Subinternship Surgery · Year 4 · from Subinternship Surgery

Case 1: Surgical Site Infection and Wound Dehiscence

Patient Presentation

Demographics: 58-year-old male

Chief Complaint: Fever and wound drainage POD 6 following open colectomy

History of Present Illness: Mr. Garcia underwent an open right hemicolectomy 6 days ago for a cecal adenocarcinoma. His initial postoperative course was unremarkable - he was tolerating a regular diet, had return of bowel function, and was ambulating well. However, over the past 24 hours, he has developed fever to 38.8C, increasing pain at the incision site, and noticed purulent drainage from his midline wound this morning.

Past Medical History:

  • Colorectal adenocarcinoma (resected)
  • Obesity (BMI 38)
  • Type 2 diabetes mellitus (HbA1c 8.2%)
  • 30 pack-year smoking history (quit 2 weeks pre-op)
  • Hypertension

Surgical Details:

  • Open right hemicolectomy with primary anastomosis
  • Operative time: 3 hours 45 minutes
  • EBL: 350 mL
  • Wound class: Clean-contaminated (Class II)

Physical Examination:

  • Vitals: T 38.8C, HR 102, BP 128/78, RR 18
  • Wound: Midline incision with erythema extending 3 cm from wound edges bilaterally, warmth, induration, and purulent yellow-green drainage from the inferior aspect
  • Abdomen: Soft, non-distended, tender near incision but no peritoneal signs
  • Lower extremity: Mild bilateral edema, no calf tenderness

Laboratory Studies:

  • WBC: 16,400 (up from 9,200 on POD 2)
  • Glucose: 285 mg/dL
  • Procalcitonin: 1.8 ng/mL

Clinical Questions

  1. How do you classify this surgical site infection, and what is your initial management?

SSI Classification:

| Classification | Definition | This Patient | |----------------|------------|--------------| | Superficial incisional SSI | Involves skin and subcutaneous tissue only | Possibly | | Deep incisional SSI | Involves fascia and muscle | Requires exploration | | Organ/space SSI | Involves any organ or space opened during surgery | Must rule out |

Assessment: Without exploration, this appears to be at least a superficial SSI, but depth must be determined by wound examination.

Initial Management:

  1. Open the wound - Remove staples/sutures over the area of drainage
  2. Explore - Probe wound to determine depth; does it extend to fascia?
  3. Obtain culture - Wound culture to guide antibiotic therapy
  4. Debride - Remove any necrotic tissue
  5. Pack wound - Moist gauze packing for healing by secondary intention
  6. Antibiotics - Start empirically pending culture (consider MRSA coverage)
  7. Glycemic control - Tighten glucose management
  1. While examining the wound, you find that the fascia is intact but gapping is noted when the patient coughs. What is your concern?

Concern: Impending fascial dehiscence

Risk Factors for Dehiscence in This Patient: | Risk Factor | Present | |-------------|---------| | Obesity (BMI >30) | Yes - BMI 38 | | Diabetes | Yes - poorly controlled | | Infection | Yes - active SSI | | Malnutrition | Possible - cancer patient | | Emergency surgery | No | | Coughing/straining | Yes | | Wound classification | Clean-contaminated |

Management:

  • Apply abdominal binder to reduce strain on fascia
  • Treat the infection aggressively
  • Optimize nutrition (albumin, prealbumin levels)
  • Serial wound examinations
  • Consider early surgical repair if fascial integrity is compromised
  1. The next morning, the nurse calls emergently because the patient sat up and "something came out of his wound." What is the diagnosis and immediate management?

Diagnosis: Wound evisceration (fascial dehiscence with bowel protruding through wound)

IMMEDIATE MANAGEMENT (First 5 minutes):

| Step | Action | Rationale | |------|--------|-----------| | 1 | Call for help - notify attending surgeon STAT | This is a surgical emergency | | 2 | Do NOT attempt to replace bowel | Risk of injury, contamination | | 3 | Cover with sterile saline-soaked gauze | Prevent desiccation and injury | | 4 | Position patient supine with knees flexed | Reduces abdominal wall tension | | 5 | Keep patient NPO | Prepare for OR | | 6 | IV access, send labs | Type and screen, CBC, BMP | | 7 | Start IV fluids | Volume resuscitation | | 8 | Keep patient calm | Straining worsens evisceration |

Do NOT:

  • Push bowel back into abdomen
  • Let the gauze dry out
  • Allow the patient to bear down or cough
  • Delay surgical intervention
  1. What are the principles of operative repair for evisceration?

Operative Repair Principles:

| Step | Technique | |------|-----------| | Inspection | Examine bowel for viability and injury | | Irrigation | Copious saline irrigation of abdominal cavity | | Return bowel | Gently return viable bowel to abdomen | | Fascial closure | Re-close fascia with interrupted sutures (often #1 PDS or nylon) | | Retention sutures | Consider mass closure with retention sutures if high-risk | | Wound | May leave skin open for delayed primary closure | | Abdominal binder | Apply postoperatively |

Post-Operative Considerations:

  • Continue antibiotics
  • Optimize nutrition
  • Tight glycemic control
  • Early mobilization with binder
  • Wound VAC may be considered for skin defect

Clinical Image

Image: Diagram illustrating the phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. Understanding these phases helps recognize normal versus abnormal healing and identify factors that impair repair. Source: Wikimedia Commons.

Image Attribution: Wound healing phases diagram. Wikimedia Commons. CC BY-SA 4.0. URL: https://commons.wikimedia.org/wiki/File:Wound_healing_phases.png

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