Post operative wound complications

POST-OPERATIVE WOUND

COMPLICATIONS

Dr.B.Selvaraj MS;Mch;FICS;

Professor Of Surgery

Melaka Manipal Medical college

Melaka 75150 Malaysia

POST-OPERATIVE WOUND

COMPLICATIONS- CAUSES

SeromaHematomaSuperficial Wound infectionWound dehiscence- Burst abdomenEntero-cutaneous fistula- Fecal fistulaNecrotising fasciitis

CLINICAL APPROACH

Reviewing the details of the operative procedure allows you to evaluate the wound intelligently.

Check the VS

Communicate with the nursing staff about the details of the wound care, and verify regarding the drains or special wound management.

Evaluate the patient for signs of systemic infection, local infection, or unexpected wound drainage.

R/O wound complications that might require immediate surgical attention.

HISTORY/SYMPTOMS

Review the details of the surgical procedure. Review the method of closure (staples or sutures, retention sutures, open packing, drains)

Determine the timing of the complication in relation to surgery

Foul smelling serous drainage with crepitus in the first 12 hours may indicate necrotizing fasciitis.

Salmon-colored serosanguinous fluid draining within the first week after abdominal surgery implies wound dehiscence.

Drainage suggestive of intestinal contents is probably an enterocutaneousfistula, which can present from days to weeks following abdominal surgery.

Risk factors for wound complications include malnutrition, steroids,obesity, smoking, diabetes mellitus, ischemia, infection, a technically inadequate method of wound closure, and emergency or multiple surgeries.

Physical Exam/Signs

Dressings should be changed daily. Inspect the wound for surrounding erythema, skin breakdown, bleeding, or obvious drainage. Characterize and quantify drainage.

Palpate the wound gently to elicit skin blanching, tenderness, crepitus, or drainage. The four classic signs of wound infection are redness, swelling, heat, and pain (rubor, tumor, calor, dolor)

Wounds should not be opened casually when wound dehiscence is suspected. Hematomas and superficial wound infections may require exploring the wound more deeply.

INVESTIGATIONS

WBC: Can be elevated in wound infection

Hb: Can be decreased in large hematomas.

Gram stain and wound culture: Particularly when clostridia (gram-positive rods) are suspected; antibiotic sensitivities are important.

Albumin/prealbumin: Assess nutritional status.

Obstruction series: Erect CXR and two-view abdominal plain film. Postoperative free air may be present for up to a week. Look for gas in the soft tissues.

CT abdomen/pelvis: Requires oral and IV contrast. Consider water-soluble gastrograffin oral contrast if suspicious of bowel leak. Extravasation of oral contrast into the wound confirms enterocutaneous fistula.

SEROMA

Etiopathogenesis Clinical features Diagnosis Treatment

A seroma is a

pocket of clear

serous fluid that

develops after

extensive surgical

dissection that

disrupt lymphatic

channels, which

leak into a closed

space.

Seromas are

particularly

common after

hernia mesh

repairs, after

axillary and

inguinal

dissections, and

after raising skin

flaps for plastic

surgery.

Dx is by clinical

examination of the

wound. When

necessary, can

be confirmed by

USG abdomen or

simple needle aspiration

90% of seromas will

resorb within 6 weeks

and should be left

alone. Symptomatic,

persistent, or infected

seromas will require

aspiration and

drainage. Antibiotics

are indicated only if

infection is suspected.

SEROMA

HEMATOMA


- Inadequate

intraoperative

hemostasis

-In patients who are

anticoagulated in

the perioperative

period.

- bloody wound

drainage or

- an expanding

mass and is a

clinical dx made

at the bedside.

Dx is by clinical

examination

-Tx is usually

supportive with pain

control, ice packs,

and local compression

- Surgical evacuation

if it is rapidly

increasing in size,

neck hematoma

compromising airway

and hematoma in

contaminated areas.

HEMATOMA

Superficial Wound Infection

No Antibiotics

Prophylactic

Antibiotics

Therapeutic

Antibiotics



- It is a local

infection in the

subcutaneous

tissues beneath the

incision.

- Wounds are

classified by risk for

contamination. The

risk for wound

infection increases

exponentially by the

type of the wound

- Risk factors

include obesity,

hypothermia,hypox

ia,ischemia,

smoking, and

diabetes.

- Manifests as

erythema,tenderne

ss ,purulent wound

drainage, fever and

leucocytosis.

-Dx is by clinical

examination

- The need for

wound culture

depends on the

clinical context.

(When in doubt,

obtain a C&S)

-Tx is draining the

infection by opening

the incision.

- Antibiotics depend

on the clinical

context. Evidence

indicates

that wound infections

are best prevented by

preoperative

antibiotics within 1

hour of incision.

Wound Dehiscence-Burst Abdomen


-Wound dehiscence

is disruption or

loss of continuity of

a surgically closed

layer of skin or

fascia.

- Evisceration is a

frank fascial

disruption resulting

in exposure of

abdominal contents.

- Wound tension,

ischemia, poor

nutrition, steroids,

obesity, and

infection are the

most common risk

factors.

- You can see

abdominal contents

lying outside the

abdominal cavity

- It is a clinical

diagnosis

-DehiscenceSkin

alone or fascia

alone may open

- Evisceration

both are open

-Salmon-colored

serosanguinous

fluid in 1st postop

week impending

dehiscence

Dehiscence:

-Early recognition &

stable patient

immediate operative

closure

- Late recognition &

unstable patient

healing by 2nd

intention

-Evisceration:cover

with saline pad

initially and then

emergency surgery

Wound Dehiscence-Burst Abdomen

ENTEROCUTANEOUS FISTULA


-It is an abnormal

communication

between the bowel

lumen and the skin,

with drainage of

bowel contents to

the outside.

- Gastrocutaneous,

Enterocutaneous

and Colocutaneous

fistulas

- occur most

commonly in

patients with

Multiple

abdominal

injuries, multiple

surgeries, or a

“damage control”

abdomen (skin and

fascia left open to

granulate because

abdomen cannot be

closed).

- Bowel contents

and air bubbles

draining into the

wound make the

clinical diagnosis.

-A fistula may be

confirmed by CT

scan with oral

contrast, a small

bowel series with

contrast looking for

extravasation of

contrast into the

wound, or sinogram

-Treatment consists

of bowel rest, TPN,

correction of

electrolytes,acid

suppression and

wound care

- Octrotide to reduce

secretions.

-Low output fistulas

heal in weeks to

months if no distal

obstruction

-High ouput fistulas

need surgical closure

ENTEROCUTANEOUS FISTULA

NECROTISING FASCIITIS


-Develops as a

progressive, rapidly

spreading,

inflammatory

infection, is a

surgical emergency.

-Occurs in the deep

fascia with

secondary necrosis

of the subcutaneous

tissues.

-Present with early

and rapid spread

of dusky, bluish

purple skin with

subcutaneous

emphysema and a

foul smelling, gray

serous fluid.

-Tissue destruction

and sepsis occur

within hours and

become lethal if

not treated

immediately.

- Early recognition

is imperative.

- classic organisms

responsible are ß-

haemolytic

streptococci,

coagulase-negative

staphylococci,

or Clostridium

perfringens.

- In many infections

a polymicrobial

profile will be

cultured

-Emergent surgical

debridement of all

nonviable tissue.

- Broad spectrum

antibiotics are

initiated, and

aggressive fluid

resuscitation is

mandatory

- Ex: Fournier’s

gangrene &

Meleney’s gangrene

NECROTISING FASCIITIS

FOURNIER’S GANGRENE MELENEY’S GANGRENE

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Post operative wound complications

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