post-operative complications

Question 1

what are the four categories of wound separation?

Answer 1

• superficial separation (anterior to rectus fascia)
• fascial dehiscence
• complete dehiscence
• evisceration (10-35% mortality risk)

Question 2

what are treatments for each type of wound separation?

Answer 2

superficial wound separation

• typically happens 3-5 days post-op
• usually with infection
• tx:
  1. evacuation of hematoma/seroma/pus, debridement of necrotic tissue. get cx. clean wound
  2. WTD BID or neg pressure dressing
  3. closure? can consider 4 days after resolution of infection. reduces healing time and post-op visits

fascial dehisence
- typically 10 days from surgery
- assess for subfascial infection, complete dehiscence, evisceration
- tx: surgical emergency
1. cover eviscerated contents with saline soaked sterile towels; replace bowel/omentum if possible
2. broad spectrum abx
in OR:
3. take down entire incisional closure if concern for infection below fascia
4. if complete dehisence: cx of incision/peritoneal fluid
5. bowel inspection
6. debride necrotic tissue with copious irrigation in abdomen
7. if stable: interrupted mass closure of fascia with permanent no 2 suture
7b. if unstable; retention sutures to close when pt is stable
8. if clean/clean contaminated cases, can close layers, and skin with stables. otherwise WTD dressings until infection resolved for delayed primary closure (typically 3-5 days) vs healing by secondary intention
9. post op abx and NGT

abx: ampicilling/cephalosporin and gentamycin

Question 3

management of vaginal cuff dehisence?

Answer 3

• caution with vaginal or speculum exam due to 2/3 rate of evisceration
• if evisceration present, cover with sterile saline towel.
• IV hydration, broad spectrum abx

In OR:
1. inspect for ischemia/necrosis/trauma.
If not: copious irrigation reduce if possible, and close vaginally with figure of 8 stitches.

2. if above noted: need lsc/abdominal approach. can close cuff vaginally or abdominally.
3. post-operative broad spectrum abx x 24 hours. if no clinically apparent infection can dc then. if present, continue until clinically apparent infeciton resolves.