A 58-year-old woman is evaluated due to increasing leakage of fluid from her abdominal incision. The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for ovarian cancer 5 days ago and initially had a normal postoperative course. However, after walking the hallway this morning, she had increasing fluid leakage and a bulge at her incision site. The patient has had no increase in pain and is continuing to tolerate a regular diet and pass flatus. Temperature is 36.7 C (98.1 F), blood pressure is 144/92 mm Hg, and pulse is 88/min. BMI is 40 kg/m². Palpation of the abdomen shows no rebound or guarding. The vertical midline abdominal incision has surrounding erythema and a large amount of serosanguineous fluid seeping through the incision. After some of the skin staples are removed, fatty tissue and a loop of bowel are seen protruding from a separation of the rectus abdominus muscles. A moist dressing is placed over the wound. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d90e_de9b_bc81_3328994eba1f_MD0003_00 Abdominal surgery can result in a variety of postoperative wound complications (eg, infection, dehiscence). These complications are more common after procedures with large incisions and in patients with risk factors for poor wound healing (eg, cancer, chronic corticosteroids, hypoalbuminemia) or increased intraabdominal pressure (eg, cough, obesity). Postoperative abdominal wounds can be categorized based on fascial involvement: Superficial wound dehiscences are separations of the skin and subcutaneous tissue with intact rectus fascia. These typically develop within the first postoperative week due to an abnormal subcutaneous fluid buildup (eg, seroma) and can often be managed conservatively with careful dressing changes. Deep (fascial) wound dehiscences involve the rectus fascia (ie, nonintact) and result in exposure of the intraabdominal organs to the external environment. This patient's separation of the rectus abdominus muscles with protruding fat and bowel is consistent with a deep (fascial) wound dehiscence complicated by evisceration (ie, herniation of underlying abdominal organs). Additional clinical features include heavy drainage of peritoneal fluid, local bulging, and a popping sensation (from fascial suture failure). Fascial dehiscence is typically seen in the first 1-2 weeks after surgery but occasionally occurs up to 30 days postoperatively. Patients with fascial dehiscence, particularly with evisceration, require emergency surgery because the eviscerated bowel is at risk for continued herniation and strangulation. (Choice A) Abdominal binders may be placed briefly in preparation for surgery in patients with fascial dehiscence to prevent evisceration. They are contraindicated in patients with bowel evisceration because they can cause strangulation and perforation. (Choice B) In cases of suspected wound dehiscence not apparent on examination, an ultrasound or CT scan may be indicated. This patient has visible evisceration; therefore, delaying surgery may increase morbidity and mortality risk. (Choices D and E) Wound packing with saline gauze dressings is appropriate for management of superficial wound dehiscences. Negative pressure dressings are used to prevent dehiscence in high-risk wounds. This patient has a gross defect in the deep fascia, and nonoperative management is inappropriate. Educational objective: Deep (fascial) wound dehiscences can result in exposure or herniation (ie, evisceration) of intraabdominal organs (eg, bowel), resulting in possible strangulation. Therefore, patients with fascial dehiscence require emergency surgery.

A 58-Year-Old Woman Is Evaluated Due to Increasing Leakage of Fluid