# Clinical Cases: Wound Care and Surgical Complications

## 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

2. **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

3. **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

4. **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

![Wound healing phases](case_01_image.jpg)

*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

---

## Case 2: Postoperative Fluid Collection and DVT

### Patient Presentation
**Demographics:** 45-year-old female

**Chief Complaint:** Swelling at surgical site and leg pain POD 5 following mastectomy

**History of Present Illness:**
Ms. Williams underwent a left modified radical mastectomy with axillary lymph node dissection for invasive ductal carcinoma 5 days ago. She was discharged on POD 2 with a Jackson-Pratt drain in place, which has been draining 60-80 mL of serosanguinous fluid daily. Today she noticed increased swelling at the surgical site with fluctuance, and the drain output has decreased to 20 mL. She also reports new left calf pain and swelling that started this morning.

**Past Medical History:**
- Breast cancer (newly diagnosed)
- Obesity (BMI 34)
- Oral contraceptive use (discontinued 1 week pre-op)
- No prior VTE

**Physical Examination:**
- Vitals: T 37.2C, HR 88, BP 118/72, RR 16
- Left chest wall: Well-healing mastectomy incision, but notable fluctuant collection medial to the incision measuring approximately 8x6 cm, minimal erythema, no warmth
- JP drain: In place, minimal output
- Left lower extremity: 3 cm asymmetric calf swelling compared to right, mild tenderness along the course of the deep veins, no erythema or warmth

**Laboratory Studies:**
- WBC: 8,200
- Hgb: 10.8 g/dL
- D-dimer: 2.4 mg/L (elevated)

### Clinical Questions

1. **What is the most likely diagnosis for the chest wall collection, and how should it be managed?**

   **Diagnosis:** Seroma (most likely) vs. Hematoma

   **Differentiation:**
   | Feature | Seroma | Hematoma |
   |---------|--------|----------|
   | Timing | POD 5-14 typical | Usually earlier (POD 0-3) |
   | Consistency | Fluctuant | May be firm, tense |
   | Fluid character | Clear/straw-colored | Bloody/dark |
   | Erythema | Minimal | Variable |
   | Pain | Mild | Moderate-severe |
   | Risk procedure | Lymph node dissection | Any surgery |

   **Management of Seroma:**
   | Size | Management |
   |------|------------|
   | Small, asymptomatic | Observation, compression |
   | Moderate, symptomatic | Aspiration with sterile technique |
   | Large or recurrent | Serial aspirations, may need drain replacement |
   | Infected | Drainage + antibiotics |

   **For this patient:**
   1. Aspirate under sterile conditions
   2. Send fluid for culture (to rule out infection)
   3. Apply compression dressing
   4. Warn patient that recurrence is common (may need multiple aspirations)

2. **What is your concern regarding the leg symptoms, and how do you evaluate?**

   **Concern:** Deep venous thrombosis (DVT)

   **VTE Risk Factors in This Patient:**
   | Factor | Risk Level |
   |--------|------------|
   | Recent major surgery | High |
   | Cancer diagnosis | High |
   | Obesity | Moderate |
   | Recent OCP use | Moderate |
   | Immobility post-op | Moderate |

   **Wells Score for DVT:**
   | Criteria | Points | This Patient |
   |----------|--------|--------------|
   | Active cancer | +1 | Yes |
   | Paralysis/immobilization | +1 | No |
   | Bedridden >3 days or major surgery within 12 weeks | +1 | Yes |
   | Localized tenderness along deep veins | +1 | Yes |
   | Entire leg swollen | +1 | No (calf only) |
   | Calf swelling >3 cm asymmetry | +1 | Yes |
   | Pitting edema | +1 | Not specified |
   | Collateral superficial veins | +1 | No |
   | Alternative diagnosis more likely | -2 | No |
   | **Total** | **4** | **DVT likely** |

   **Diagnostic Evaluation:**
   - **Duplex ultrasound of left lower extremity** - First-line test for suspected DVT

3. **The ultrasound confirms an acute DVT in the left popliteal vein. What is the treatment?**

   **DVT Treatment:**

   | Component | Recommendation |
   |-----------|----------------|
   | **Anticoagulation** | Initiate immediately unless contraindicated |
   | **Agent selection** | LMWH, fondaparinux, or DOAC (rivaroxaban, apixaban) |
   | **Duration** | Minimum 3 months; extended for cancer-associated VTE |
   | **Monitoring** | No routine monitoring needed for LMWH/DOAC |
   | **Ambulation** | Encourage early mobilization |
   | **Compression** | Graduated compression stockings controversial |

   **Cancer-Associated Thrombosis Considerations:**
   - LMWH traditionally preferred over warfarin
   - DOACs (edoxaban, rivaroxaban) now acceptable per recent trials
   - Longer duration (6 months or while cancer active) recommended
   - Higher recurrence risk

   **IVC Filter Indications:**
   - Absolute contraindication to anticoagulation
   - Recurrent PE despite adequate anticoagulation
   - NOT indicated for this patient

4. **What could have been done to prevent this complication?**

   **VTE Prevention Strategies:**

   | Intervention | Timing | Notes |
   |--------------|--------|-------|
   | Risk stratification | Pre-operative | Caprini score or similar |
   | Mechanical prophylaxis | Intraoperative and post-op | SCDs, graduated compression |
   | Pharmacologic prophylaxis | Per protocol | LMWH or UFH based on risk and bleeding risk |
   | Early ambulation | POD 0-1 | Most important intervention |
   | Hydration | Perioperative | Avoid dehydration |
   | Extended prophylaxis | High-risk patients | Cancer surgery: consider 4 weeks LMWH |

   **This Patient's Risk Profile Warranted:**
   - SCDs intraoperatively and until fully ambulatory
   - Pharmacologic prophylaxis with LMWH
   - Given cancer surgery, extended prophylaxis (4 weeks) should have been considered
   - OCP discontinuation pre-op (she did this)

### Clinical Image

![Seroma aspiration](case_02_image.jpg)

*Image: Post-mastectomy seroma is a common complication following breast surgery with axillary lymph node dissection. Sterile aspiration may be required for large or symptomatic collections, though recurrence is common. Source: Wikimedia Commons.*

**Image Attribution:** Surgical wound care. Wikimedia Commons. CC BY-SA 3.0.
**URL:** https://commons.wikimedia.org/wiki/File:Wound_healing_phases.png

---

## Summary Points

1. **SSI Classification:** Superficial (skin/subcutaneous), deep incisional (fascia/muscle), and organ/space - management differs for each depth

2. **SSI Management:** Open the wound, explore to determine depth, culture, debride necrotic tissue, pack with moist gauze, and start appropriate antibiotics

3. **Dehiscence Risk Factors:** Obesity, diabetes, infection, malnutrition, smoking, emergency surgery, wound classification, and technical factors

4. **Evisceration Emergency:** Do NOT push bowel back; cover with sterile saline-soaked gauze, position supine with knees flexed, and prepare for emergent OR

5. **Seroma Management:** Small collections can be observed; larger ones require aspiration with sterile technique; recurrence is common

6. **DVT Evaluation:** Use Wells score to stratify probability; duplex ultrasound is the first-line diagnostic test

7. **Cancer-Associated VTE:** Higher risk of recurrence; extended anticoagulation recommended; LMWH or DOAC preferred over warfarin

8. **VTE Prevention:** Combines risk stratification, mechanical prophylaxis, pharmacologic prophylaxis, and early ambulation; extended prophylaxis for high-risk cancer surgery