wound Deihiscence

You are the General Surgery CT1 and are asked to see a 65 year old gentleman who is day 10 post anterior resection. His procedure was complicated by post-operative ileus, which was treated with NG tube for decompression and IV fluids. He has since passed flatus but still has ongoing abdominal distension. The nurse calls you as she reports that the patient had a bout of coughing and is now complaining of abdominal pain and pink discharge from his wound and now bulging.  

Example answer introduction

In this scenario, I would be most concerned about a possible post operative wound dehiscence.  I therefore attend immediately and assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the CCISP Algorithm:

A - Patent, no stridor or stertor

B - Check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen 

C – Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output 

  • Bloods - FBC, U&E, LFTs, clotting, Group & Save, lactate, blood cultures

  • IV access - large bore 

  • IV fluid resuscitation with crystalloids

  • Catheterise patient to assess urine output urine output >0.5L/kg/hr

D – Glasgow Coma Score, temperature, pupillary response, blood glucose

E – Expose patient and look for rashes, systemic signs of shock. 

During this acute phase state remember to provide constant reassessment

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets, analgesia, VTE prophylaxis, steroids etc

  • Past medical history – previous bowel surgery, chronic cough/respiratory problems, diabetes

  • Last meal

  • Events leading up to this point:

    • Review operation notes – any high risk of complication, was the operation difficult, closure method and materials

    • Review post operative course

    • Review nutritional status

Examination

Examine to determine source of infection:

  • Abdominal Examination – examine wound

  • Evidence of infection 

  • Is the wound dehiscent – partial or complete

  • Are the abdominal contents extruding?

Investigations:

  • Blood tests–FBC, U&E, LFTs, clotting, Group & Save, lactate, protein level

  • Cultures–wound swab

Initial management

  • Cover the wound with saline or betadine soaked sterile gauze.

  • Do not attempt to reduce the bowel back in. This would be painful and the abdomen will also be rigid.

  • Empirical antibiotics as per local guidelines

  • IV fluids

  • Analgesia – consider IV morphine for pain relief and provide sedation

  • Antiemetic to prevent retching and vomiting

  • Keep patient NBM – the patient will need to return to theatre

  • Contact general surgery registrar and theatres as the patient will need wound washout and re-suturing under general anaesthetic immediately

  • Ensure DVT prophylaxis

  • Document clearly

  • Update patient and family

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Anaesthetics and theatres 

The patient will need re-suturing under general anaesthetic urgently

Notes:

The incidence of abdominal wound dehiscence should be less than 1%. This may be complete which involve all layers, including skin, or partial, which affects the deep layer only.

A serosanguinous discharge is characteristic of partial wound dehiscence. This looks pink due to the serous peritoneal exudate being tinged with blood. 

Evisceration (extrusion of abdominal viscera through a complete abdominal wound dehiscence) is rare and usually occurs first 2 weeks after surgery.

Example questions. 

Q1 What are the risk factors for wound dehiscence?

Patient factors

  • obesity

  • smoking

  • respiratory disease

  • obstructive jaundice

  • nutritional deficiencies

  • renal failure,

  • malignancy

  • diabetes 

 

Peri-operative Factors

  • Poor surgical technique

  • Persistently increased intra-abdominal pressure

  • Local tissue necrosis due to infection

  • Steroid therapy

 

Q2 What is the rate of incisional herniation post wound dehiscence?

Incisional herniation complicates approximately 25% of cases

Q3 What is Jenkins Rule?

In abdominal wound closure, for continuous suture closure, the suture must be 4 times the length of the wound with 1cm bites from the wound edge and 1cm apart.

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