A 36-year-old woman comes to the office for a postoperative visit due to incisional pain. A week ago, the patient had an abdominal hysterectomy for heavy menstrual bleeding, and intraoperative blood loss was 500 mL. After surgery, heparin was administered for venous thromboembolism prophylaxis and discontinued when she started ambulating. Since leaving the hospital, the patient has had incisional pain and light vaginal bleeding. In addition, she has a pulling sensation to the left of her incision that worsens when she bends over and when she strains to have a bowel movement. Temperature is 37.2 C (99 F), blood pressure is 134/78 mm Hg, and pulse is 78/min. BMI is 34 kg/m². The abdomen is soft and there are normoactive bowel sounds. The low, horizontal abdominal incision is closed with staples, and the skin edges are intact. There is mild incisional induration but no erythema, drainage, or fluctuance. The incision is diffusely tender to deep palpation, and no palpable masses or defects are present. Hemoglobin is 9 g/dL and leukocytes are 10,000/mm³. Which of the following is the best next step in management of this patient?

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Explanation: This patient has postoperative incisional pain after open abdominal surgery. A week after surgery, the most concerning potential cause is a wound complication, particularly in patients with risk factors (eg, obesity, increased intraabdominal pressure [eg, straining with bowel movements]). Therefore, the initial postoperative examination includes evaluation for the following: Infection (eg, erythema, purulent drainage, fever, leukocytosis) Fluid collection, as in a seroma or hematoma (eg, fluctuance, serous or sanguineous drainage) Wound dehiscence, either superficial or fascial (eg, bulge, profuse drainage) This patient is afebrile and has a normal leukocyte count, as well as a normal postoperative examination. The mild induration and diffuse tenderness to deep palpation over her incision are consistent with normal healing. Therefore, this patient requires observation and reassurance only. (Choices A and E) If this patient's symptoms or clinical examination worsen (eg, fever, rebound or guarding), further imaging (eg, CT scan of the abdomen and pelvis, pelvic ultrasound) is recommended to evaluate for postoperative complications (eg, pelvic abscess). (Choice B) Incisional exploration and packing is used to manage superficial wound dehiscence (ie, skin separation with intact fascia) or subcutaneous fluid collection (eg, seroma, hematoma) by removing excessive fluid and closing potential dead space to promote healing and prevent infection. This patient's incision is intact and there is no fluctuance. superficial wound dehiscence (Choice D) If this patient develops signs of superficial cellulitis (eg, erythema, increased incisional induration), she may require oral antibiotic therapy. More severe wound infections (eg, necrotizing fasciitis) require broad-spectrum intravenous antibiotics and possible surgery (eg, debridement). Educational objective: Postoperative incisional pain in the absence of signs of infection, fluid collection, and wound dehiscence is managed with observation and reassurance. References: Complications of hysterectomy. (http://www.ncbi.nlm.nih.gov/pubmed/23635631) Hysterectomy in obese patients: special considerations. (http://www.ncbi.nlm.nih.gov/pubmed/24335622)

A 36-Year-Old Woman Comes to the Office for a Postoperative